Corrective Action Plans

Finding 1162257 (2024-002)

Material Weakness 2024

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

Finding 1161791 (2024-001)

Material Weakness 2024

Mha Housing of Eastern North Carolina, Inc.

NC

Eligibility HUD Housing Programs Significant Deficiency

To address the noted deficiencies in tenant file documentation, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed ...

To address the noted deficiencies in tenant file documentation, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.

View Audit 371719

Finding 1161722 (2024-006)

Material Weakness 2024

Union League Boys and Girls Clubs

IL

Allowable Costs / Cost Principles Reporting Significant Deficiency

Supporting Documentation of Payroll Costs Recommendation: Policies and procedures over the processing of payroll transactions should include proper review and approval of timesheets to ensure hours match the hours per payroll register and correct hours are charged to the grant. There is no disagreem...

Supporting Documentation of Payroll Costs Recommendation: Policies and procedures over the processing of payroll transactions should include proper review and approval of timesheets to ensure hours match the hours per payroll register and correct hours are charged to the grant. There is no disagreement with the audit finding. Action planned/taken in response to finding: High quality accounting personnel will ensure hours match the hours per payroll register and correct hours are charged to the grant. Name(s) of the contact person(s) responsible for corrective action: Mary Ann Mahon Huels, President and CEO Planned completion date for corrective action plan: Immediately

View Audit 371657

Finding 1161718 (2024-005)

Material Weakness 2024

Union League Boys and Girls Clubs

IL

Cash Management Reporting Significant Deficiency

Supporting Documentation of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure proper supporting documentation is maintained and available for each expenditure. There is no disagreement with the audit finding. Act...

Supporting Documentation of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure proper supporting documentation is maintained and available for each expenditure. There is no disagreement with the audit finding. Action planned/taken in response to finding: Outside accounting firm will be ensure proper supporting documentation is maintained and available for each expenditure. Name(s) of the contact person(s) responsible for corrective action: Mary Ann Mahon Huels, President and CEO Planned completion date for corrective action plan: Immediately

View Audit 371657

Finding 1161714 (2024-004)

Material Weakness 2024

Union League Boys and Girls Clubs

IL

Reporting Cash Management Significant Deficiency

Proper Cut-Off of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure completion in accordance with the accrual basis to ensure expenditures are being recorded and reported in the proper period. There is no disagre...

Proper Cut-Off of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure completion in accordance with the accrual basis to ensure expenditures are being recorded and reported in the proper period. There is no disagreement with the audit finding. Action planned/taken in response to findings: Outside Accounting Firm will oversee the monthly voucher process to ensure completion in accordance with the accrual basis to ensure expenditures are recorded and reported in the proper period. Name(s) of the contact person(s) responsible for corrective action: Mary Ann Mahon Huels, President and CEO Planned completion date for corrective action plan: Immediately

View Audit 371657

Finding 1161572 (2024-003)

Material Weakness 2024

Planned Parenthood Association of Utah

UT

Allowable Costs / Cost Principles Procurement, Suspension & Debarment HUD Housing Programs § 200.303

Review AP policies, train AP personnel, and require double approval before using grant funds

View Audit 371449

Finding 1161556 (2024-001)

Material Weakness 2024

Tashbar of Lakewood Inc.

NJ

Procurement, Suspension & Debarment Significant Deficiency

Recommendation: To create a policy that follows the procurement guidelines and implement those policies during the procurement process. Action Taken: Since being made aware of the issue, the School’s administrator will create a procurement policy and ensure that all procurement procedures are enacte...

Recommendation: To create a policy that follows the procurement guidelines and implement those policies during the procurement process. Action Taken: Since being made aware of the issue, the School’s administrator will create a procurement policy and ensure that all procurement procedures are enacted and followed. Implementation Date: Corrective Action Plan has been implemented as of July 15, 2025. Person Responsible for Implementation: Dovid Hertz, the administrator, is the responsible party for implementation of the CAP. Telephone Number: (732)-905-1111.

View Audit 371434

Finding 1161498 (2024-002)

Material Weakness 2024

Capital Area Community Action Agency, INC

FL

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

2024-002 Internal Controls Over Compliance - Special Tests and Provisions (Tri-Partite Board) - Community Service Block Grant (CSBG) - CFDA 93.569 - Grant Period Year Ended September 30, 2024 Criteria: In accordance with the requirements of the Program outlined in ALN 93.569 CSBG, and the CSBG Act a...

2024-002 Internal Controls Over Compliance - Special Tests and Provisions (Tri-Partite Board) - Community Service Block Grant (CSBG) - CFDA 93.569 - Grant Period Year Ended September 30, 2024 Criteria: In accordance with the requirements of the Program outlined in ALN 93.569 CSBG, and the CSBG Act at 42 USC 9910, nonprofit organizations administer CSBG through a board. One-third (1/3) of the board members must be chosen in a democratic selection process adequate to assure that these members are representative of the low-income individuals and families served. An additional 1/3 of the board must be public elected and/or appointed officials. Condition: The Agency was unable to meet the 1/3 requirements for the public elected/appointed officials and the 1/3 requirement for low-income individuals and families served during the year ended September 30, 2024. Cause: While the Agency's controls did identify a lack of participation in these areas, they did not include control activities to resolve the non-compliance in a timely manner. Effect: The Agency is out of compliance with the provisions requiring Tri-Partite Board as defined by the CSBG Act at 42 USC 9910. Recommendation: We recommend the Agency recruit board members from the areas identified for compliance with this requirement. Corrective Action Plan: The Capital Area Community Action Agency Board membership fluctuates over time. Sometimes there are several public representatives or their designees on the board. Other times there are several private sector representatives. As a tripartite board, low-income representatives are always on the board. While the numbers are not always equal, the Agency strives to meet the spirit of the law in its recruitment efforts. The Board will work to develop a more robust recruitment method to ensure a balance of representation from the three sectors, as well as the eight counties we serve. We anticipate correcting this finding by the next review period.

View Audit 371414

Finding 1161449 (2024-001)

Material Weakness 2024

Arukah Institute of Healing, Inc.

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

The policies and procedures around the Single audit will be reviewed, assigning responsibility, and implementing tracking systems. The CEO, COO, CFO, and Grants Manager will be responsible for overseeing the data collection and submission process internally, keeping track of the audit deadlines to e...

The policies and procedures around the Single audit will be reviewed, assigning responsibility, and implementing tracking systems. The CEO, COO, CFO, and Grants Manager will be responsible for overseeing the data collection and submission process internally, keeping track of the audit deadlines to ensure that all processes are moving forward in a timely fashion. All relevant parties will be trained on the reporting requirements and due dates.

View Audit 371331

Finding 1161288 (2024-005)

Material Weakness 2024

Association of Village Council Presidents Regional Housing Authority

AK

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Finding 2024-005 Significant Deficiency in Internal Control over Compliance and Noncompliance – Reporting Deadline for Federal Single Audit Questioned Programs ALN 15.022 Tribal Self Governance Agencies: Department of Interior ALN 84.250 American Indian Vocational Rehabilitation Services Agencies: D...

Finding 2024-005 Significant Deficiency in Internal Control over Compliance and Noncompliance – Reporting Deadline for Federal Single Audit Questioned Programs ALN 15.022 Tribal Self Governance Agencies: Department of Interior ALN 84.250 American Indian Vocational Rehabilitation Services Agencies: Department of Education Award Numbers GT-OSGT812- Year 2013 GT-OSGT812- Year 2017 GT-OSGT812- Year 2018 GT-OSGT812- Year 2019 GT-OSGT812- Year 2020 GT-OSGT812- Year 2021 GT-OSGT812- Year 2022 GT-OSGT812- Year 2023 GT-OSGT812- Year 2024 GT-OSGT812- Year 2025 H250N210051- Year 2023 H250N210051- Year 2024 Condition The Association did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2024. Status In Progress. Management’s Corrective Action Plan Management acknowledges that the data collection form and reporting package was filed late for Fiscal Year 2024 due to employee turnover. As these positions have been filled subsequent to year end, we do not anticipate any such issues for Fiscal Year 2025.

View Audit 371211

Finding 1161287 (2024-003)

Material Weakness 2024

Association of Village Council Presidents Regional Housing Authority

AK

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-003 Significant Deficiency in Internal Control Over Compliance – Eligibility Application Review Questioned Programs ALN 84.250 American Indian Vocational Rehabilitation Services Agencies: Department of Education Award Numbers H250N210051- Year 2023 H250N210051- Year 2024 Condition The A...

Finding 2024-003 Significant Deficiency in Internal Control Over Compliance – Eligibility Application Review Questioned Programs ALN 84.250 American Indian Vocational Rehabilitation Services Agencies: Department of Education Award Numbers H250N210051- Year 2023 H250N210051- Year 2024 Condition The Association is not consistently following their own internal control procedures for keeping evidence of reviewing the eligibility certification form. Status In Progress Management’s Corrective Action Plan Vocational Rehabilitation (VR) will update its required document checklist to include a check for required signatures. The intake staff will utilize the checklist for its first level of application intake to ensure all supporting documents are included and the application is complete, including required signatures. Another step VR will add in the process is a second level of review. Each application that has been approved for support will be reviewed by a second reviewer before final approval. Further, each application that exceeds an award of $10,000, will be reviewed by a third approver. Since applications for services are sometimes foreword to AVCP VR by the Yukon Kuskokwim Health Corporation Audiology Department, AVCP VR will conduct regular training to Audiology staff on the correct process for completing its application. Internally, AVCP VR will continue to conduct yearly training to Village based AVCP staff, who sometimes accept and forward applications to the VR staff, on the correct process for completing its application. Lastly, AVCP VR will update its internal policies and procedures to include these four key steps to ensure applications are complete and signed

View Audit 371211

Finding 1161279 (2024-002)

Material Weakness 2024

New Hampshire Children's Trust

NH

Subrecipient Monitoring Reporting Significant Deficiency § 200.329

Director of Operations & Impact will draft an 18-month reporting deliverables schedule to be reviewed quarterly. The schedule of reporting deliverables will be added to a dedicated calendar in SharePoint, shared with the President and programs team staff, and a series of reminders and notifications ...

Director of Operations & Impact will draft an 18-month reporting deliverables schedule to be reviewed quarterly. The schedule of reporting deliverables will be added to a dedicated calendar in SharePoint, shared with the President and programs team staff, and a series of reminders and notifications will be integrated into the system. The system itself will be reviewed every six months going forward to address any technological issues and make recommendations for improved functionality. Planned Implementation Date of Corrective Action: 9/22/25 Person Responsible for Corrective Action: Director of Operations & Impact

View Audit 371198

Finding 1161158 (2024-002)

Material Weakness 2024

Walla Walla County

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Walla Walla County is taking significant steps to address the recent audit finding regarding inadequate internal controls for compliance with federal requirements. Development of a New Policy To rectify this issue, the county is committed to formulating a new policy specifically tailored to meet fed...

Walla Walla County is taking significant steps to address the recent audit finding regarding inadequate internal controls for compliance with federal requirements. Development of a New Policy To rectify this issue, the county is committed to formulating a new policy specifically tailored to meet federal standards. This development process is already in motion, with the expected completion date set for December 2025. Enhancing Internal Controls We believe that the new policy will significantly improve our internal controls and ensure full compliance with federal mandates. Training Initiatives Additionally, we will seek training opportunities to increase the knowledge of all staff regarding federal programs and compliance requirements, ensuring adherence to these programs and grants.

View Audit 371174

Finding 1161141 (2024-001)

Material Weakness 2024

Grace House INC

MS

Subrecipient Monitoring Cash Management Material Weakness

Views of Responsible Officials and Planned Corrective Action — Grace House has created and will implement the following new controls: a) Every reimbursement request made by any employee will require approval from the Executive Director, Assistant Director, or board of directors vote where appropriat...

Views of Responsible Officials and Planned Corrective Action — Grace House has created and will implement the following new controls: a) Every reimbursement request made by any employee will require approval from the Executive Director, Assistant Director, or board of directors vote where appropriate. b) For rental invoices, the immediate supervisor must approve all rental invoices for payment processing before being submitted to the administrative office. If the immediate supervisor is absent, the invoice must be approved by the Executive Director or Assistant Director. c) When a new client invoice is submitted for approval for an existing approved landlord, the invoice along with the traditional client identifying information will be reviewed by both the immediate supervisor and the Executive Director. d) When a new client invoice is submitted for approval for a new landlord, the invoice will be reviewed by both the immediate supervisor and the Executive Director. Each invoice requires a W9 form to validate the legal name, property records verifying ownership matching the legal name on the W9, a picture ID of the individual listed on the W9, and a copy of the agreement if a property management company is listed on the W9 instead of an individual. e) All new clients and landlords will be researched through an investigative software to prove there is no evidence of false identity. f) Grace House has contracted an independent certified fraud investigator to conduct periodic reviews for compliance with fraud prevention policies at least semiannually but beginning quarterly through 2025.

View Audit 371153

Finding 1161075 (2024-003)

Material Weakness 2024

Center for Abuse and Rape Emergencies of Charlotte County INC

FL

Reporting Significant Deficiency

Management concurs. Procedures have been established to ensure timely submission of the Single Audit Reports and SF-SAC forms. Internal deadlines will be implemented to allow adequate time for audit completion and compliance with the Uniform Guidance.

View Audit 371063

Finding 1161069 (2024-005)

Material Weakness 2024

Lincoln County

OR

Reporting Significant Deficiency Internal Control / Segregation of Duties

Condition: The County did not report project obligations or expenditures or provide a project description for funds spent under the revenue loss eligable use catagory. Cause: This condition appears to be the result of a misunderstanding of what was required by the Compliance and Reporting Guidance. ...

Condition: The County did not report project obligations or expenditures or provide a project description for funds spent under the revenue loss eligable use catagory. Cause: This condition appears to be the result of a misunderstanding of what was required by the Compliance and Reporting Guidance. Auditor Recommendation: We recommend that the County implement policies, procedures and internal controls to ensure that all required reporsts are submitted correctly and accurately and evidence of the submission is retained. Plan of Action: The Finance department will provide education to the other departments on which categories and what sort of expected documentation is needed for expenditures under this program and verify that they are appropriated to the correctly related funds. Finance staff will follow up with the departments prior to year end to ensure we have what documentation is needed, properly recorded. Date of implementation: Immediately and ongoing.

View Audit 371039

Corrective Action Plans

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