Corrective Action Plans

Finding 574604 (2024-002)

None 2024

IL

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

FINDING NUMBER: 2024-002 Condition: During the audit it was noted that management had difficulties providing expenditure reports for the federal grants. It was also noted that for the SLFRF grant, performance reports that are due annually, 30 days following the end of the period, were submitted late...

FINDING NUMBER: 2024-002 Condition: During the audit it was noted that management had difficulties providing expenditure reports for the federal grants. It was also noted that for the SLFRF grant, performance reports that are due annually, 30 days following the end of the period, were submitted late in the case of the 2024 grant. Plan: Management will monitor grant expenditure reports closely and will improve their control activities to ensure that grant performance reports are filed as required by the grant agreement. Anticipated Date of Completion: As soon as possible – before FY26 year end Name of Contact Person: Mary Ventrella, CPA - Finance Director Management Response: Since the audit, we have evaluated our monitoring procedures and control activities to ensure that grant expenditure reports are readily available and grant performance reports are filed timely.

View Audit 364860

Finding 574463 (2024-004)

Material Weakness 2024

Winner Regional Healthcare Center

SD

Special Tests & Provisions Subrecipient Monitoring Material Weakness

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan:...

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan: The required monthly balance and the actual monthly reserve fund account balance will be presented to the board on a monthly basis for review and approval. Previously only the actual balance and a YES/NO were provided. Starting in August 2025, monthly board packets for approval will now include the required vs actual comparison with a YES/NO of meeting the requirement. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Anticipated Completion Date: August 2025

View Audit 364799

Finding 574462 (2024-001)

None 2024

Adjoin

CA

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302

June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Su...

June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Supportive Services for Veterans Families: CFDA 64.033 b. Criteria: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as tracking administrative expenses charged to the program outside of the general ledger and in other matters noted in licensing reviews. c. Condition: The Organization has failed to comply with grant requirements due to lack of proper tracking of administrative expenses, limited compliance policies including approval over supplemental pay wages, and lack of proper training over verification and documentation processes. d. Response: The organization has been successfully running the SSVF program for 11+ years and tracking/calculating administrative costs utilizing offline Excel spreadsheets since inception which provided a low cost and flexible solution for our accounting team. However, as an outcome of our last SSVF audit and due to the size and scope of our SSVF operations, the VA is requiring Adjoin to cease maintaining offline spreadsheets and ensure that all SSVF grant costs are logged in the general ledger. We're partnering with JMT Consulting (our Sage Intacct solution provider) for their assistance in implementing a new Dynamic Allocation Module to our Sage platform allowing click thru capabilities to all of the administrative costs that hit the grant (not to exceed 10%). We're committed to rolling out this functionality and are excited about the efficiencies it will bring to the team along with ensuring compliance with VA requirements. 2. Prior Year Finding 2023-001 None noted. Contact person responsible for corrective action: Pat Phelan, CFO Completion date: August 31, 2025 If you have any questions regarding this plan, please contact Pat Phelan, CFO, 858- 292-2030, pat.phelan@adjoin.org. Sincerely, Pat Phelan CFO Adjoin

View Audit 364796 Questioned Costs: $1

Finding 574459 (2024-002)

Significant Deficiency 2024

Intertribal Agriculture Council

MS

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.214

Effect: The Organization may be paying subcontractors that are suspended or debarred, which would be unallowable costs. However, none of the 4 subcontractors were suspended or debarred as of the date audit procedures were performed. Recommendation: The auditor recommends that the Organization implem...

Effect: The Organization may be paying subcontractors that are suspended or debarred, which would be unallowable costs. However, none of the 4 subcontractors were suspended or debarred as of the date audit procedures were performed. Recommendation: The auditor recommends that the Organization implement policies and procedures to ensure that all subcontractors and subrecipients of covered transactions are properly verified before entering into transactions, and that this be documented as a control each time it is performed. 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit findings. 2. Action Planned in Response to Finding: The Organization has implemented procedures to verify that subcontractors with goods or services transactions expected to exceed $25,000 are verified before entering into transactions, which will be documented each time. 3. Official Responsible for Ensuring CAP: Kari Jo Lawrence, Chief Executive Officer and Jernon Kelly, Chief Financial Officer are responsible for ensuring corrective action of this deficiency. 4. Planned Completion Date for CAP: December 31, 2025.

View Audit 364795

Finding 574452 (2024-002)

Significant Deficiency 2024

Indiana University Health, Inc. and Subsidiaries

IN

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees...

Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees to the program who were transferred internally. A correction was made to the April 2025 claim to adjust for the amount overclaimed. Indiana University Health strengthened claim review controls to ensure such changes go through additional review before claim submission. Contact Person(s) Responsible for Corrective Action: Christine Smith Completion Date: July 31, 2025

View Audit 364785

Finding 574451 (2024-001)

None 2024

Indiana University Health, Inc. and Subsidiaries

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...

Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A

View Audit 364785

Finding 574175 (2024-001)

Significant Deficiency 2024

East Texas Crisis Center, Inc.

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Procurement, Suspension & Debarment § 200.112 § 200.303 § 200.331 § 200.333 § 200.338

Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allow...

Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.

View Audit 364753

Finding 574149 (2024-001)

None 2024

Medical Debt Resolution, Inc.

NY

Subrecipient Monitoring Reporting

Finding Number: 2024-001 Compliance Requirement: Reporting Programs: United States Department of the Treasury • ALN Number: 21.027 • ALN Name: Coronavirus State and Local Fiscal Recovery Funds • Contract Periods: June 16, 2023 – December 31, 2025 (City of New Orleans, Louisiana); April 1, 2022 - Dec...

Finding Number: 2024-001 Compliance Requirement: Reporting Programs: United States Department of the Treasury • ALN Number: 21.027 • ALN Name: Coronavirus State and Local Fiscal Recovery Funds • Contract Periods: June 16, 2023 – December 31, 2025 (City of New Orleans, Louisiana); April 1, 2022 - December 31, 2026 (City of Toledo, Ohio); August 1, 2024 - September 30, 2026 (County of Orange, Florida) Management’s Corrective Action Plan: The Organization recognizes the importance of timely reporting to its government partners, and has developed a plan to improve the timeliness of progress reporting, which includes: • Establishing a Government Initiatives department to oversee all government projects, as well as enhance operational efficiency and planning to meet the increased reporting demands from the growing number of grants. • Further expanding internal capacity by hiring additional team members - Vice President of Government Affairs (January 2025), Grant Accountant (June 2025), and Grant Initiatives Program Manager (September 2025), as well as other departments that are integral for programmatic delivery - most importantly, debt acquisition and analysis (Associate Vice President of Analytics) to accelerate and optimize the preparation of data for reporting. • Standardizing the various reporting pertaining to government funders. • Preparing, monitoring, and updating the reporting schedule for government funders. • Utilizing new software to facilitate and track fiscal and progress reporting. • Extending standardized timeframe for progress reporting from 45 days to 60 days on government contracts where available. Person(s) Responsible: Chief Operating Officer (performance reporting) and Vice President, Finance & Administration (fiscal reporting) Expected Completion Date: September 30, 2025

View Audit 364723

Finding 574144 (2024-004)

Significant Deficiency 2024

Christmas Valley Domestic Supply District

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.328 § 200.329

Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.

View Audit 364712

Finding 574118 (2024-003)

Material Weakness 2024

Paint Valley Local School District

OH

Subrecipient Monitoring Period of Performance Reporting § 200.328 § 200.344 § 200.502

Management will ensure Federal expenditures are obligated during proper period and reported appropriately.

View Audit 364686

Finding 574104 (2024-001)

Significant Deficiency 2024

Search for Common Ground

DC

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.328

We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took so...

We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took some time before we got the access to all the projects on PMS. We are already tracking both financial and narrative reports from the signing stage of projects, and most of the reports are prepared on time. Going forward, we will further strengthen our backup plans for submission of reports, both online and through email. We will develop a backup plan and strengthen delegation plans for each region during the times when the primary contact is not available

View Audit 364670

Finding 574102 (2024-002)

Significant Deficiency 2024

Search for Common Ground

DC

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting § 200.303

Due to lack of submission date field in Sam.gov system, we agree that we will add an alternate process to document timely submission for subawards reports on Sam.gov. This will be done by downloading the PDF report and confirming through email from Senior compliance officer.

View Audit 364670

Finding 574076 (2024-002)

Material Weakness 2024

City of Palmer, Alaska

AK

Subrecipient Monitoring Material Weakness Reporting

Finding 2024-002 Reporting – Material Weakness in Internal Control over Compliance and Material Noncompliance Corrective Action Implementation Finance will report the subawards to the Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting System. Future internal controls will...

Finding 2024-002 Reporting – Material Weakness in Internal Control over Compliance and Material Noncompliance Corrective Action Implementation Finance will report the subawards to the Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting System. Future internal controls will include a review by the Finance Director and the Controller to evaluate the applicability of grant requirements for all grants that the City receives. Anticipated Completion Date Finance plans to have the FFATA report filed by 9/30/2025.

View Audit 364645

Finding 574075 (2024-001)

Material Weakness 2024

City of Palmer, Alaska

AK

Subrecipient Monitoring

Finding 2024-001 Subrecipient Monitoring – Material Weakness in Internal Control over Compliance and Material Noncompliance Corrective Action Implementation Finance will issue subaward agreements to the organizations that received COSSUP funding during the term of the grant over $30,000. Future inte...

Finding 2024-001 Subrecipient Monitoring – Material Weakness in Internal Control over Compliance and Material Noncompliance Corrective Action Implementation Finance will issue subaward agreements to the organizations that received COSSUP funding during the term of the grant over $30,000. Future internal controls will include a review by the Finance Director and the Controller to evaluate the applicability of grant requirements for all grants that the City receives. Anticipated Completion Date Finance plans to have the subaward agreements issued by 9/30/2025.

View Audit 364645

Finding 574053 (2024-004)

Significant Deficiency 2024

Easter Seals Serving Dc/md/va

MD

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.327

Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automate...

Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automated procurement approval process that allows us to set approval levels for each user and will reduce potential for errant approvals Ensure all new management staff receive and acknowledge the procurement policy

View Audit 364634

Finding 574052 (2024-003)

Significant Deficiency 2024

Easter Seals Serving Dc/md/va

MD

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.510 § 200.518

COO will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly COO will ensure we have written documentation for all federal pass-through funding We have added an experienced grants accountant supervised by the CFO to verify th...

COO will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly COO will ensure we have written documentation for all federal pass-through funding We have added an experienced grants accountant supervised by the CFO to verify the federal nature of all awards and stay current on SEFA and Uniform Guidance

View Audit 364634

Finding 574045 (2024-001)

Significant Deficiency 2024

United Way of Middle Tennessee, INC

TN

Subrecipient Monitoring § 200.332

2024-001: Internal Control Over Compliance with Subrecipient Monitoring and Noncompliance with Subrecipient Monitoring U.S. Department of Health and Human Services; Passed through the State of Tennessee Department of Health: ALN #93.558 Temporary Assistance for Needy Families Management’s Response: ...

2024-001: Internal Control Over Compliance with Subrecipient Monitoring and Noncompliance with Subrecipient Monitoring U.S. Department of Health and Human Services; Passed through the State of Tennessee Department of Health: ALN #93.558 Temporary Assistance for Needy Families Management’s Response: We concur. View of Responsible Officials and Corrective Action: United Way has an Agency Eligibility Review (AER) to ensure an organization is financially sound prior to awarding funding. As part of this process, subrecipients are required to provide their most recent From 990, as well as audited or reviewed financial statements, based on their gross revenue. United Way utilizes the AER as part of subrecipient application process government grants awarded to United Way. Historically, the majority of the government grants awarded to United Way have been for a 12-month period. However, the Temporary Assistance for Needy Families grant represents the first multi-year grant received by United Way from the State. Due to the multi-year nature of this award, United Way initially obtained financial records only after subrecipients entered the program. Going forward, we will review our processes to ensure financial records are collected and reviewed in a timely manner for all multi-year grants. The Senior Director of Innovation & Strategy and the Senior Director of Finance will obtain and review the most recent audited financial statements for the subrecipients. Supporting documentation will be maintained with the grant activity to ensure proper compliance documentation is kept. Name(s) of the Contact Person(s) Responsible for Corrective Action: Rod DeVore and Matt Lim Anticipated Completion Date: September 30, 2025

View Audit 364630

Finding 574019 (2024-002)

None 2024

Housing Initiatives, INC

WI

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rent...

2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rented to eligible low-income households. Complete and accurate income documentation is essential to demonstrate compliance with program eligibility requirements and long-term affordability commitments. Condition: During our review of 34 tenant files for HOME-funded rental units, we noted the following: • 6 files did not contain any income verification documentation • 1 file include income documentation, but it was incomplete and missing required supporting documentation Cause: These issues primarily occurred during a transition in property management. The change in personnel and processes led to a lapse in documentation and inconsistent application of income verification procedures. Effect: Without proper income verification, there is a risk that units may be rented to households that do not meet eligibility requirements. Additionally, the absence of documentation may hinder the Organization’s ability to demonstrate compliance during monitoring or audit reviews. Questioned Costs: Not applicable. Auditor’s Recommendation: We recommend that management strengthen internal controls over the income verification process by: • Implementing a standardized checklist for required documentation • Providing staff training on income verification procedures • Conducting supervisory reviews of all files prior to tenant approval, especially during periods of staff transition Auditee’s Response: Management agrees with the finding and has taken steps to address the issue. Four of the seven identified files have been updated with complete income documentation for 2025, and the remaining three are in process. Contact Person: Brad Hinkfuss Anticipated Completion: 9.30.2025

View Audit 364605

Finding 573967 (2024-001)

Significant Deficiency 2024

Old Pueblo Community Services

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.

View Audit 364575

Finding 573966 (2024-005)

None 2024

Minnesota Farmers Union

MN

Subrecipient Monitoring Reporting § 200.512

Recommendation: The auditee implement procedures to ensure the timely submission of future Single Audit reporting packages to the FAC. This may include establishing an internal deadline well in advance of the federal due date, assigning responsibility to a designated staff member, and monitoring su...

Recommendation: The auditee implement procedures to ensure the timely submission of future Single Audit reporting packages to the FAC. This may include establishing an internal deadline well in advance of the federal due date, assigning responsibility to a designated staff member, and monitoring submission status. Views of Responsible Officials: Management concurs with the finding and has implemented procedures to ensure future submissions to the FAC are made within the required timeframe.

View Audit 364574

Finding 573883 (2024-006)

Significant Deficiency 2024

Northern Lakes Community Mental Health

MI

Subrecipient Monitoring Cash Management Reporting § 200.303

Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and a...

Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and approvals. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that cash requests are reviewed and approved prior to submission. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530

Finding 573882 (2024-005)

Material Weakness 2024

Northern Lakes Community Mental Health

MI

Reporting Subrecipient Monitoring Cash Management § 200.328

Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes...

Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes to ensure that reports are filed in accordance with the grant requirements. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530

Finding 573860 (2024-001)

None 2024

Midd-West School District

PA

Subrecipient Monitoring Reporting

The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The...

The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The Federal Program Director attended The Pennsylvania Association of Federal Program Coordinators annual conference in 2024 and 2025 and will attend yearly in the future. We are also in contact with our Regional Coordinator, Emily Johnson who has been able to assist as needed.

View Audit 364515

Finding 573843 (2024-002)

Significant Deficiency 2024

Winnebago County, Wisconsin

WI

Procurement, Suspension & Debarment Subrecipient Monitoring

Recommendation: We recommend the County evaluate policies and update to be in accordance with Uniform Guidance. The procurement policy in place does not meet UG requirements, which includes having a policy on suspension and debarment verification. Explanation of disagreement with audit finding: Ther...

Recommendation: We recommend the County evaluate policies and update to be in accordance with Uniform Guidance. The procurement policy in place does not meet UG requirements, which includes having a policy on suspension and debarment verification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The County is working on reviewing policies and procedures and updating as necessary. Further, they have hired a Management Analyst to help with training and ensuring grant compliance. Name(s) of the contact person(s) responsible for correction action: Carol Van Gruensven Planned completion date for corrective action: Ongoing

View Audit 364493

Finding 573840 (2024-001)

Significant Deficiency 2024

Central Tribes of the Shawnee Area, Inc.

OK

Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties § 200.328

Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.

View Audit 364487

Corrective Action Plans

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