Corrective Action Plans

Finding 1157578 (2024-001)

Material Weakness 2024

MO

Cash Management § 200.303 § 200.305

Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsib...

Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsible Fatherhood Grants Award Period: September 30, 2023 – September 29, 2024 Award Period: September 30, 2024 – September 29, 2025 Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Teen Pregnancy Prevention Education Assistance Listing Number: 93.297 Assistance Listing Program Title: Adolescent Health Programs Award Period: July 1, 2023 – June 30, 2024 Award Period: July 1, 2024 – June 30, 2025 Management response to 2024-001: In response to the auditors’ recommendation, management has addressed this deficiency by assigning appropriate personnel to properly track and monitor drawdown requests to ensure the costs requested for reimbursement have been incurred, are complete and accurate, and in line with Federal award requirements. Additionally, management has implemented specific procedures for review and approval of all drawdown requests.

View Audit 369809

Finding 1157538 (2024-001)

Material Weakness 2024

Washington State Building & Construction Trades Council

WA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

The Council has implemented procedures to include documentation of approval for all grant-funded expenditures to strengthen internal controls and ensure compliance with federal standards.

View Audit 369756

Finding 1157517 (2024-001)

Material Weakness 2024

Coburn Place Safehaven Ii, Inc.

IN

Matching / Level of Effort / Earmarking Reporting § 200.303

Views of Responsible Officials and Planned Corrective Action: We agree with the recommendation and have implemented the recommendation as noted.

View Audit 369728

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 1157438 (2024-003)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Reporting HUD Housing Programs Significant Deficiency § 200.303

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25

View Audit 369689

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 1157390 (2024-003)

Material Weakness 2024

Educare of Omaha, Inc.

NE

Cash Management Eligibility Material Weakness § 200.303

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR...

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2025

View Audit 369654

Finding 1157364 (2024-002)

Material Weakness 2024

Keystone Restituere Justice Center, Inc.

PA

Cash Management § 200.303 § 200.305

Finding 2024-002: Material weakness in internal controls over compliance – cash management Recommendation: Management should improve the monitoring of actual expenditures ot better algin cash needs and draw down requests with actual expenditures incurred. Explanation of Disagreement with Audit Findi...

Finding 2024-002: Material weakness in internal controls over compliance – cash management Recommendation: Management should improve the monitoring of actual expenditures ot better algin cash needs and draw down requests with actual expenditures incurred. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: In April of 2024, KRJC established a financial policy that ensures that funds are only drawn down for expenses incurred and/or accrued during the reporting period. All expenses are booked into KRJC’s accounting system. KRJC then calculates any funding due from BJA and then completes a draw down for any payments due. In an effort to ensure that funds are never overdrawn but that KRJC can pay sub-awardees and contracts in a timely manner, this process may occur multiple times in any given quarter. In addition, KRJC has worked to develop a pool of unrestricted funds and is working to develop an operating reserve, using private funds, that will allow the organization some additional flexibility in our financial operations and will ultimately allow KRJC to shift to quarterly drawdowns. Planned completion date for corrective action plan: July 2024

View Audit 369651

Finding 1157363 (2024-007)

Material Weakness 2024

Polk County

MN

Eligibility Internal Control / Segregation of Duties § 200.303

Name of Contact Person Responsible for Corrective Action: Karen Warmack, Social Services Director Corrective Action Planned: The County will implement additional procedures, including reviews, to provide reasonable assurance that all necessary documentation to support eligibility determination exist...

Name of Contact Person Responsible for Corrective Action: Karen Warmack, Social Services Director Corrective Action Planned: The County will implement additional procedures, including reviews, to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input into MAXIS. County Comment: A Corrective Action Plan has been established with an anticipated completion date of December 31, 2025. Anticipated Completion Date: December 31, 2025.

View Audit 369649

Finding 1157285 (2024-001)

Material Weakness 2024

Fort Worth Housing Solutions

TX

Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.303

Significant Deficiency in Internal Control over Compliance, Other Matters U.S. Department of the Treasury U.S. Department of Housing and Urban Development Coronavirus State and Local Fiscal Recovery Funds Community Development Block Grants/Entitlement Grants 21.027 14.218 Recommendation: We recommen...

Significant Deficiency in Internal Control over Compliance, Other Matters U.S. Department of the Treasury U.S. Department of Housing and Urban Development Coronavirus State and Local Fiscal Recovery Funds Community Development Block Grants/Entitlement Grants 21.027 14.218 Recommendation: We recommend that the Authority implements controls to ensure that the preliminary SEFA is mostly accurate so that the correct programs are tested. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Finance Department has implemented several processes and procedures to ensure pass-through funds or sub-awards are reported timely and accurately in the SEFA. The new processes include (1) review of grant award letters to determine reporting requirements, (2) comparing the award letter against the Minutes of the City Council or County Commissioners meetings to ensure grants accepted during the year are disclosed as such on both ends, (3) confirmed with source Agency Single Audit requirements, (4) and the implementation of revenue source checklist that will identify the source of the funds, type of grant, program name and cluster title, name of federal funding agency, federal assisting listing number (formerly known as CFDA number), etc. Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2025 Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2025

View Audit 369582

Finding 1157263 (2024-001)

Material Weakness 2024

The Arc of Delaware

DE

HUD Housing Programs Special Tests & Provisions § 200.303

Corrective Action Plan: The ARC of Delaware will update monthly replacement reserve deposit amounts upon notification from HUD. The Arc will perform an analysis every 30 days to ensure deposits have been made for the appropriate amount. ARC completed this corrective action plan when it was notified ...

Corrective Action Plan: The ARC of Delaware will update monthly replacement reserve deposit amounts upon notification from HUD. The Arc will perform an analysis every 30 days to ensure deposits have been made for the appropriate amount. ARC completed this corrective action plan when it was notified during the prior period single audit. Contact Person Responsible for Correction Action: Stanley Kihara, Controller Completion Date: July 15, 2024

View Audit 369576

Finding 1157239 (2024-005)

Material Weakness 2024

County of Alpena, Michigan

MI

Reporting Internal Control / Segregation of Duties § 200.303 § 200.510

Corrective Action Plan: The County has agreed to strengthen internal controls through regular reconciliations between project managers and the Clerk’s office to ensure timely reporting, submission for reimbursement and inclusion on the financial statements. Responsible Party: Alpena County Treasurer...

Corrective Action Plan: The County has agreed to strengthen internal controls through regular reconciliations between project managers and the Clerk’s office to ensure timely reporting, submission for reimbursement and inclusion on the financial statements. Responsible Party: Alpena County Treasurer and Alpena County Administrator Date of Planned Corrective Action: July 1, 2025 Management Assessment: We concur with the audit assessment regarding this matter.

View Audit 369562

Finding 1157234 (2024-001)

Material Weakness 2024

Ellwood City Borough

PA

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

CONDITION: During my review of the Borough of Ellwood City’s internal controls over federal awards, I noted that the Borough does not have formal written policies and procedures surrounding the management of their federal award funds. Although not all-inclusive, an example of some of the required po...

CONDITION: During my review of the Borough of Ellwood City’s internal controls over federal awards, I noted that the Borough does not have formal written policies and procedures surrounding the management of their federal award funds. Although not all-inclusive, an example of some of the required polices would include written procedures for procurement, conflict of interest, and allowable costs. This is a repeat finding (2023-001) from the prior year.CRITERIA: Section 2 CFR 200.303 of the Uniform Guidance requires non-federal entities such as the Borough of Ellwood City to maintain effective internal controls over federal awards. In addition, the Uniform Guidance also recommends these internal controls follow guidance in Standards for Internal Control in the Federal Government (the Green Book), issued by the Comptroller General of the United States.RECOMMENDATION: I recommend that the Borough of Ellwood City adopt the required written policies and procedures surrounding the management of federal award funds as prescribed by Section 2 CFR 200.303 of the Uniform Guidance. The focus of these policies and procedures should be to ensure that the Borough officials who are responsible for carrying out the objectives of the federal financial award understand 1) the federal statutes, regulations, and terms and conditions of the award, 2) how to evaluate and properly monitor compliance, and 3) the steps to take if noncompliance is identified.MANAGEMENT’S PLANNED CORRECTIVE ACTION: Management of the Borough will begin the process of reviewing Section 2 CFR 200.303 of the Uniform Guidance with the objective of understanding what specific policies and procedures surrounding the management of their federal award funds are required. As recommended, the focus of these policies and procedures will be to ensure that the Borough officials who are responsible for carrying out the objectives of the federal financial award understand 1) the federal statutes, regulations, and terms and conditions of the award, 2) how to evaluate and properly monitor compliance, and 3) the steps to take if noncompliance is identified. The timeframe for researching the required written policies and procedures of the Uniform Guidance, and the development and implementation of these written policies and procedures will cover the period including the last quarter of calendar year 2025 through and including the 2nd quarter of calendar year 2026.Borough Officials responsible for the implementation of the Corrective Action Plan:Kevin Swogger, Borough Manager.

View Audit 369555

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 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 1157178 (2024-005)

Material Weakness 2024

Big Valley Rancheria Band of Pomo Indians

CA

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.327

Individual(s) Responsible: LaNita Perez, Controller and AP Specialist Action: Management will ensure that all procurement transactions comply with established policies and procedures. Competitive bidding, documentation of procurement methods, justification for sole-source contracts, and price/cost a...

Individual(s) Responsible: LaNita Perez, Controller and AP Specialist Action: Management will ensure that all procurement transactions comply with established policies and procedures. Competitive bidding, documentation of procurement methods, justification for sole-source contracts, and price/cost analyses will be required for all applicable purchases. Staff will receive training on procurement requirements under Uniform Guidance. Management will monitor procurement activities and verify that each purchase is supported by proper documentation. Compliance with policies and procedures will be checked regularly. Anticipated Completion Date: December 31, 2025

View Audit 369484

Finding 1157177 (2024-004)

Material Weakness 2024

Big Valley Rancheria Band of Pomo Indians

CA

Questioned Costs Allowable Costs / Cost Principles § 200.303

Individual(s) Responsible: Enrique Martinez, Grant Manager and Program Director Action: Management will implement a process to ensure all expenditures are properly documented and reviewed for allowability before being charged to the Program. Staff will be trained on documentation and compliance requ...

Individual(s) Responsible: Enrique Martinez, Grant Manager and Program Director Action: Management will implement a process to ensure all expenditures are properly documented and reviewed for allowability before being charged to the Program. Staff will be trained on documentation and compliance requirements. Internal controls will be strengthened to prevent unallowable costs. Anticipated Completion Date: December 31, 2025

View Audit 369484 Questioned Costs: $1

Finding 1157174 (2024-001)

Material Weakness 2024

Chisago County

MN

Procurement, Suspension & Debarment § 200.303

Finding Number: 2024-001 Finding Title: Suspension and Dearment Program: 21.027 COVID-19 – Coronavirus State and Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Verifying that a new vendor has not been suspended or debarred i...

Finding Number: 2024-001 Finding Title: Suspension and Dearment Program: 21.027 COVID-19 – Coronavirus State and Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Verifying that a new vendor has not been suspended or debarred is analyzed on a case-by-case basis depending on the Federal award. Doing this for each vendor for ARPA would significantly disrupt our A/P process with the limited number of staff we have. Anticipated Completion Date: Immediately

View Audit 369483

Finding 1157132 (2024-001)

Material Weakness 2024

Edna Martin Christian Center, Inc.

IN

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

The purchase of the grant management system will interface directly with the organization’s accounting software, allowing for the automated extraction of financial data. This data will be systematically mapped to the corresponding budgetary lines of each grant to ensure accurate tracking and reporti...

The purchase of the grant management system will interface directly with the organization’s accounting software, allowing for the automated extraction of financial data. This data will be systematically mapped to the corresponding budgetary lines of each grant to ensure accurate tracking and reporting. On a monthly basis, the Financial Grant Coordinator will collaborate with Senior Directors and Program Directors to review financial activity. These reviews aim to verify that expenditure aligns with the allowable costs defined by each grant, ensuring full compliance with funding requirements. Corrective: Budget vs. actual reviews are conducted with senior directors to evaluate financial performance and ensure alignment with programmatic, administrative guidelines, and funding guidelines. During these reviews, directors assess which costs are permissible and identify any expenditure that falls outside allowable parameters. Non-compliant costs are reallocated to appropriate programs that permit such expenses or to administrative accounts as necessary.

View Audit 369464 Questioned Costs: $1

Finding 1157129 (2024-002)

Material Weakness 2024

Disability Services Inc.

CO

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303 § 200.332 § 200.510 § 200.518

Finding summary: an internal control deficiency affecting the accuracy of the Schedule of Expenditures of Federal Awards (SEFA) Responsible department: Finance and PPACG Contact person: Finance Corrective action plan: As of 2025 SEFA internally will be prepared by Grant coordinator and review by Fin...

Finding summary: an internal control deficiency affecting the accuracy of the Schedule of Expenditures of Federal Awards (SEFA) Responsible department: Finance and PPACG Contact person: Finance Corrective action plan: As of 2025 SEFA internally will be prepared by Grant coordinator and review by Finance. Envida will ensure that all appropriate ALNs and Federal identifications and amounts are included on the contracts. Envida will implement a process for all appropriate department directors, including CEO to sign off on each grant received. Timeline for completion: Dec 31 2025 Monitoring plan: Monthly Review with Grant coordinator Anticipated outcome: SEFA will reflect accurate federal expenditures.

View Audit 369453

Finding 1157077 (2024-005)

Material Weakness 2024

Unity Health Care, Inc.

MD

Allowable Costs / Cost Principles § 200.303

Management Response #2024-005: Due to staff turnover the Corporation did not have adequate personnel or infrastructure in place to monitor costs in order to calculate and determine an updated indirect cost rate. Also, the current indirect cost rate allocations is based on historical assumptions. Cor...

Management Response #2024-005: Due to staff turnover the Corporation did not have adequate personnel or infrastructure in place to monitor costs in order to calculate and determine an updated indirect cost rate. Also, the current indirect cost rate allocations is based on historical assumptions. Corrective Action Plan: The Finance Team will develop overall operational costs reports to calculate and support a new rate. The proposed rate will be submitted to HRSA for approval. This will allow us to ensure the calculation for indirect costs and documentation supporting the indirect cost pool conform to the current regulations. Management expects to be completed by December 31, 2026. Responsible Party: Tamara Barnes, CFO

View Audit 369390

Finding 1157055 (2024-001)

Material Weakness 2024

West End Neighborhood House, Inc.

DE

Reporting Allowable Costs / Cost Principles HUD Housing Programs § 200.303

Management has updated its compliance responsibility procedures to clarify roles and responsibilities and to ensure accountabilities for all federal reporting requirements. Specifically: • A compliance calendar will be established to track all non-standard reporting deadlines (other than monthly or ...

Management has updated its compliance responsibility procedures to clarify roles and responsibilities and to ensure accountabilities for all federal reporting requirements. Specifically: • A compliance calendar will be established to track all non-standard reporting deadlines (other than monthly or quarterly cost reimbursement grant request). • Responsibility for preparing and submitting DRGR reports has been formally assigned to Finance Department. • Verification procedures have been implemented to confirm that all reports are filed timely. • Periodic internal reviews will be conducted to ensure compliance with reporting requirements.

View Audit 369363

Finding 1157011 (2024-001)

Material Weakness 2024

Housing Authority of the Town of Vernon

CT

HUD Housing Programs Subrecipient Monitoring § 200.303

Auditee’s Response and Corrective Action 2024-001- Internal Controls over Compliance These matters were identified in a HUD Compliance and Monitoring Report. Following this report, the VHA has taken the following corrective actions: • In June 2025, VHA adopted and implemented EIV/UIV policy • VHA co...

Auditee’s Response and Corrective Action 2024-001- Internal Controls over Compliance These matters were identified in a HUD Compliance and Monitoring Report. Following this report, the VHA has taken the following corrective actions: • In June 2025, VHA adopted and implemented EIV/UIV policy • VHA contacted the system software customer service to see how to include the minimum rents as part of the payments standards. All payments standards for the VHA covered areashave been updated. • In June 2005, VHA established a minimum rent policy for Public Housing. • In June 2025, VHA adopted and implemented a Program Monitoring QA policy in accordance with HUD required SEMAP indicators. • In June 2005, VHA established adopted and implemented a voucher program termination policy and a Public Housing lease termination policy. . • In September 2025, the VHA implemented a Violence Against Women Act (VAWA) policy effective November 1, 2025. • VHA has reached out to Nan McKay for Assistance with developing a new Admissions and Continued Occupancy Plan (ACOP). • VHA has sent out 126 OBV preference update notices to all applicants currently on the PBV 0/1 bedroom waitlist. Only 21 have been returned to date. VHA will continue to collect and update preferences. Planned Implementation Date of Corrective Action: October 2025 Person Responsible for Corrective Action: Shenoa Steves, Housing Programs Manager

View Audit 369314

Corrective Action Plans

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