Corrective Action Plans

Finding 1157504 (2024-002)

Material Weakness 2024

CA

Subrecipient Monitoring Reporting

We are taking immediate, multi-layered action to strengthen financial stability and restore a positive operating balance. The Board of Directors is establishing an emergency fundraising committee to raise $1 million over the next nine months. The committee is composed of current and former board mem...

We are taking immediate, multi-layered action to strengthen financial stability and restore a positive operating balance. The Board of Directors is establishing an emergency fundraising committee to raise $1 million over the next nine months. The committee is composed of current and former board members, as well as long-standing influential supporters, who have a provden ability to mobilize resources quickly. In parallel, we are convening a staff leadership committee composed of the organization's most experienced and innovative staff to design and advance high-quality proposals to private foundations, building on our strong track record of successful grant-making partnerships.

View Audit 369724

Finding 1157503 (2024-001)

Material Weakness 2024

Public Health Advocates

CA

Subrecipient Monitoring Reporting

The untimely completion of bank reconcilations during the audit period was due to changes in staffing and a transition to a new credit card provider, which created delays in the reconcilation process. To address this, the organization has implemented a calendar-based tracking system to ensure that a...

The untimely completion of bank reconcilations during the audit period was due to changes in staffing and a transition to a new credit card provider, which created delays in the reconcilation process. To address this, the organization has implemented a calendar-based tracking system to ensure that all reconciliations are completed and documented promptly each month. In addition, reconcilation responsibilities have been reassigned and reinforced through updated financial procedures. Managment believes that these steps will ensure reconciliations are completed within the required timeframe moving forward and the risk of untimely reconciliations will be mitigated.

View Audit 369724

Finding 1157496 (2024-001)

Material Weakness 2024

North Pacific Fishery Management Council

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Special Tests & Provisions § 200.318 § 200.327

Finding # 2025-001 Type: Immaterial noncompliance U.S. Department of Commerce, National Oceanic and Atmospheric Administration Assistance Listing #11.441 Finding: The Organization’s fiscal policies and procedures do not meet the required federal standards for procurement set out at 2 CFR sections 20...

Finding # 2025-001 Type: Immaterial noncompliance U.S. Department of Commerce, National Oceanic and Atmospheric Administration Assistance Listing #11.441 Finding: The Organization’s fiscal policies and procedures do not meet the required federal standards for procurement set out at 2 CFR sections 200.318 through 200.327. The Organization's procurement policy must have documented procurement procedures, consistent with state, local, and tribal laws and regulations for the acquisition of property or services required under a federal award or subaward. The Organization should maintain records sufficient to detail the history of procurement. Corrective Action: Management will work on revising the Organization’s procurement policies to incorporate the necessary provisions. Anticipated Completion Date December 2025

View Audit 369715

Finding 1157453 (2024-003)

Material Weakness 2024

Urban Sustainability Directors Network

NC

Subrecipient Monitoring § 200.332

The Organization recognizes that subrecipient agreements must include all elements required by 2 CFR 200.332(b)(1). To address this, management will update the standard subrecipient agreement template to incorporate each required element and will adopt a checklist to be used during the agreement dra...

The Organization recognizes that subrecipient agreements must include all elements required by 2 CFR 200.332(b)(1). To address this, management will update the standard subrecipient agreement template to incorporate each required element and will adopt a checklist to be used during the agreement drafting and review process to ensure completeness. Staff responsible for preparing and executing subrecipient agreements will receive training on Uniform Guidance requirements. These steps will ensure that all subrecipient agreements fully comply with Federal regulations going forward.

View Audit 369704

Finding 1157447 (2024-005)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Cash Management Subrecipient Monitoring § 200.303 § 200.305

U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...

U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25

View Audit 369689

Finding 1157446 (2024-004)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25

View Audit 369689

Finding 1157418 (2024-001)

Material Weakness 2024

Christian Military Academy, Inc.

PR

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.327

Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was d...

Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was due on January 30, 2025, was submitted late on February 7, 2025. Corrective Action Plan Christian Military Academy, Inc. acknowledges this finding and has implemented corrective measures to ensure compliance with future reporting deadlines: 1. Enhanced Monitoring of PMS Submissions – A reporting calendar with reminders has been established to track all SF-425 deadlines and submission confirmations through the Payment Management System (PMS). 2. Secondary Reviewer – A second staff member has been assigned to review and confirm timely report submissions before each deadline. 3. System Contingency Plan – In the event of PMS malfunctions or access issues, management will immediately notify DHHS/ACF program officers in writing and retain evidence of the communication on or before the due date. 4. Staff Training – Fiscal staff responsible for federal reporting have been trained on the importance of timely submission and the procedures to follow in case of technical issues. Responsible Official Maribel Batista Marrero Christian Military Academy, Inc. Anticipated Completion Date The corrective actions have been implemented as of October 2025 and will remain in place on an ongoing basis.

View Audit 369684

Finding 1157414 (2024-001)

Material Weakness 2024

Partnership4health Community Health Board

MN

Subrecipient Monitoring Cash Management Significant Deficiency § 200.303 § 200.305

Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal poli...

Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal policy where any payment remittance advices' must be responded to and completed within two weeks of receipt to ensure that payments are deposited, and member counties of the CHB are reimbursed for the expenses that were submitted for in a prompt manner. Anticipated Completion Date: August 15, 2025

View Audit 369676

Finding 1157412 (2024-001)

Material Weakness 2024

Denver Health and Hospital Authority

CO

Matching / Level of Effort / Earmarking Subrecipient Monitoring Eligibility § 200.303

FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a man...

FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025

View Audit 369665

Finding 1157403 (2024-005)

Material Weakness 2024

Heart City Health Center, Inc.

IN

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-005: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then...

Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-005: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then or in the incorrect grant period

View Audit 369664 Questioned Costs: $1

Finding 1157367 (2024-005)

Material Weakness 2024

Keystone Restituere Justice Center, Inc.

PA

Subrecipient Monitoring § 200.332

Finding number 2024-005, material weakness in internal controls over compliance – subrecipient monitoring. Recommendation: We recommend that management implement procedures to ensure that all subrecipient agreements include the information required by 2 CFR 200.322. This should include a standardize...

Finding number 2024-005, material weakness in internal controls over compliance – subrecipient monitoring. Recommendation: We recommend that management implement procedures to ensure that all subrecipient agreements include the information required by 2 CFR 200.322. This should include a standardized checklist or template for subaward agreements and periodic reviews to verify compliance. We further recommend the entity implement and document procedures to (1) perform and retain evidence of subrecipient risk assessments, and (2) verify and document whether sub-recipients are subject to the Since Audit and, if so, obtain and review the audit reports for findings related to the federal program. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: KRJC will develop a standardized checklist for all subaward agreements and will conduct semi-annual reviews to verify compliance with that checklist. As part of this updated review, KRJC will perform updated risk assessments with all sub-awardees and will retain evidence of those risk assessments in sub-awardee files. KRJC will also verify and document whether sub-recipients are subject to the single audit, and, if so, obtain and review the audit reports for findings related to the federal program. KRJC will ensure that any existing sub-awardees are reviewed for compliance no later than November 1, 2025. Planned completion date for corrective action plan: November 1, 2025.

View Audit 369651

Finding 1157349 (2024-004)

Material Weakness 2024

Missouri Organic Association

MO

Subrecipient Monitoring § 200.332

Management agrees with the finding. The Organization hired a new Executive Director in the fall of 2024 and has discussed the matter with the Department of Agriculture and legal counsel to ensure compliance requirements are followed.

View Audit 369638

Finding 1157341 (2024-001)

Material Weakness 2024

Journey's End Refugee Services, Inc.

NY

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting

Corrective Action Plan – Single Audit Finding Entity Name: Journey’s End Refugee Services, Inc. Audit Period: For the year Ended December 31, 2024 Finding Reference Number: 19.510 Federal Program: U.S. Refugee Admissions Program 1. Audit Finding Summary (Describe the audit finding and the specific n...

Corrective Action Plan – Single Audit Finding Entity Name: Journey’s End Refugee Services, Inc. Audit Period: For the year Ended December 31, 2024 Finding Reference Number: 19.510 Federal Program: U.S. Refugee Admissions Program 1. Audit Finding Summary (Describe the audit finding and the specific noncompliance identified by the auditor.) Failure to Submit monthly financial reports by the 15th of each month following, resulting in noncompliance with grant agreement. 2. Root Cause (Explain the underlying reasons for the finding, such as process gaps, training issues, or lack of controls.) Lack of process, including a tracking mechanism that identifies due dates and completion dates of all reports due. 3. Corrective Actions: A) Create a report in excel to track grant reports deadlines. B) Weekly review of the report by the Grants and Finance committee. C) Purchase and implementation of grants monitoring software. 4. Monitoring Plan (Describe how the implementation of corrective actions will be monitored and evaluated.) New Chief Financial Officer will review the action items and monitor the progress with the Chief Operating Officer monthly.

View Audit 369618

Finding 1157334 (2024-001)

Material Weakness 2024

Pennsylvania District Attorneys Institute

PA

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Audit Finding: During the 2024 audit, it was noted that there was a miscalculation in the facility use expenses charged to grants. While the error was not material, it highlights a need for improved oversight to prevent future errors. Root Cause: The spreadsheet used to calculate facility use expens...

Audit Finding: During the 2024 audit, it was noted that there was a miscalculation in the facility use expenses charged to grants. While the error was not material, it highlights a need for improved oversight to prevent future errors. Root Cause: The spreadsheet used to calculate facility use expenses was not reviewed or verified by a second party prior to posting, which led to a calculation error. Corrective Action: Beginning in Quarter 4 of 2025, the facility use expense calculation spreadsheet will be reviewed and verified by a second staff member prior to submission or charging to grants. The reviewer will sign off (physically or electronically) to confirm accuracy of the calculation and grant allocation. Responsible Parties: Allison Hrestak, COO Tina Fornstrom, Business Manager Implementation Date: October 1, 2025 (start of Q4 2025) Ongoing Monitoring: The COO will conduct periodic spot checks (quarterly) to ensure the review and sign-off process is consistently followed. The Business Manager will conduct monthly reviews on the SALBENT AX workbook and facility use workbook for accuracy. Expected Outcome: This added level of review is expected to prevent future calculation errors, ensure accurate cost allocations to grants, and strengthen internal controls related to expense tracking.

View Audit 369613

Finding 1157332 (2024-004)

Material Weakness 2024

Lawrence County District Board of Health

OH

Procurement, Suspension & Debarment Subrecipient Monitoring

The County will implement procedures to ensure this isn’t an issue in the future.

View Audit 369607

Finding 1157294 (2024-001)

Material Weakness 2024

Town of Southold

NY

Subrecipient Monitoring § 200.332

Finding 2024-001 Audit Finding: In accordance with 2 CFR § 200.332(a) of the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), pass-through entities are required to “clearly identify to the subrecipient” certain information and requir...

Finding 2024-001 Audit Finding: In accordance with 2 CFR § 200.332(a) of the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), pass-through entities are required to “clearly identify to the subrecipient” certain information and requirements at the time of subaward, including the Federal award identification, all compliance requirements, and any additional terms and conditions imposed by the pass-through entity. The Town did not execute a formal subrecipient agreement with Fishers Island Ferry District, to whom federal funds were passed through during the audit period. Specifically, no written agreement was in place outlining the subrecipient’s responsibilities, applicable compliance requirements, or the terms and conditions of the award. Recommendation: We recommend that the Town develop and implement procedures to ensure that formal written subrecipient agreements are executed prior to the disbursement of federal funds. These agreements should contain all elements required by 2 CFR § 200.332(a), including the identification of the federal award, applicable compliance requirements, and any additional terms and conditions. Corrective Action Plan: In coordination with the Supervisor’s office, Town Attorney’s office, and Comptroller’s office, formal subrecipient agreements will be prepared and executed, with adoption of Town Board resolutions, between the Town of Southold and pass-through entities concurrently as Federal grant contracts are awarded, as applicable. Responsible Individual: Albert J. Krupski Jr., Town Supervisor Paul DeChance, Town Attorney Michelle Nickonovitz, Town Comptroller Planned Date of Implementation: Corrective action plan procedures have already been communicated and implemented to ensure that formal written subrecipient agreements with pass-through entities are executed prior to the disbursement of federal funds.

View Audit 369589

Finding 1157284 (2024-002)

Material Weakness 2024

Pierce Mortuary Colleges, Inc.

IL

Student Financial Aid Subrecipient Monitoring Reporting

Actions Taken: The institution has implemented an automated process for Exit Counseling to ensure compliance with Title IV requirements. As of August 2025, the system has been configured to automatically send an exit counseling notification to students when they enter one of the following statuses: ...

Actions Taken: The institution has implemented an automated process for Exit Counseling to ensure compliance with Title IV requirements. As of August 2025, the system has been configured to automatically send an exit counseling notification to students when they enter one of the following statuses: • Withdrawal • Graduation • Less than half-time enrollment System Workflow: When a student’s status changes, the system immediately generates and sends an email alert containing exit counseling instructions and the necessary links for completion. This ensures timely notification without requiring manual tracking by staff. Monitoring and Compliance: • Reports will be reviewed monthly to confirm that all required students received the exit counseling notifications. • Any discrepancies will be immediately investigated and resolved. Outcome: This automation eliminates the manual process previously in place, ensuring 100% notification compliance and greatly reducing the likelihood of future deficiencies in this area.

View Audit 369581

Finding 1157283 (2024-001)

Material Weakness 2024

Pierce Mortuary Colleges, Inc.

IL

Internal Control / Segregation of Duties Student Financial Aid Subrecipient Monitoring

Actions Taken / Planned The institution recognizes the importance of timely processing of Title IV credit balances and refunds. To address the deficiencies identified: 1. Short-Term Action (Current Practice): Effective immediately, all staff are required to submit for processing refunds within 24 ho...

Actions Taken / Planned The institution recognizes the importance of timely processing of Title IV credit balances and refunds. To address the deficiencies identified: 1. Short-Term Action (Current Practice): Effective immediately, all staff are required to submit for processing refunds within 24 hours of identifying a credit balance. Staff will also promptly correct any errors discovered during the reconciliation process. o Monitoring: Supervisors will conduct weekly reviews to ensure compliance with this 24-hour policy. o Training: Refresher training on Title IV credit balance processing has been provided to all relevant staff as of September 2025. o Instead of one ‘check run’ per week, numerous ‘check runs’ may be necessary to ensure 14 day window is met. 2. Long-Term Action (System Integration and Automation): The institution is actively working to integrate QuickBooks into our Student Information System (SIS) to automate Title IV and refund documentation. o This integration will streamline the reconciliation process, reduce manual errors, and ensure consistent, timely processing of refunds. o Projected Completion Date: Implementation and full automation are expected to be completed within 9–12 months, with a target date of September 2026. Expected Outcome: These measures will ensure timely and accurate processing of Title IV credit balances, improve compliance, and reduce the risk of future findings.

View Audit 369581

Finding 1157227 (2024-004)

Material Weakness 2024

Community Housing Solutions

OH

Subrecipient Monitoring Cash Management Significant Deficiency

Management will implement a dual-review process for payroll submissions, requiring both supervisor approval of timecards and accounting verification against payroll system reports. Supervisors and payroll staff will undergo training on compliance requirements. Ongoing random spot checks will be perf...

Management will implement a dual-review process for payroll submissions, requiring both supervisor approval of timecards and accounting verification against payroll system reports. Supervisors and payroll staff will undergo training on compliance requirements. Ongoing random spot checks will be performed to ensure consistency and accuracy, and to confirm compliance.

View Audit 369522

Finding 1157225 (2024-003)

Material Weakness 2024

Community Housing Solutions

OH

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Management will enforce a standardized reimbursement packet review checklist, requiring documented approval prior to submission. All reimbursement packets will be stored electronically in a central repository. Training will be provided to all accounting staff on documentation standards. Periodic sup...

Management will enforce a standardized reimbursement packet review checklist, requiring documented approval prior to submission. All reimbursement packets will be stored electronically in a central repository. Training will be provided to all accounting staff on documentation standards. Periodic supervisory reviews will be performed to confirm compliance.

View Audit 369522

Finding 1157223 (2024-001)

Material Weakness 2024

New Beginnings

WA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Finding Reference Number: 2024-001 – Internal Control over Special Tests and Provisions Description of Finding: Documentation of the rent reasonableness determination could not be located for one program participant. Statement of Concurrence or Nonconcurrence: There is no disagreement with this find...

Finding Reference Number: 2024-001 – Internal Control over Special Tests and Provisions Description of Finding: Documentation of the rent reasonableness determination could not be located for one program participant. Statement of Concurrence or Nonconcurrence: There is no disagreement with this finding. Corrective Action: Going forward, management will incorporate rent reasonableness determination procedures into the purchase request form checklist for all payments for rent assistance. Projected Completion Date: December 31, 2025

View Audit 369520 Questioned Costs: $1

Finding 1157218 (2024-003)

Material Weakness 2024

Clark County

IN

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.332 § 200.501

Finding 2024-003 - Subrecipient Monitoring Contact Person Responsible for Corrective Action: Danny Yost Contact Phone Number: 812-285-6221 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will obtain all subrecipient audit reports and forma...

Finding 2024-003 - Subrecipient Monitoring Contact Person Responsible for Corrective Action: Danny Yost Contact Phone Number: 812-285-6221 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County will obtain all subrecipient audit reports and formally document their review of each subrecipient's audit report. Anticipated Completion Date: October 2025

View Audit 369511

Finding 1157181 (2024-001)

Material Weakness 2024

Skagit County

WA

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

We agree with the above mentioned finding. All vendors were checked and none of the vendors paid with federal funds were suspended or disbarred but no documentation was maintained. For the subrecipient monitoring calls were made and inquiry on an ongoing basis but no documentation was maintained the...

We agree with the above mentioned finding. All vendors were checked and none of the vendors paid with federal funds were suspended or disbarred but no documentation was maintained. For the subrecipient monitoring calls were made and inquiry on an ongoing basis but no documentation was maintained there as well. Policies have been put into place for suspension and debarment to be included in all contracts and those vendors with no contracts a search for suspension and debarment will take place before any purchases. Policies have also been put into place to have a uniform spreadsheet to document the monitoring of all subrecipients.

View Audit 369495

Finding 1157180 (2024-001)

Material Weakness 2024

The Carmelite System, Inc.

NY

Internal Control / Segregation of Duties Subrecipient Monitoring Significant Deficiency § 200.303 § 200.403

To whom it may concern: The Carmelite System, Inc. and Affiliates 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 as...

To whom it may concern: The Carmelite System, Inc. and Affiliates 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. FINDING – FEDERAL AWARD PROGRAM AUDITS 2024-001 Federal Agency: U.S. Department of Homeland Security Federal Program Title: Federal Emergency Management Agency Disaster Grants Assistance Listing Number: 97.036 Federal Award Number and Year: 4496DR 2024 Pass-Through Agency: State of Massachusetts Pass-Through Number: CTFEMA4496STPAT00971 Criteria or Specific Requirement: In accordance with 2 CFR §200.403(g), to be allowable under federal awards, costs must be adequately documented. Additionally, 2 CFR §200.303 requires non-federal entities to establish and maintain effective internal control over the federal award that provides reasonable assurance that the entity is managing the award in compliance with federal statutes, regulations, and the terms and conditions of the award. Condition: During testing of expenditures under the FEMA grant, the System was unable to provide documentation showing approval of an invoice dated May 2020. This invoice was selected as part of the single audit sample. The lack of approval documentation represents a deficiency in internal controls over compliance with federal requirements. Questioned Costs: None. Context: The invoice in question was incurred in May 2020, prior to the implementation of the Acumatica AP approval workflow. In June 2020, the facility transitioned to Acumatica, which provides electronic tracking of invoice approvals. Cause: At the time of the expenditure, the facility did not have a centralized or electronic approval process in place. Approval documentation was maintained manually and was not retained or accessible during the audit. Effect: The absence of approval documentation for the invoice creates a risk that expenditures may not be properly reviewed or authorized, potentially leading to noncompliance with federal requirements. Although the cost was ultimately deemed allowable, the control deficiency could impact future compliance if not addressed. Recommendation: We recommend that the System ensure all expenditures under federal awards are supported by documented approvals. For legacy transactions, efforts should be made to retain or reconstruct approval documentation where feasible. Continued use and monitoring of the Acumatica system should be maintained to ensure compliance going forward. Planned Corrective Actions: Management agrees with the finding. The invoice in question was incurred during an emergency response period prior to the implementation of the Acumatica system. While approval was likely obtained at the time, documentation was not retained. With the implementation of the Acumatica AP approval process in June 2020, the System has taken appropriate steps to address the finding and enhance internal controls over invoice approvals. Name of contact person responsible for corrective action: Corrinne Schindler

View Audit 369486

Finding 1157173 (2024-001)

Material Weakness 2024

Genesis Homes, Inc.

SC

Eligibility Subrecipient Monitoring HUD Housing Programs

Corrective Action: The finding was a result of prior staff that was replaced in the current fiscal year. Management has designated a resident intake and compliance manager to be responsible for monitoring tenant recertification schedule across all HOME-assisted unites. Any exceptions will be correct...

Corrective Action: The finding was a result of prior staff that was replaced in the current fiscal year. Management has designated a resident intake and compliance manager to be responsible for monitoring tenant recertification schedule across all HOME-assisted unites. Any exceptions will be corrected immediately and reported to management.

View Audit 369480

Corrective Action Plans

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