Corrective Action Plans

Finding 1155663 (2024-001)

Material Weakness 2024

AL

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of tim...

2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of time spent on a grant monthly. These personnel have been informed of the proposed process and trained to promote consistent and accurate reporting relative to federal standards Anticipated completion date: October 2025 Contact person responsible for corrective action: Russ Chambliss

View Audit 367937

Finding 1155651 (2024-001)

Material Weakness 2024

The National Dry Bean Council Incorporated

OR

Internal Control / Segregation of Duties Significant Deficiency § 200.303

FINDING 2024-001 Planned Corrective Action USDBC management acknowledges finding 2024-001 made by Rood & Dinis, LLP during its financial statement audit for the fiscal year ended December 31, 2024. USDBC will submit a revised Fraud Prevention Program to FAS for approval. USDBC believes that their cu...

FINDING 2024-001 Planned Corrective Action USDBC management acknowledges finding 2024-001 made by Rood & Dinis, LLP during its financial statement audit for the fiscal year ended December 31, 2024. USDBC will submit a revised Fraud Prevention Program to FAS for approval. USDBC believes that their current internal control framework is appropriately designed to mitigate fraud. Responsible Party Danny Raulerson, Executive Director Completion Date September 30, 2025

View Audit 367915

Finding 1155650 (2024-001)

Material Weakness 2024

D'youville Elderly Housing Corporation

MA

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

To whom it may concern: D’Youville Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assig...

To whom it may concern: D’Youville Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Supportive Housing for the Elderly (Section 202) Assistance Listing Number: 14.157 Award Period: Year ended December 31, 2024 Criteria: Federal regulations require that projects make required deposits to the replacement reserve account monthly. Condition: In May 2024, the Project’s required monthly replacement reserve amount was increased. Questioned Costs: $661 Context: It was noted that eight of the twelve monthly deposits to the replacement reserve account were below the required monthly deposit amount. Effect: The replacement reserve account was underfunded. Recommendation: We recommend that funding amounts to the replacement reserve account be reviewed by an appropriate level of management, especially when there are changes to the required monthly deposit. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will implement procedures to ensure proper review of the monthly deposits. The $661 shortfall was deposited to the replacement reserve account in 2025. Name of contact person responsible for correction action: Corrinne Schindler.

View Audit 367901 Questioned Costs: $1

Finding 1155648 (2024-001)

Material Weakness 2024

D'youville Senior Living, Inc.

MA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

To whom it may concern: D’Youville Senior Living, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in t...

To whom it may concern: D’Youville Senior Living, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Supportive Housing for the Elderly (Section 202) Assistance Listing Number: 14.157 Award Period: Year ended December 31, 2024 Criteria: Federal regulations require that project funds may only be used for expenses that are reasonable and necessary to the operation of the project. Condition: The Project’s internal controls related to cash disbursements state that expenditures be authorized to ensure they relate to that project and shared costs are properly allocated between the sole member’s projects. Questioned Costs: $24,331 Context: It was noted that there were five instances where cash disbursements were made to the project’s related parties for costs allocated to the project that were subsequently discovered to be erroneously charged to the project. Effect: Expenses were paid out of project funds that did not relate to the project. Recommendation: We recommend that all allocated intercompany costs be reviewed by an appropriate level of management before being charged to the project. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will implement procedures to ensure proper allocation and documentation of intercompany transactions. $15,163 has been returned to the project as of December 31, 2024 and the remaining balance was returned in 2025. Name of contact person responsible for corrective action: Corrinne Schindler.

View Audit 367899 Questioned Costs: $1

Finding 1155629 (2024-003)

Material Weakness 2024

Town of Bellingham, Massachusetts

MA

Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-003 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Complianc...

Finding 2024-003 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs Criteria: Where employees work solely or partially on a single Federal program or cost objective, their salaries or wages must be supported by periodic certification that the employee worked on these programs for the period covered by the programs. The certifications should be prepared at least semi-annually, and should be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Condition: During our test of controls over compliance with time and effort certifications the Town was not able to provide evidence that the required certifications of time and effort for those employees whose time was spent either completely or partially spent on these programs was performed as required by Uniform Guidance. Questioned Costs: Unknown Context: During our test of payroll transactions of the major programs (Education Stabilization Fund and Special Education Cluster) it was noted that the time and effort certifications for the employees tested were not singed by the supervisory official. Effect: The Town was not in compliance with the time and effort certification requirements. Cause: The District has made great efforts to ensure time and effort certification compliance. While the District is having the Supervisor execute and approve timesheets for payment, the Supervisor’s signature was omitted from the Time & Effort Certification. The District is issuing Time & Effort Certifications to all employees working and being paid from a Federal grant semi-annually, including sending Certified Mail, Return Receipt documentation to former employees. Identification as a Repeat Finding: 2023-004 Recommendation: We recommend the Town of Bellingham follow procedures to ensure that semi-annual certifications and/or monthly certifications are prepared and signed by either the employees and/or supervisory official having first-hand knowledge of the work performed by the employees in a timely manner in order to comply with the time and effort certification requirement. Responsible for Corrective Plan: Director of Finance Estimated Completion Date: January 1, 2026 Action Taken: The District will incorporate the Supervisor’s signature to all Time & Effort Certifications immediately upon this finding, January 1, 2026.

View Audit 367881

Finding 1155621 (2024-001)

Material Weakness 2024

Downstreet Housing and Community Development, Inc.

VT

Allowable Costs / Cost Principles Reporting Significant Deficiency

Federal program: FAL 21.027, Coronavirus State and Local Fiscal Recovery Funds Significant deficiency Criteria: Management is responsible for designing, implementing, and maintaining effective internal controls to ensure accurate financial reporting and safeguard assets. Downstreet’s internal contro...

Federal program: FAL 21.027, Coronavirus State and Local Fiscal Recovery Funds Significant deficiency Criteria: Management is responsible for designing, implementing, and maintaining effective internal controls to ensure accurate financial reporting and safeguard assets. Downstreet’s internal control procedures require the Vermont Housing Improvement Program (VHIP) expenditure tracking spreadsheets to be updated and reviewed prior to disbursements of VHIP grant funds to grant awardees. Condition: During testing of the VHIP grant fund disbursement process, the auditor found that the control designed to ensure all payments were supported by adequate documentation was not operating effectively. Corrective action plan: Downstreet has revised the VHIP approval process to ensure invoices and tracking sheets are verified before disbursement, with documentation uploaded to client files. Staff roles within the Homeownership Center have been realigned to improve accuracy, and a new staff member now supports the program, with responsibilities that include auditing files at disbursement to confirm completeness. All corrective actions have been implemented as of September 2025. Responsible official: Schuyler Anderson, CFO/COO

View Audit 367878

Finding 1155546 (2024-007)

Material Weakness 2024

Itasca County

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency

REPORTING (PRIOR YEAR 2023-007) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community H...

REPORTING (PRIOR YEAR 2023-007) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2405MN5ADM, 2405MN5MAP Compliance Requirement Affected: Reporting Award Period: Year Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that the County ensure each report is reviewed by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure each report is reviewed by someone other than the preparer. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025

View Audit 367845

Finding 1155538 (2024-008)

Material Weakness 2024

Itasca County

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency

SUSPENSION AND DEBARMENT Federal Agency: U.S. Department of the Treasury Federal Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Assistance Listing Number: 21.027 Pass-Through Agency: Not applicable, direct Federal Award Identification Number and Pass-Through Number:...

SUSPENSION AND DEBARMENT Federal Agency: U.S. Department of the Treasury Federal Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Assistance Listing Number: 21.027 Pass-Through Agency: Not applicable, direct Federal Award Identification Number and Pass-Through Number: Not applicable, direct Compliance Requirement Affected: Suspension and Debarment Award Period: Year Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: We recommend the County review their procedures to ensure they are following their policy that requires all suspension and debarment checks to be retained and follow federal guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure each report is reviewed by someone other than the preparer. Name of the contact person responsible for corrective action: Gail Guck, Accounting Manager Planned completion date for corrective action plan: December 31, 2025

View Audit 367845

Finding 1155511 (2024-004)

Material Weakness 2024

Shatterproof A Nonprofit Corporation

CT

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Cash Management Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Shatterproof implement contro...

Cash Management Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Shatterproof implement controls to ensure anadequate review process is in place to review reimbursement requests to determine anddocument the request is properly supported and in compliance with the grant agreement. Explanation of disagreement with audit finding: There is no disagreement with the auditfinding. Action taken in response to finding: State Directors review and approve all invoices prior to submission to the state. Name of the contact person responsible for corrective action: Young Kim Planned completion date for corrective action plan: January 1st, 2025

View Audit 367790

Finding 1155510 (2024-003)

Material Weakness 2024

Shatterproof A Nonprofit Corporation

CT

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

Allowable Costs – Nonpayroll Disbursements Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Sh...

Allowable Costs – Nonpayroll Disbursements Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Shatterproof ensure internal controls are in place and operating effectively so that when changes in vendors involved in the financial reporting process occur there is an evaluation of the electronic evidence of the performance of internal controls and other data to ensure needed documentation is retained or continues to be accessible in line with their record retention policies and requirements of the grant agreements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In April 2024, Shatterproof implemented Bill Spend & Expense (Divvy), a cloud-based platform designed to automate receipt tracking, provide a clear audit trail for expense coding, and support a streamlined approval workflow. Name of the contact person responsible for corrective action: Young Kim Planned completion date for corrective action plan: 4/1/2024

View Audit 367790 Questioned Costs: $1

Finding 1155461 (2024-002)

Material Weakness 2024

Aid Upstate

SC

Cash Management Significant Deficiency

Contact Person: Tracy Carr, Rajee Rao Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: A schedule has been developed which has enabled the submission of the monthly grant reim...

Contact Person: Tracy Carr, Rajee Rao Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: A schedule has been developed which has enabled the submission of the monthly grant reimbursement reports by the due date. It has required a group effort by the entire staff and the individual members of the finance team in the responsibilities to meet the deadline. The continued use of this schedule has proven to keep the process on track and allow the organization to adhere to the grant deadlines. Completion Date: Beginning June 1, 2024 and thereafter.

View Audit 367743

Finding 1155384 (2024-001)

Material Weakness 2024

Cheyenne Health and Wellness Center Doing Business As Healthworks

WY

Reporting Allowable Costs / Cost Principles Material Weakness

2024-001 Reporting Corrective action planned: For employee expenses calculation for the Uniform Data System (UDS) reporting annual accrued PTO calculations will not be used. Anticipated completion date: Complete date of this corrective action plan is immediate. The next UDS report is due 2/15/2026. ...

2024-001 Reporting Corrective action planned: For employee expenses calculation for the Uniform Data System (UDS) reporting annual accrued PTO calculations will not be used. Anticipated completion date: Complete date of this corrective action plan is immediate. The next UDS report is due 2/15/2026. For the 2025 UDS report accrued PTO for employees will not be included employee expenses. Contact person responsible for corrective action: Margaret Cox CFO mcox@wyhealthworks.org

View Audit 367639

Finding 1155370 (2024-004)

Material Weakness 2024

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties Significant Deficiency

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1...

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1, 2025

View Audit 367616

Finding 1155369 (2024-003)

Material Weakness 2024

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties HUD Housing Programs

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Ac...

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: September 18, 2025

View Audit 367616

Finding 1155367 (2024-001)

Material Weakness 2024

Suffolk County, New York

NY

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant...

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant eligibility, nor did it ensure that non-long-term care program participants were properly classified. Sixty participants were selected for testing and the following exceptions were noted: • For five of sixty participants selected for testing, the County was unable to provide documentation that a program supervisor had approved the application. • For one of sixty participants selected for testing, the County was unable to provide a signed participant application. • For one of sixty participants selected for testing, upon reapplication and further documentation, a long-term care case was determined to be non-long-term care, but the County did not make this change and the participant was misclassified. Questioned Costs Undetermined. Recommendation The County should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility. It should also enhance procedures and internal controls to ensure participants are correctly classified as long-term care versus non-long-term care. Corrective Action Plan The Medicaid Division will continue to emphasize the need for signatures at both levels of eligibility Examiner level and Quality Control Examiner II or higher level. This will be stressed at all appropriate training for not only new staff but current staff as well. As far as the “misclassified” the Consumer left nursing home during a period when documentation requirements were waived, due to the Public Health Emergency (COVID-19); The coverage was correct, but coding indicated the need for Long Term Care. This code does not allow or authorize any services on its own, and as such, no inappropriate services were authorized. Even though this has little impact the Division will continue to stress to staff and supervisors the need to properly code cases. NYS DOH is in the process of transitioning away from LDSS 3209 forms and automating the process; we will continue to work with our state partners to assist in this transition when it becomes available to us. This transition should mitigate these type of situations. Action Date September 5, 2025 Final Implementation Date December 31, 2025 Name And Phone No. Of Person Responsible For Implementation James Sluder – 631-854-5830

View Audit 367602

Finding 1155354 (2024-002)

Material Weakness 2024

Goodwill Industries of Michiana, Inc.

IN

Cash Management Significant Deficiency Internal Control / Segregation of Duties

2024-002 PAYROLL POPULATION The Organization uses general ledger detail to create draws to submit reimbursement claims. Some reimbursements are for payroll expenses that are paid through a separate system. The Organization could not reconcile the general ledger to the payroll software detail used to...

2024-002 PAYROLL POPULATION The Organization uses general ledger detail to create draws to submit reimbursement claims. Some reimbursements are for payroll expenses that are paid through a separate system. The Organization could not reconcile the general ledger to the payroll software detail used to submit reimbursements. Recommendation: The Organization should perform and maintain monthly reconciliations of the payroll software, general ledger, and draw detail that all agree. Action Taken: The Organization was billing the grantor for payroll fees, the additional fees for each employee or contract that participated in the grant. Originally, the funds were coded to payroll (compensation) expenses, which generated a discrepancy between the Payroll Register and the General Ledger. The unemployment expense was also coded to benefits, which created a variance between the payroll register (generated from payroll software) and the general ledger. Going forward, the trail balance and general ledger will be reconciled to the draw request. Additionally, the team has been trained in how to properly code these expenses. Contact Person: Shire Kuch Effective Date: 25 September 2025.

View Audit 367596

Finding 1155330 (2024-005)

Material Weakness 2024

City of Muskegon Heights

MI

Allowable Costs / Cost Principles Cash Management Reporting

2024-005 – Reporting (Repeat Finding) Auditor Description of Condition and Effect. While the City performed the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting for each quarter of 2024, the Project and Expenditure reports for the first three quarters of 2024 did not ...

2024-005 – Reporting (Repeat Finding) Auditor Description of Condition and Effect. While the City performed the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting for each quarter of 2024, the Project and Expenditure reports for the first three quarters of 2024 did not report any current period expenditures. Rather, the cumulative expenditures for the year were included in the fourth quarter Project and Expenditure report. In addition, the Project and Expenditure reports for the third and fourth quarters of 2024 were not filed within the required timeframe. As a result of this condition, the City did not comply completely with the reporting requirements of the Coronavirus State and Local Fiscal Recovery Funds grant. Auditor Recommendation. We recommend that the City review the reporting requirements for each grant and complete all required reporting as required under the terms of the grant agreement. Corrective Action. City staff has accessed these reports and attempted to submit all required reports. Ongoing reports have been submitted on time. Assistance will be sought with federal agencies as necessary. Responsible Person. Finance Director Anticipated Completion Date. December 31, 2025

View Audit 367568

Finding 1155277 (2024-002)

Material Weakness 2024

Sibley County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A ...

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A at least 2 times per month to identify outstanding verifications for MA cases in METS. This will identify specific cases missing SSN verifications. Anticipated Completion Date: The MNCM 220A reported is generated quarterly. The anticipated completion date is October 6th for the next quarterly report.

View Audit 367509

Finding 1155276 (2024-001)

Material Weakness 2024

Health Education Learning Project

TX

Allowable Costs / Cost Principles Reporting Significant Deficiency

This serves as a response to your audit memo regarding Finding 2024-001 Allowable Costs - Significant deficiency in internal controls over compliance in Section II - Federal Award Findings and Questioned Costs. The organization concurs with the finding and has made corrective actions effective immed...

This serves as a response to your audit memo regarding Finding 2024-001 Allowable Costs - Significant deficiency in internal controls over compliance in Section II - Federal Award Findings and Questioned Costs. The organization concurs with the finding and has made corrective actions effective immediately to ensure the deficiency no longer occurs. Specifically, an active confirmation of billing amounts matching the general ledger from the CPA to the CEO has been added to our internal controls. Previously, the CPA only contacted the CEO if there was a need for correction. As stated in the audit report, this error occurred during the transition time between our contracted CPA and the new CFO beginning. Neither the CPA nor the CFO informed the CEO of the discrepancy between the billing and general ledger amounts, and therefore no correction was made or even looked for. This finding identified a flaw in our existing internal controls if the CPA does not complete the final validation process. Below are the internal control procedures for grant billing that were in place at the time of the error with the new addition in red: • All time sheets are forwarded to the CPA. • The CPA, or their designee, develops a payroll report utilizing the timesheets to allocate payroll by work function. • The payroll report is forwarded to the CEO for approval and billing purposes. • The detailed monthly billing is sent to the CPA for verification that the billing matches the general ledger. • The CPA will send an email to the CEO either confirming the amounts billed match the general ledger or identifying the need for a billing/general ledger correction. • Any discrepancies between billing and the general ledger are corrected via a corrected billing being submitted or a general ledger journal entry being made to reallocate costs. The organization is confident the above augmented internal control procedures will provide the necessary oversight and quality control measures needed to ensure the identified deficiency from recurring. The CEO is responsible for monitoring and ensuring compliance with the revised internal control measures.

View Audit 367506

Finding 1155259 (2024-003)

Material Weakness 2024

Boys & Girls Club of Brazoria County

TX

Reporting Significant Deficiency

Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: Boys & Girls Club was unable to produce a report from its general ledger system that supported the expenditures reported in the schedule of expenditures of federal awards. Recommendation: Establish policies an...

Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: Boys & Girls Club was unable to produce a report from its general ledger system that supported the expenditures reported in the schedule of expenditures of federal awards. Recommendation: Establish policies and procedures to record all federal expenditures in the general ledger system by class code in order to generate a report of expenditures by grant. Planned corrective action: Government funded transactions will be recorded in our general ledger in a manner which facilitates reporting by federal award. Management will review grant reports monthly to ensure transactions are properly recorded. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.

View Audit 367470

Finding 1155257 (2024-004)

Material Weakness 2024

Boys & Girls Club of Brazoria County

TX

Cash Management Allowable Costs / Cost Principles Significant Deficiency

Finding #2024-004 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found one instance of reimbursement by the grantor approximately five months before payment was made to the vendor. Recommendation: Strengthen controls to ensure that invo...

Finding #2024-004 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found one instance of reimbursement by the grantor approximately five months before payment was made to the vendor. Recommendation: Strengthen controls to ensure that invoices are paid in a timely manner to ensure federal reimbursements are not being held for an excess period of time. Planned corrective action: As part of our enhanced review of government transactions, we will be mindful that federal reimbursement requests should only include expenses that have been disbursed or have been accrued with expectation of disbursement in a timely manner. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.

View Audit 367470

Finding 1155255 (2024-002)

Material Weakness 2024

Boys & Girls Club of Brazoria County

TX

Cash Management Reporting Significant Deficiency

Finding #2024-002 – Significant Deficiency and Other Noncompliance. Condition and context: Same as finding reported as #2024-001. Recommendation: Same as finding reported as #2024-001. Planned corrective action: Year-end closing policies and procedures will be modified to ensure grant transactions a...

Finding #2024-002 – Significant Deficiency and Other Noncompliance. Condition and context: Same as finding reported as #2024-001. Recommendation: Same as finding reported as #2024-001. Planned corrective action: Year-end closing policies and procedures will be modified to ensure grant transactions are reviewed, reconciled, and include applicable accruals. Management will review grant reports monthly to ensure transactions are properly recorded. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2025.

View Audit 367470

Finding 1155204 (2024-003)

Material Weakness 2024

Wilkes-Barre/scranton International Airport

PA

Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management

Finding 2024-003 Condition: As part of our audit of the Federal Aviation Administration Program, it was noted that the Airport did not adopt written policies/procedures surrounding certain areas to comply with the requirements of the Uniform Guidance Corrective Action Plan: Corrective Action Planned...

Finding 2024-003 Condition: As part of our audit of the Federal Aviation Administration Program, it was noted that the Airport did not adopt written policies/procedures surrounding certain areas to comply with the requirements of the Uniform Guidance Corrective Action Plan: Corrective Action Planned: Airport Finance department has adopted written policies and procedures to satisfy Uniform Guidance Name(s) of Contact Person(s) Responsible for Corrective Action: Director of Finance Anticipated Completion Date: August 1, 2025

View Audit 367446

Finding 1155070 (2024-003)

Material Weakness 2024

City of Gary

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Respon...

FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Response to Finding: Segregation of Duties and Oversight of Required FFATA Reporting To address the finding related to segregation of duties and the lack of an established oversight or review process for required reports submitted under the Federal Funding Accountability and Transparency Act (FFATA), the Department of Community Development will implement a formalized review process. This process will include the use of a signature form to document the roles of the: • Preparer – responsible for compiling the report, • Reviewer – responsible for independently verifying the report’s accuracy, and • Submitter – responsible for final submission of the verified report. All parties will be required to sign the form upon completion of their respective responsibilities, ensuring accountability, verification of data accuracy, and compliance with FFATA reporting requirements. Anticipated Completion Date: February 2026

View Audit 367388

Finding 1155031 (2024-001)

Material Weakness 2024

Watts Healthcare Corporation

CA

Questioned Costs Subrecipient Monitoring Cash Management

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients a...

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients above 200% FPG, with no discount applied. • Patient Reclassification – All previously misclassified patients are being reclassified to full-pay status. Prior balances will be reconciled in accordance with HRSA requirements and organizational policy. • Staff Training – Front office, billing, and eligibility staff will undergo mandatory refresher training on the Sliding Fee Discount Program, income verification, and proper application of the fee schedule. Additional refresher training on Self-Pay procedures will be led by the Director of Member Services. • Ongoing Monitoring – A quarterly compliance audit of the sliding fee program has been implemented. Results will be reviewed by management, with corrective actions taken as necessary. • Transparency & Communication – Patients will be notified in writing of their payment category. Appeals or questions will be addressed per organizational policy and HRSA guidelines. • Financial Remediation – Refunds will be issued to patients who were overcharged. For cases involving undercharges, the outstanding balance will be applied to the patient’s next visit. Personnel responsible for implementation: Jose Juarez, Director of Member Services Date of implementation: August 31, 2025

View Audit 367364 Questioned Costs: $1

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