Corrective Action Plans

Finding 575672 (2024-001)

Significant Deficiency 2024

City of Glendora

CA

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.512

Contact Person: Kyle Johnson, Finance Director Corrective Action Plan: The City will review and update internal policies and procedures related to Single Audit completion and submission to ensure compliance with Uniform Guidance. The City is actively working with the part time employees and consulta...

Contact Person: Kyle Johnson, Finance Director Corrective Action Plan: The City will review and update internal policies and procedures related to Single Audit completion and submission to ensure compliance with Uniform Guidance. The City is actively working with the part time employees and consultant to document the procedures and strengthen internal controls. Anticipated Completion Date: March 31, 2026.

View Audit 365679

Finding 575670 (2024-005)

Significant Deficiency 2024

Indiana Diaper Bank, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...

Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft a new CRM to track benefit limitation and mandatory documentation. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.

View Audit 365678

Finding 575669 (2024-004)

Significant Deficiency 2024

Indiana Diaper Bank, Inc.

IN

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identif...

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. As a result, three of the sixty transactions tested did not include sufficient documentation to support eligibility determinations, representing instances of noncompliance with the eligibility requirements under the federal program. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.

View Audit 365678 Questioned Costs: $1

Finding 575668 (2024-003)

Material Weakness 2024

Indiana Diaper Bank, Inc.

IN

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.403

Finding 2024-03 Insufficient Documentation of Other Direct Expenses Condition: During testing of direct costs charged to the federal program, the Organization did not maintain sufficient documentation to fully support all expenditures claimed. In one instance, a receipt supporting a claimed expense...

Finding 2024-03 Insufficient Documentation of Other Direct Expenses Condition: During testing of direct costs charged to the federal program, the Organization did not maintain sufficient documentation to fully support all expenditures claimed. In one instance, a receipt supporting a claimed expense was missing. In three additional cases, although the expenditures were generally supported, the documentation did not clearly reflect how the amounts allocated to the major federal program were determined. While these issues were isolated and the known and likely questioned costs were immaterial, the lack of complete documentation represents noncompliance with federal requirements for allowable costs. Corrective Actions Taken or Planned: The Organization will develop written guidelines specifying the required supporting documentation for each type of direct expense. Set up vendors in QuickBooks. We will hire and train Finance Manager to manage and track revenue and expenses, QuickBooks, grant reporting etc. All receipts and expenses will be scanned in and kept electronically. The Organization will provide training on documentation requirements, proper record submission, and compliance expectations.

View Audit 365678 Questioned Costs: $1

Finding 575667 (2024-002)

Material Weakness 2024

Indiana Diaper Bank, Inc.

IN

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Finding 2024-02 Insufficient Documentation of Personnel Expenses Condition: The Organization charges a material amount of payroll-related costs to its major federal program. However, it does not maintain sufficient documentation to support the level of effort charged to the award, as required by fe...

Finding 2024-02 Insufficient Documentation of Personnel Expenses Condition: The Organization charges a material amount of payroll-related costs to its major federal program. However, it does not maintain sufficient documentation to support the level of effort charged to the award, as required by federal regulations. While staff members are required to complete timesheets, the current format does not capture the level of detail needed to substantiate payroll allocations to federal programs. Additionally, there is no formal process for supervisory review and approval of these timesheets. Although no overcharges or double-dipping were identified, the lack of adequate documentation results in known and likely questioned costs due to noncompliance with documentation requirements. Corrective Actions Taken or Planned: The Organization will develop and implement a standardized timesheet template (Gusto) that captures employee name, pay period, hours worked by funding source, and supervisory approval. Provide mandatory training for all staff whose salaries are charged in whole or in part to grants on documentation and time allocation requirements. Require monthly reconciliation of time sheets to payroll records before submission to grants. The Organization will conduct quarterly internal reviews to ensure compliance and adjust as needed.

View Audit 365678 Questioned Costs: $1

Finding 575666 (2024-001)

Material Weakness 2024

Indiana Diaper Bank, Inc.

IN

Material Weakness Reporting Equipment & Real Property Management

Finding 2024-01 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in multiple material audit adjustments across key financial statement accounts, including inventory, accounts payable,...

Finding 2024-01 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in multiple material audit adjustments across key financial statement accounts, including inventory, accounts payable, fixed assets, deferred revenue, and related activity accounts. These adjustments were proposed by the auditors and subsequently recorded by management to fairly present the financial statements in accordance with generally accepted accounting principles. The extent and materiality of the adjustments indicate that the Organization's existing closing procedures were insufficient to identify and correct errors prior to the audit. Corrective Actions Taken or Planned: The Organization will develop a financial close calendar with clear deadlines. We will create a standard operating procedure for account reconciliations, journal entries, and financial reporting with assignments to specifics staff. The Organization will implement a review and sign-off process for financial reports at board meetings. The Organization plans on hiring a part-time finance manager to help us with documentation and reporting.

View Audit 365678

Finding 575660 (2024-002)

None 2024

Chickahominy Indian Tribe

VA

Questioned Costs

The Chickahominy Indian Tribe respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, Virginia 22801 Audit period: December 31, 2024 ...

The Chickahominy Indian Tribe respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, Virginia 22801 Audit period: December 31, 2024 The findings from the December 31, 2024 Schedule of Findings and Questioned Costs (the “Schedule”) are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS – FINANCIAL STATEMENT AUDIT 2024-001: Material Audit Adjustments (Material Weakness) Condition: Multiple material audit adjustments were proposed. Criteria: Financial information should be materially correct. Cause: The Tribe switched from using an excel spreadsheet to an accounting software for tracking financial information in 2023. During the year, there were reconciliation issues between the software and the spreadsheet which did not get resolved. Material audit adjustments needed to be made to ensure the accuracy of the financial statement, but the cumulative effect of these entries was significantly less than in the prior year. Effect: Audit adjustments were required to ensure the financial statements are materially correct. Recommendation: We do not consider it necessary to reconcile between the Tribal Ledger and Abila; however, we strongly encourage adding a procedure to the monthly bank reconciliations. Bank deposits should be matched to Abila revenue, and bank disbursements to Abila expenses. This will ensure revenues and expenses are properly recorded in addition to ending cash balances being reconciled. Corrective Action: The accounting software is the only source of accounting information now. The Tribal Ledger is no longer being maintained. We continue to learn the intricacies of the new software and the proper way to use it. We are instituting a more formal schedule for review of accounting entries, to ensure they are done in a more timely manner. We have been developing a handbook which will list proper procedures, including proper entry of non- typical transactions. It will also include the procedure for bank reconciliation. We anticipate that material audit adjustments will not be required in the future. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT 2024-002: Child Care Development Fund Cluster ALN 93.575 and 93.596 Condition There was one expenditure tested under the CCDF American Rescue Plan Act Child Care Supplementary Discretionary grant that did not get obligated by the required date. Criteria Funds should be obligated by the end of the succeeding federal fiscal year after award and expended by the end of the third federal fiscal year. Cause The CCDF ARP Supplementary Discretionary grant was the only grant that did not receive a federal extension or Tribal waiver. The Tribe was under the impression that all CCDF grants would have waivers. Effect One item was not obligated by the required date, total $13,604. Perspective Information One tested of one in the ARP discretionary, but one of 25 in all CCDF. Recommendation We recommend establishing a formal policy regarding definitions of obligation and liquidation. This should be formally approved by Council with a resolution. Corrective Action: During a meeting prior to the end of the obligation period, we decided how we would use the referenced funds. We documented that decision in the meeting minutes and believed we had met the obligation requirements. The Funding Agency was satisfied with our explanation of the funds being considered obligated, as Tribes can define obligation in their own terms. However, the actual contract wasn’t executed until after the obligation period was over. In addition, we also thought the obligation and liquidation periods for this particular grant had been extended along with those of similar grants that we have from this agency, but realized later that they had not been. We immediately started a review at the beginning of each month of all grants to determine those whose obligation period ends that month. We also review at that time for grants whose liquidation period ends that month. When either of these occurs, I issue a notification to FinanceStaff to make them aware. I also notify the manager of those grants to ensure they are aware of the obligation and liquidation deadlines. We will also review our Financial Policy and clarify our definition of Obligation as needed. If the Federal Audit Clearinghouse has questions regarding this plan, please call Wayne Adkins, First Assistant Chief and Finance Officer at 804-829-2027. Sincerely yours, Wayne Adkins First Assistant Chief and Finance Officer

View Audit 365677 Questioned Costs: $1

Finding 575659 (2024-004)

Material Weakness 2024

City of Dell Rapids

SD

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318 § 200.326

Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The City does not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individ...

Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The City does not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Finance Officer Corrective Action Plan: The City will establish controls to follow all applicable procurement requirements under Uniform Guidance and applicable CFR sections. Anticipated Completion Date: December 31, 2025

View Audit 365664

Finding 575658 (2024-003)

Material Weakness 2024

City of Dell Rapids

SD

Internal Control / Segregation of Duties Material Weakness Reporting

Reporting Material Noncompliance and Material Weakness in Internal Control over Compliance Finding Summary: The annual project and expenditure report submitted for the year ended December 31, 2024 for Federal Financial Assistance Listing No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recover...

Reporting Material Noncompliance and Material Weakness in Internal Control over Compliance Finding Summary: The annual project and expenditure report submitted for the year ended December 31, 2024 for Federal Financial Assistance Listing No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds, had amounts reported that did not agree to the general ledger of the City. Responsible Individuals: Finance Officer Corrective Action Plan: The City will establish controls to follow all applicable reporting requirements under Uniform Guidance and applicable CFR sections. Anticipated Completion Date: December 31, 2025

View Audit 365664

Finding 575657 (2024-003)

Material Weakness 2024

City of Cherry Hills Village

CO

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Federal Progarm Name: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (CSLFRF Progarm) - Assistance Listing No. 21.027 Recommendation: We recommend that the Annual Report be approved by someone other than preparer prior to submission. Explanation of disagreement with audit finding: Ther...

Federal Progarm Name: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (CSLFRF Progarm) - Assistance Listing No. 21.027 Recommendation: We recommend that the Annual Report be approved by someone other than preparer prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken is response to finding: The City will create and enact financial reporting procedures that outlines how to handle reporting for funding such as ARPA to ensure that these reports are being reviewed and approved before submission in the future. Name of the contact person responsible for corrective action: Kelly Newman, Director of Finance and Administration. Planned completion date for corrective action plan: December 31, 2025.

View Audit 365663

Finding 575655 (2024-001)

Material Weakness 2024

Herbert Brooks Housing Development Fund Company, INC

NY

Questioned Costs HUD Housing Programs Cash Management

Recommendation The Company must deposit $116,553 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date...

Recommendation The Company must deposit $116,553 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2025 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

View Audit 365662 Questioned Costs: $1

Finding 575653 (2024-001)

Material Weakness 2024

Minford Gardens Housing Development Fund Company, INC

NY

Questioned Costs HUD Housing Programs Cash Management

Finding Reference Number: 2024-1 Recommendation The Company must deposit $223,644 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Com...

Finding Reference Number: 2024-1 Recommendation The Company must deposit $223,644 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2025 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

View Audit 365660 Questioned Costs: $1

Finding 575647 (2024-003)

None 2024

Southeastern Vermont Community Action, Inc.

VT

Procurement, Suspension & Debarment § 200.318 § 200.327

The executive level, including the finance director of SEVCA, acknowledge these weaknesses in our practice in FY24. SEVCA has renewed focus on well documented proper procurement procedures and accountability for oversight of procurement action steps by multiple team partners. The following correctiv...

The executive level, including the finance director of SEVCA, acknowledge these weaknesses in our practice in FY24. SEVCA has renewed focus on well documented proper procurement procedures and accountability for oversight of procurement action steps by multiple team partners. The following corrective actions are in place: 1. Policy Reinforcement and Training o Conducted mandatory training for all staff involved in procurement, emphasizing the documentation requirements outlined in the Organization’s procurement policy.o Distributed updated procurement documentation checklists to ensure clear understanding of required elements for each procurement file. 2. Standardized File Documentation Process o Implemented a standardized cover sheet or checklist for each procurement file to be completed and reviewed before contract finalization. This indicates whether all required steps (e.g., solicitation of bids) were completed or, if not, the reason for deviation in standard practice. 3. Internal Review and Monitoring o Established a quarterly internal review of a random sample of procurement files to ensure compliance with documentation standards. o Assigned a staff member or team (e.g., Finance Support Specialist) to oversee this review process and report findings to Finance Director and Program Director. 4. Follow-Up and Accountability o Require program director and finance director sign-off on all procurement files over $20,000 to ensure all documentation requirements are fulfilled. o Include procurement documentation compliance as part of staff performance evaluations where relevant. Responsible Person: Finance Director, Lisa Whitney and Executive Director, Josh Davis

View Audit 365651

Finding 575646 (2024-002)

Significant Deficiency 2024

Boat People Sos, INC

VA

Reporting

Management acknowledged the importance of reporting grants properly for all accounting matters, especially Federal grants, to be compliant with Government agency, and accounting principles. Management has reviewed and revised our internal control for grant management. As such, new grants and contrac...

Management acknowledged the importance of reporting grants properly for all accounting matters, especially Federal grants, to be compliant with Government agency, and accounting principles. Management has reviewed and revised our internal control for grant management. As such, new grants and contracts will be reviewed by branch/program managers as well as COO for compliance purposes. The project team, including project manager, support staff, financial staff and COO, will hold a kick-off meeting to go over the project type, the project's goals, expected outcomes and reporting. For any missing CFDA, the COO is responsible for identifying and searching using government database and other resources to find the information for reporting. All steps of verification are reflected in project briefs with initials by Project Manager, COO, Finance and HR team. Everyone is accountable for the accuracy and completeness of the information. A grant tracking sheet will also be reviewed per quarter.

View Audit 365650

Finding 575645 (2024-001)

Significant Deficiency 2024

Boat People Sos, INC

VA

Internal Control / Segregation of Duties

Accounting staff will be trained to record monthly lease expenses according to their lease schedules and cash payments. These accounts will be reviewed quarterly, including year end and signed off by a qualified accountant. Management will create a tracking sheet to monitor the renewal, terminatio...

Accounting staff will be trained to record monthly lease expenses according to their lease schedules and cash payments. These accounts will be reviewed quarterly, including year end and signed off by a qualified accountant. Management will create a tracking sheet to monitor the renewal, termination, expiration dates, and review of their schedules. It will be reviewed quarterly by COO and finance department. Branch manager is required to update COO for any changes related to lease. A copy of the lease along with all other relevant items will be sent to finance department either by COO or branch manager.

View Audit 365650

Finding 575640 (2024-001)

Significant Deficiency 2024

Pro Bono Resource Center of Maryland, Inc.

MD

Questioned Costs Reporting Significant Deficiency § 200.62

Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. ...

Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. Name of Contact Person: Amy M Smitherman, amy.smitherman@gmail.com, 646-240-3185 Projected Completion Date: 9/15/2025

View Audit 365647 Questioned Costs: $1

Finding 575638 (2024-001)

Significant Deficiency 2024

Housing Authority of the County of Santa Barbara

CA

Questioned Costs Special Tests & Provisions HUD Housing Programs

Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standa...

Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least biennially to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussion with management, there was a failed inspection that did not pass reinspection within 30 days without penalty. Context: There were approximately six hundred ninety four (694) failed inspections during the audit period. Of a sample size of twenty-five (25) failed inspections, one (1) unit did not pass reinspection within 30 days. HAP was not abated nor was the tenant transferred. Known Questioned Costs: $5,322 Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor and will make the necessary changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement). Sanford Riggs, Director of Operations, is responsible for implementing this corrective action by December 31, 2025

View Audit 365643 Questioned Costs: $1

Finding 575635 (2024-002)

Material Weakness 2024

One Roof Community Housing

MN

Procurement, Suspension & Debarment

2024-002 Material Weakness in Internal Control over Compliance and Other Matters Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing #21.027 Recommendation: We recommend that management implement a policy to test whether entities receiving federal funds are not currently deb...

2024-002 Material Weakness in Internal Control over Compliance and Other Matters Coronavirus State and Local Fiscal Recovery Funds Federal Assistance Listing #21.027 Recommendation: We recommend that management implement a policy to test whether entities receiving federal funds are not currently debarred or suspended, and to report the results if necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: One Roof is in the process of updating policies to include testing if individuals or entities that are contractors for One Roof are neither debarred or suspended from federal funding. Name(s) of the contact person(s) responsible for corrective action: Vickie Hartley, Senior Finance Director. Planned completion date for corrective action plan: 12/31/2025 If the Department of Treasury has questions regarding this plan, please call Vickie Hartley, Senior Finance Director at 218-393-6037.

View Audit 365637

Finding 575634 (2024-001)

Significant Deficiency 2024

Franklin County Government

IL

Internal Control / Segregation of Duties

Franklin County will work to document current procedures and redevelop internal control procedures as appropriate for the management of federal funds.

View Audit 365604

Finding 575629 (2024-003)

Significant Deficiency 2024

Newport County Community Mental Health Center, Inc.

RI

Cash Management Significant Deficiency § 200.302 § 200.303 § 200.305

Finding 2024.003 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur to ensure accuracy. Not a repeat finding. Action Taken Since September 2023, the Center has implemented weekly grants management reviews with the grants team and key exec...

Finding 2024.003 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur to ensure accuracy. Not a repeat finding. Action Taken Since September 2023, the Center has implemented weekly grants management reviews with the grants team and key executives. Action items are tracked through meeting agendas, minutes, and NMH’s project management platform, Monday.com. Meetings include invoice approvals for grant-funded expenditures, and review of allocations, payroll dates, and stipends for drawing down calculations. The meetings going forward will document the amounts for federal grants drawdowns and will be logged within Monday.com and through an external verification spreadsheet. Starting May 2025, an updated verification spreadsheet along with an itemized attestation was implemented.

View Audit 365599

Finding 575628 (2024-002)

Significant Deficiency 2024

Newport County Community Mental Health Center, Inc.

RI

Procurement, Suspension & Debarment

Finding 2024.002 – Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compli...

Finding 2024.002 – Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Not a repeat finding Action Taken Beginning in FY26, NMH has formally adopted the following policy and procedure to address uniform guidance requirements for suspension and debarment. This policy updates and clarifies the Center’s internal procedures, building upon the initial check process and the sporadic exclusion of monthly suspension and debarment checks conducted in FY24. See policy and procedure below: NMH POLICY & PROCEDURE FOR UNIFORM GUIDANCE REQUIREMENTS FOR SUSPENSION AND DEBARMENT To ensure that Newport Mental Health (NMH) is not doing business with vendors who have been suspended or debarred from doing business with the federal government, prior to contracting/purchase, the Vice President of Finance, or designee, will ensure the vendor/contractor is not on the List of excluded Individuals and Entities (LEIE) in the Office of Inspector General (OIG) Exclusion Database before creating a purchase order or making a payment. Procedures for Accounts Payable: New vendors or contractors must complete a current W-9 and debarment attestation form. Accounts Payable will verify that the vendor is not suspended or debarred. If a vendor or contractor is found to be suspended or debarred, Accounts Payable will flag them in NXT. This alert notifies invoice processors that federal funds cannot be used for this vendor. Any NMH Department who detects a suspended or debarred vendor should notify Accounts Payable to ensure proper flagging in the system. Procedures for Ongoing Checks: The Finance Department will generate a list of all vendors and employees paid with Federal funds and review it monthly against the LEIE using Verify Comply, an OIG Exclusion Search Software. If a vendor is found to be suspended or debarred, the Finance Department will reclassify purchases off the Federal grant and notify Accounts Payable to flag the vendor in NXT. Accounts Payable must keep documentation of each check. The Vice President of Finance oversees these processes to ensure compliance.

View Audit 365599

Finding 575610 (2024-001)

Significant Deficiency 2024

Western Landowners Alliance

CO

Reporting § 200.508

Auditee Corrective Action Plan Finding 2024-001: Schedule of Federal Awards (SEFA) Preparation – Significant Deficiency Audit Finding: During our audit, we noted that the Schedule of Expenditures of Federal Awards (SEFA) initially prepared by Western Landowners Alliance did not include the required...

Auditee Corrective Action Plan Finding 2024-001: Schedule of Federal Awards (SEFA) Preparation – Significant Deficiency Audit Finding: During our audit, we noted that the Schedule of Expenditures of Federal Awards (SEFA) initially prepared by Western Landowners Alliance did not include the required Assistance Listing Numbers (formerly CFDA numbers) for each federal program, and the amounts of federal expenditures reported contained inaccuracies. We understand this was Western Landowners Alliance’s first year preparing a SEFA and that staff are still becoming familiar with the detailed requirements of the Uniform Guidance (2 CFR Part 200). As the SEFA is a critical component of the Single Audit reporting package and serves as the basis for major program determination and compliance testing, it is essential that it be prepared accurately and in accordance with Uniform Guidance. We recommend that management enhance its understanding of SEFA preparation requirements, consider additional training on Uniform Guidance, and implement review procedures to help ensure the completeness and accuracy of the SEFA in future reporting periods. Audit Recommendation: We recommend that management enhance its understanding of SEFA preparation requirements, consider additional training on Uniform Guidance, and implement review procedures to help ensure the completeness and accuracy of the SEFA in future reporting periods. Management’s Response and Corrective Action Plan: Western Landowners Alliance (WLA) acknowledges and agrees with the finding, and have taken the following corrective actions to address the issue: (1) Implementation of SEFA Template: given the diversity of awards WLA receives (primary, subawards, and awards with both federal/non-federal funding), a standardized template has been developed and implemented to ensure accurate tracking and reporting of awards, funding sources, and expenditures. (2) Proactive Collection of Assistance Listing Numbers: WLA will proactively request and document the Assistance Listing Numbers (formerly CFDA numbers) from funding agencies upon receipt of awards to ensure compliance, and complete and accurate reporting. (3) Documentation of Expense Allocation Process for Awards with Federal and Non-Federal Funding: WLA’s financial policies and procedures have been updates (as of August 2025) to document the process for allocating expenses on awards that include both federal and non-federal resources. Documentation of this process will ensure consistent and appropriate allocation in accordance with federal requirements. (4) Per recommendation from RGO, Robinson has enrolled in two trainings: Uniform Guidance Training Part 1 and Part 2-Single Audit Training-the importance of the SEFA, hosted by Illumeo, to augment knowledge to support future compliance. Contact and Completion Date: Rachael Robinson, 505-466-1495, rrobinson@westernlandowners.org, is the primary contact, and the Chief Operating Officer at Western Landowners Alliance. The corrective action is currently in effect and trainings will be completed by August 31, 2025, to ensure compliance with the current fiscal year. Please reach out with any questions. Rachael Robinson Chief Operating Officer Western Landowners Alliance 505-466-1495

View Audit 365598

Finding 575592 (2024-001)

None 2024

Firstmed Health and Wellness Center

NV

Special Tests & Provisions Eligibility

The Center will - Provide immediate re-training to staff on issues identified, and - Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing, and - Ha...

The Center will - Provide immediate re-training to staff on issues identified, and - Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing, and - Has updated procedures for the Sliding Fee Discount Program approval process in which all sliding fee required documents are first reviewed and approved by a Clinic Supervisor or Center Manager for program compliance. This process was implemented in July 2025, which was at the mid-point of the current fiscal year and will assist in addressing any issues and training proactively, and - Will continue ongoing Sliding Fee Audit Tracers and Chart Audits to assess staff knowledge, provide feedback, and offer guidance, as needed

View Audit 365587

Finding 575582 (2024-002)

Material Weakness 2024

City of East Chicago

IN

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.328

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur ...

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: To ensure proper implementation of the policies and procedures in place related to SLFRF reporting, in the future, no submittal of reports will be approved without the City Controller and a Senior Staff Accountant reviewing and approving the P&E reports. This will ensure policies and procedures are followed and possibly added to, if needed, to ensure compliance over SLFRF reporting. Anticipated Completion Date: Corrective action is now in effect as of August 18, 2025.

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Finding 575581 (2024-001)

Material Weakness 2024

City of East Chicago

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2024-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Offici...

FINDING 2024-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: A Suspension and Debarment policy was adopted at the conclusion of the 2023 audit, however, the policy was not presented to and officially adopted by the East Chicago Board of Works until the August 22, 2024, meeting. This oversight resulted in a delay of the anticipated enactment of the policy resulting in there being sufficient time to enact the new policy for the current audit year of 2024. The current summary schedule of prior audit findings reflects the issue as partially corrected, providing the supporting documents consisting of Board of Works actions in regard to the policy. Going forward, all steps are in place for correction of the situation. See policy below. CITY OF EAST CHICAGO SUSPENSION/ OR DEBARMENT POLICY FOR VENDOR WHEN FEDERAL FUNDS/ ASSISTANCE INVOLVED: The following specific provisions to be followed under the City of East Chicago purchasing policy and procedure for determining Suspension and Debarment status of any vendor doing business with the City for which federal funds and/ or federal assistance are to be utilized by City. A. SAM search, verification by contracted vendor or contractual provision. Prior to any purchase for which federal funds or federal assistance is to be utilized by the City, the purchasing agency, or its designee, shall: 1. Examine and verify the status of any vendor participating in or to be contracting for business with the City utilizing federal funds and or federal assistance for debarment and suspension status to determine whether the vendor is qualified to participate. The check or verification for debarment and suspension shall be performed using the System for Award Management (SAM) or any similar system currently approved for such purpose. The City Departments/ Boards responsible for facilitating, coordinating and utilizing federal funds will be required to conduct and complete the SAM search, or its approved equivalent, as such procedures and methods are amended, on all vendors with whom the City intends to conduct business utilizing federal funds. Further the City or entity responsible shall provide a hard copy proof and verification of each SAM search for record keeping. 2. Require each contracted vendor utilizing federal funds to certify that the contracted vendor was not suspended or debarred; or 3. Add a clause to appropriate contract to ensure that the contracted vendors were not suspended or debarred. 4. Further these policy requirements for determination of suspension and/ or debarment status of any vendor doing business with the City of East Chicago, in which federal funds and/or federal assistance are utilized shall pertain to "Covered Transactions" under 2 C.F. R. pt. 180, subpt. 8 which include those government contracts for goods and services awarded under a non-procurement transaction (e.g. grant or cooperative agreement) that are expected to equal or exceed $25,000, or meet certain other specified criteria. B. No business with a debarred or suspended entity. It is specifically directed and required that the City of East Chicago, shall not conduct any business with any firm, individual, or entity that has been identified as having been debarred or suspended for such purposes, in conformance with applicable law; in particular, 2CFR 180.300 a. 2 CFR 180.300 states: When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified. You must do this by: 1. Checking SAM Exclusions; or 2. Collecting a certification from that person; or 3. Adding a clause or condition to the covered transaction with that person. Anticipated Completion Date: Corrective action is now in effect as of August 18, 2025.

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