Corrective Action Plans

Finding 1162507 (2024-002)

Material Weakness 2024

TOWN OF SHIRLEY

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contra...

Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contractors are eligible to receive federal funds and not excluded or disqualified from doing business. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator

View Audit 372227

Finding 1162506 (2024-001)

Material Weakness 2024

TOWN OF SHIRLEY

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawy...

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator

View Audit 372227

Finding 1162475 (2024-006)

Material Weakness 2024

HEARTLAND ALLIANCE HEALTH AND SUBSIDIARY

IL

Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions

Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now ...

Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now generates and reviews weekly documentation and billing completeness reports to identify and resolve missing or incomplete encounter records. Clinic managers and providers receive weekly follow-ups to ensure that documentation is corrected promptly and that all billed services are properly supported. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved

View Audit 372215

Finding 1162429 (2024-002)

Material Weakness 2024

National Council on Radiation Protection and Measurements

MD

Reporting Significant Deficiency

Action Taken: We agree with the findings and have established new written policies and procedures to ensure the SEFA is properly reconciled and reviewed prior to the start of the audit.

View Audit 372211

Finding 1162414 (2024-003)

Material Weakness 2024

Community Housing Partnership

CA

Significant Deficiency Internal Control / Segregation of Duties

Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CH...

Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CHP will be updating internal controls to include evidence of appropriate reviews and approvals of rent reasonableness.

View Audit 372194

Finding 1162368 (2024-006)

Material Weakness 2024

Housing Authority of the City of Newark

NJ

Questioned Costs Eligibility HUD Housing Programs

Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Execu...

Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.

View Audit 372175 Questioned Costs: $1

Finding 1162347 (2024-004)

Material Weakness 2024

The Greening of Detroit

MI

Allowable Costs / Cost Principles Significant Deficiency

The Greening of Detroit has adjusted all indirect costs from being charged to the DNR grant for the current year 2025 and future years. The Greening of Detroit has also updated the grant budget to reflect the change to match the grant requirements.

View Audit 372154

Finding 1162346 (2024-003)

Material Weakness 2024

The Greening of Detroit

MI

Significant Deficiency

The Greening of Detroit will ensure that we plan and complete our audits on time. Next year, we will schedule audits earlier in the year and set defined date range with our auditors to avoid late audit reports in the future. Our audits will be completed 15 days before the audit report is due to the ...

The Greening of Detroit will ensure that we plan and complete our audits on time. Next year, we will schedule audits earlier in the year and set defined date range with our auditors to avoid late audit reports in the future. Our audits will be completed 15 days before the audit report is due to the clearing house.

View Audit 372154

Finding 1162342 (2024-003)

Material Weakness 2024

School Board City of Richmond

VA

Subrecipient Monitoring Cash Management Reporting

Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency...

Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency as the state educational agency and Secretary may require to enable the state educational agency and the Secretary to perform their duties under the program; The LEA has also submitted an official correspondence to the Auditors from the Commonwealth of Virginia Department of Education’s Director of the Office of Federal Pandemic Relief Programs stating the following: On April 25, 2023, the Virginia Department of Education conducted monitoring to ensure that certain federally funded programs and activities supported with Elementary and Secondary School Emergency Relief (ESSER) formula grants; ESSER and Governor’s Emergency Education Relief (GEER) state setaside grants; and Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) HVAC grants were implemented as stipulated by law. These federally funded programs were reviewed as operated by Richmond City Public Schools. Furthermore, RPS is a subrecipient. As such it is our stance that RPS was not required to create or submit quarterly financial activity reports to US Treasury. We were also not required to submit quarterly financial reports to the recipient (i.e. the Commonwealth of Virginia). Instead, RPS regularly submitted expenditures for reimbursement to VDOE on a nearly monthly basis via OMEGA. We also maintained financial records (invoices, GL transactions) via AS400 and LINQ and conducted annual single audits as required by the Single Audit Act & 2 CFR part 200, subpart F. We also complied with all monitoring activities conducted by VDOE. In turn, VDOE (the award recipient) used these artifacts to create and submit its quarterly financial reports to US Treasury, as required by statute. For more evidence of this "passthrough" structure of reporting, see the attached SLFRF Compliance and Reporting Guidance published by US Treasury and Updated October 2025 Part 2 Section B (p. 21-22) for a detail of which entities are required to submit quarterly reports. The following recipients are required to submit quarterly Project and Expenditure Reports: • States and U.S. territories • Tribal governments that are allocated more than $30 million in SLFRF funding • Metropolitan cities and counties with a population that exceeds 250,000 residents Coronavirus State and Local Fiscal Recovery Funds C • Metropolitan cities and counties with a population below 250,000 residents that are allocated more than $10 million in SLFRF funding • NEUs [Non-Entitlement Units of Government] that are allocated more than $10 million in SLFRF funding RPS does not fall into any of the aforementioned categories. We humble ask that you reconsider this finding.

View Audit 372149

Finding 1162311 (2024-005)

Material Weakness 2024

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Subrecipient Monitoring HUD Housing Programs Reporting

Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data...

Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data that is prepared is locked so only the owner can make changes.

View Audit 372119

Finding 1162310 (2024-004)

Material Weakness 2024

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency § 200.430

Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does th...

Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does the payroll. We save a backup timecard report each payroll that we are paying from the approved by the employee's supervisor. We also have an internal worksheet that we use to document any changes that are made. Once the accountant is done with her review the controller will do the second review before we finish processing the payroll enforcing internal controls that are in place and being followed.

View Audit 372119

Finding 1162309 (2024-003)

Material Weakness 2024

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Special Tests & Provisions Subrecipient Monitoring Eligibility

Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...

Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.

View Audit 372119

Finding 1162293 (2024-006)

Material Weakness 2024

Waikiki Health

HI

Subrecipient Monitoring HUD Housing Programs Reporting

Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system...

Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system to ensure that all Uniform Data System (UDS) related calculations are accurately documented and consistently maintained.

View Audit 372114

Finding 1162290 (2024-003)

Material Weakness 2024

Waikiki Health

HI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...

Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.

View Audit 372114

Finding 1162258 (2024-003)

Material Weakness 2024

Town of Marlborough

CT

Significant Deficiency Internal Control / Segregation of Duties

2024-003 Reporting over COVID-19 America Rescue Plan Act Recommendation: We recommend that the Town implement a control to ensure an independent review of the financial reports is performed by an individual other than the prepared to verify accuracy and completeness prior to the U.S. Department of t...

2024-003 Reporting over COVID-19 America Rescue Plan Act Recommendation: We recommend that the Town implement a control to ensure an independent review of the financial reports is performed by an individual other than the prepared to verify accuracy and completeness prior to the U.S. Department of the Treasury. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Town Manager will review filing prior to submission at next reporting deadline. Name of the contact person responsible for corrective action: Town Manager and Finance Director Planned completion date for corrective action plan: Since this report is overdue, the estimated implementation date is before the filing of the 2026 deadline

View Audit 372061

Finding 1162257 (2024-002)

Material Weakness 2024

Town of Marlborough

CT

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency

FINDING — Major Federal Program 2024-002 Suspension and Debarment over COVID-19 America Rescue Plan Act Recommendation: We recommend that the Town design controls to ensure an adequate review process in place to review potential contractors to determine they are not suspended or debarred. Explanatio...

FINDING — Major Federal Program 2024-002 Suspension and Debarment over COVID-19 America Rescue Plan Act Recommendation: We recommend that the Town design controls to ensure an adequate review process in place to review potential contractors to determine they are not suspended or debarred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town has a system in place to review contractors. A written process will be prepared to record and maintain appropriate documentation. Name of the contact person responsible for corrective action: Town Manager, Finance Director and Town Planner Planned completion date for corrective action plan: Since this report is overdue, the estimated date is before the start of the FY 25 audit.

View Audit 372061

Finding 1162231 (2024-004)

Material Weakness 2024

Fair Haven, Inc.

IN

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency § 200.303

Views of Responsible Officials and Planned Corrective Actions: Management agrees documentation must demonstrate proper approval. Corrective Action: Utilize standard purchase authorization and maintain approval documentation with supporting invoices/receipts.

View Audit 372043

Finding 1162214 (2024-001)

Material Weakness 2024

Yeshiva Tzoin Yosef Pupa, Inc. and Affiliates

NY

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Organization should implement an effective monitoring system to keep track of the compliance calendar, which includes financial reporting deadlines, and automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Orga...

The Organization should implement an effective monitoring system to keep track of the compliance calendar, which includes financial reporting deadlines, and automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. Additionally, the Organization should implement a system that will file documents in an organized manner and make them easily accessible to the Organization and auditors. Furthermore, the Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight.

View Audit 372019

Finding 1162175 (2024-004)

Material Weakness 2024

Central Minnesota Housing Partnership, Inc.

MN

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Rural Rental Housing Loans - Federal Assistance Listing #10.415 Recommendation: We recommend ensuring all income statement items are properly reviewed and reported to the USDA. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response t...

Rural Rental Housing Loans - Federal Assistance Listing #10.415 Recommendation: We recommend ensuring all income statement items are properly reviewed and reported to the USDA. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The year-end actual income statements will be prepared by the Portfolio Accountant based on year-end policies and procedures. The income statement will be reviewed by the Property Director, the Finance Director, initialed and then entered into MINC. Names of the contact persons responsible for corrective action: Julie Schueller, Finance Director and Deanna Hemmesch, Executive Director Planned completion date for corrective action plan: December 31, 2025

View Audit 371986

Finding 1162123 (2024-004)

Material Weakness 2024

Benet Place

MN

Questioned Costs HUD Housing Programs Significant Deficiency

Significant Deficiency: Missing one deposit to the replacement reserve. $11,422 Recommendation: The Project should establish and follow a consistent monthly review process to ensure all deposits to the replacement reserve are made on a timely basis. Explanation of disagreement with audit finding: Th...

Significant Deficiency: Missing one deposit to the replacement reserve. $11,422 Recommendation: The Project should establish and follow a consistent monthly review process to ensure all deposits to the replacement reserve are made on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management continues to review and establish processes related to review and approval to ensure monthly replacement reserve deposits are made.

View Audit 371924 Questioned Costs: $1

Finding 1161999 (2024-003)

Material Weakness 2024

Greater Wisconsin Agency on Aging Resources, Inc.

WI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.403

Given the complexities of the compliance requirements of the State and Federal governments, this issue will remain a finding, but GWAAR Fiscal Staff will work towards ensuring that all opportunities to follow GAAP standards will be met and all costs will be properly posted.

View Audit 371857 Questioned Costs: $1

Finding 1161951 (2024-006)

Material Weakness 2024

Washoe County

NV

Eligibility Reporting Significant Deficiency

Internal controls will be created for reviewing the determination of eligibility for participation in the Emergency Rental Assistance Program.

View Audit 371844

Finding 1161933 (2024-006)

Material Weakness 2024

Independent School District No. 197

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties School Nutrition Programs

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.555, 10.559, AND 10.553 2024-006 - Internal Control Over Compliance With Federal Suspension and Debarment Requiremen...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.555, 10.559, AND 10.553 2024-006 - Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary Criteria – 2 CFR § 180 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster. Condition – The District did not have sufficient controls in place within its child nutrition cluster to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District will review its policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – Peter Olson-Skog, the District’s Superintendent. Planned Completion Date – December 31, 2025. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – Peter Olson-Skog, the District’s Superintendent, will ensure appropriate controls are in place to verify that any vendor with which the District contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.

View Audit 371829

Finding 1161857 (2024-006)

Material Weakness 2024

Open Cities Health Center, Inc. and Affiliate

MN

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2024-006 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Significant Deficiency Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testi...

Finding 2024-006 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Significant Deficiency Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testing the Federal Poverty Guideline (FPG) was inaccurately applied for two patients. Action Planned in Response to the Finding: In the past year, the collection and retention of sliding fee discount qualifying documents have been integrated and the calculation performed by the clinic’s electronic medical record system. An employee was added, in part, to provide oversite of the sliding discount process. Official Responsible for Ensuring the CAP: Darian Davis Planned Completion Date: December 2025

View Audit 371776

Finding 1161818 (2024-003)

Material Weakness 2024

Abused Adult Resource Center

ND

Significant Deficiency § 200.512

Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center has contracted with a CPA to prepare the Statement of Expenditures of Federal Awards and to provide support for federal expenditures. Completion Date Fiscal Year 2025

View Audit 371750

Corrective Action Plans

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