Corrective Action Plans

Finding 1157239 (2024-005)

Material Weakness 2024

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 1157238 (2024-001)

Material Weakness 2024

Greenwich Communities (f/ka)housing Authority of the Town of Greenwich

CT

HUD Housing Programs

Greenwich Communities' Response This finding is mainly due to delays in the processing/payment of utility invoices which was in part attributed to staff shortage in accounts payable and increase in the number of properties under management, whereby the volume of utility invoices increased. In August...

Greenwich Communities' Response This finding is mainly due to delays in the processing/payment of utility invoices which was in part attributed to staff shortage in accounts payable and increase in the number of properties under management, whereby the volume of utility invoices increased. In August 2024, we hired an accountant where his responsibilities include the accounting for utility expenses. We have implemented additional procedures to straighten utility processing to ensure invoices are processed/paid timely including a process to maintain monthly analysis of utility expenses to track invoices and to ensure invoices are processed timely and/or accrued. We also perform variance analysis of expenses whereby significant variations are investigated and resolved. Effective for 2024/2025 utility cost reporting, we have implemented a robust review process whereby the utility cost reports will be prepared by the staff accountant, reviewed by the Controller with final approval by the Chief Financial Officer. We understand that given the timing, this may be a repeat finding for fiscal year December 31, 2025.

View Audit 369561

Finding 1157237 (2024-001)

Material Weakness 2024

Greeley-Weld County Airport Authority

CO

Reporting

The Airport has coordinated with the FAA Airport District Offic Planner and will submit the outstanding SF-425 for the grants open as of 12/31/2024 upon project close out in 2025. Going forward, SF-425 reports will be filed annually by December 31st for all open grants. The Business Manager and Airp...

The Airport has coordinated with the FAA Airport District Offic Planner and will submit the outstanding SF-425 for the grants open as of 12/31/2024 upon project close out in 2025. Going forward, SF-425 reports will be filed annually by December 31st for all open grants. The Business Manager and Airport Director will mainain a compliance calendar to ensure timely submission of future reports.

View Audit 369560

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 1157232 (2024-001)

Material Weakness 2024

Town of Clarkstown

NY

Reporting § 200.512

the Town has recently hired a new Cmptroller who will be overseeing all internal financial controls and processes, including the supervsion and preparation of timely annual SEFA reporting

View Audit 369549

Finding 1157231 (2024-001)

Material Weakness 2024

Glory Revealed Mission

MS

The Organization hired additional personnel along with additional controls implemented by management and supplemental reviews by members of the Board of Directors will increase separation of duties related to accounting functions.

View Audit 369548

Finding 1157230 (2024-001)

Material Weakness 2024

St John's Health Care Corporation

NY

HUD Housing Programs Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

September 29, 2025 U.S. Department of Housing and Urban Development St. John’s Health Care Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bonadio & Co., LLP 171 Sully’s Trail Pittsfor...

September 29, 2025 U.S. Department of Housing and Urban Development St. John’s Health Care Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bonadio & Co., LLP 171 Sully’s Trail Pittsford, NY 14534 Audit Period: January 1, 2024 – December 31, 2024 The findings from the December 31, 2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARD PROGRAMS AUDIT FINDING 2024-001: Section 232, CFDA 14.129 Recommendation: Adhere to the HUD regulatory agreement in relation to obtaining prior written approval from HUD before encumbering the Project. Action Taken: The Home obtained the additional related-party loan as a prudent business decision to meet operating expenses. The Home has implemented procedures to ensure that prior written approval is obtained from HUD before encumbering the Project in the future. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sabrina McLeod at (585)-760-1401. Sincerely yours, _______________________________ Sabrina McLeod Chief Financial Officer

View Audit 369546

Finding 1157229 (2024-002)

Material Weakness 2024

Wellspring Family Services

WA

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Contact Person(s): Calli Clevinger and Cobie Sparks-Howard Corrective Actions in Progress: 1. Policy Reinforcement: Staff will be re-trained on Wellspring’s rent reasonableness policy, with emphasis on the requirement to include comparable unit data on every form. 2. Integration with Move-In Assessm...

Contact Person(s): Calli Clevinger and Cobie Sparks-Howard Corrective Actions in Progress: 1. Policy Reinforcement: Staff will be re-trained on Wellspring’s rent reasonableness policy, with emphasis on the requirement to include comparable unit data on every form. 2. Integration with Move-In Assessment: The rent reasonableness form will now be a required document attached to the move-in assessment. A unit will not be approved for move-in until the rent reasonableness form is fully completed and attached. 3. Secondary Review: Supervisors will conduct a review of all move-in assessments, including the attached rent reasonableness form, prior to final approval. Anticipated Completion Date: Staff re-training: Completed by September 30, 2025 Integration of rent reasonableness into move-in assessment in Salesforce: October 2025 Secondary review and monitoring: Ongoing, beginning immediately Expected Outcome: These actions will ensure that all future rent reasonableness forms are completed, attached to the move-in assessment, and reviewed prior to approval of move-in. This will bring Wellspring into full compliance with both internal policy and audit requirements.

View Audit 369536

Finding 1157228 (2024-002)

Material Weakness 2024

Cirbn, LLC

IL

Procurement, Suspension & Debarment Material Weakness

Suspension and Debarment Recommendation: We recommend that for all federal funded grants CIRBN perform the required suspension and debarment verification, including implementing the necessary policies and internal controls over this process. Explanation of disagreement with audit finding: There is n...

Suspension and Debarment Recommendation: We recommend that for all federal funded grants CIRBN perform the required suspension and debarment verification, including implementing the necessary policies and internal controls over this process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement the necessary controls to ensure we perform the required suspension and debarment verification in the future. Name(s) of the contact person(s) responsible for corrective action: Mark DeKeersgieter Planned completion date for corrective action plan: September 2025

View Audit 369530

Finding 1157227 (2024-004)

Material Weakness 2024

Community Housing Solutions

OH

Subrecipient Monitoring Cash Management Significant Deficiency

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

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

View Audit 369522

Finding 1157225 (2024-003)

Material Weakness 2024

Community Housing Solutions

OH

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

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

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

View Audit 369522

Finding 1157223 (2024-001)

Material Weakness 2024

New Beginnings

WA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

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

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

View Audit 369520 Questioned Costs: $1

Finding 1157222 (2024-001)

Material Weakness 2024

Ogden Housing INC

CT

Questioned Costs HUD Housing Programs

Action Taken: The Project is waiting for HUD’s approval on the waiver. If the waiver is denied the sponsor will return the distributed funds in excess of the amount allowed by the GPR grant terms and deposit them into a Residual Receipts account. If the waiver is approved the sponsor will be allowed...

Action Taken: The Project is waiting for HUD’s approval on the waiver. If the waiver is denied the sponsor will return the distributed funds in excess of the amount allowed by the GPR grant terms and deposit them into a Residual Receipts account. If the waiver is approved the sponsor will be allowed to retain the distributed funds.

View Audit 369518 Questioned Costs: $1

Finding 1157221 (2024-003)

Material Weakness 2024

Nutrition and Health Associates, INC

WI

Procurement, Suspension & Debarment Equipment & Real Property Management

Corrective Action: Management concurs with the finding and will revise its procedures to ensure that all equipment purchases over the capitalization threshold are capitalized in accordance with GAAP, while continuing to meet grant reporting requirements through separate reporting schedules. Wegner p...

Corrective Action: Management concurs with the finding and will revise its procedures to ensure that all equipment purchases over the capitalization threshold are capitalized in accordance with GAAP, while continuing to meet grant reporting requirements through separate reporting schedules. Wegner properly capitalized equipment purchases in accordance with GAAP after the audit finding was discussed in September 2025. The Board of Directors also approved the capitalization threshold to be changed from $2,500 to $5,000 on September 25, 2025. Additionally, starting in September 2025, to prevent dual reporting to grant funded expenses, the outsourced CPA adjusted the accounting software to specifically title accounts as grant funded depreciation expenses and grant funded assets.

View Audit 369516

Finding 1157220 (2024-002)

Material Weakness 2024

Housing Authority of Champaign County

IL

Procurement, Suspension & Debarment Eligibility HUD Housing Programs

2024-002 – Allowable Activities – Moving to Work Demonstration Program - 14.881 Significant Deficiency Statement of Condition and Criteria The Authority does not appropriately evaluate and settle inter-program balances on a periodic basis. The Authority is required to implement and utilize HUD progr...

2024-002 – Allowable Activities – Moving to Work Demonstration Program - 14.881 Significant Deficiency Statement of Condition and Criteria The Authority does not appropriately evaluate and settle inter-program balances on a periodic basis. The Authority is required to implement and utilize HUD program funds in accordance with activities approved in the annual MTW plan. Recommendation We recommend the Authority evaluate and update the system coding of interfund transactions to assist with periodic settlement of balances. In addition, operating transfers should be identified and differentiated from the routine, reciprocal transactions and treated according to their purpose to assist with management of cash balances. Corrective Action The Authority is converting its accounting software to better enable it to manage the various activities of the Authority. Upon conversion, all program balances are to be formally settled. In addition, a process is being developed to capture and identify transactions generated by MTW funded activities to assist with timely and accurate recording.

View Audit 369513

Finding 1157219 (2024-001)

Material Weakness 2024

Housing Authority of Champaign County

IL

HUD Housing Programs

2024-001 – Eligibility – Moving to Work Demonstration Program - 14.881 Significant Deficiency Statement of Condition and Criteria The audit noted instances of late recertifications. PHA’s are required to determine income eligibility, calculate participant rent and housing assistance payments in acco...

2024-001 – Eligibility – Moving to Work Demonstration Program - 14.881 Significant Deficiency Statement of Condition and Criteria The audit noted instances of late recertifications. PHA’s are required to determine income eligibility, calculate participant rent and housing assistance payments in accordance with approved MTW plan and HUD regulations. Recommendation We recommend the Authority continue its work in addressing staff workload and review document workflow to ensure tasks are carried out on schedule. Corrective Action There will be an intensive focus on program integrity throughout the programs, including staff capability, training and monitoring. In addition, the Authority is converting its programmatic and accounting software to better enable it to manage the various activities of the Authority.

View Audit 369513

Finding 1157218 (2024-003)

Material Weakness 2024

Clark County

IN

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

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

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

View Audit 369511

Finding 1157216 (2024-001)

Material Weakness 2024

Npower Inc.

NY

Cash Management Reporting

Corrective Action Planned: The organization has been using the Microsoft Approvals app to capture approvals of expenditure reports and requests for drawdowns, in addition to the frequent weekly review meetings and approvals process to satisfy Uniform Guidance 2 CFR 200.511c and for Single Audit evid...

Corrective Action Planned: The organization has been using the Microsoft Approvals app to capture approvals of expenditure reports and requests for drawdowns, in addition to the frequent weekly review meetings and approvals process to satisfy Uniform Guidance 2 CFR 200.511c and for Single Audit evidence. Name(s) of Contact Person(s) Responsible for Corrective Action: Stefanie Boles, Chief Administrative Officer; Patrick Ma, Vice President for Finance and Business Operations Anticipated Completion Date: This change has already taken place as of September 2025.

View Audit 369500

Finding 1157209 (2024-003)

Material Weakness 2024

County of Fulton New York

NY

Reporting

The Treasurer will evaluate SEFA reporting to confirm that adequate internal controls are in place to support its completeness. The Accountant will collaborate with the Treasurer to ensure its accuracy.

View Audit 369498

Finding 1157181 (2024-001)

Material Weakness 2024

Skagit County

WA

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

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

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

View Audit 369495

Finding 1157180 (2024-001)

Material Weakness 2024

The Carmelite System, Inc.

NY

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

To whom it may concern: The Carmelite System, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number as...

To whom it may concern: The Carmelite System, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING – FEDERAL AWARD PROGRAM AUDITS 2024-001 Federal Agency: U.S. Department of Homeland Security Federal Program Title: Federal Emergency Management Agency Disaster Grants Assistance Listing Number: 97.036 Federal Award Number and Year: 4496DR 2024 Pass-Through Agency: State of Massachusetts Pass-Through Number: CTFEMA4496STPAT00971 Criteria or Specific Requirement: In accordance with 2 CFR §200.403(g), to be allowable under federal awards, costs must be adequately documented. Additionally, 2 CFR §200.303 requires non-federal entities to establish and maintain effective internal control over the federal award that provides reasonable assurance that the entity is managing the award in compliance with federal statutes, regulations, and the terms and conditions of the award. Condition: During testing of expenditures under the FEMA grant, the System was unable to provide documentation showing approval of an invoice dated May 2020. This invoice was selected as part of the single audit sample. The lack of approval documentation represents a deficiency in internal controls over compliance with federal requirements. Questioned Costs: None. Context: The invoice in question was incurred in May 2020, prior to the implementation of the Acumatica AP approval workflow. In June 2020, the facility transitioned to Acumatica, which provides electronic tracking of invoice approvals. Cause: At the time of the expenditure, the facility did not have a centralized or electronic approval process in place. Approval documentation was maintained manually and was not retained or accessible during the audit. Effect: The absence of approval documentation for the invoice creates a risk that expenditures may not be properly reviewed or authorized, potentially leading to noncompliance with federal requirements. Although the cost was ultimately deemed allowable, the control deficiency could impact future compliance if not addressed. Recommendation: We recommend that the System ensure all expenditures under federal awards are supported by documented approvals. For legacy transactions, efforts should be made to retain or reconstruct approval documentation where feasible. Continued use and monitoring of the Acumatica system should be maintained to ensure compliance going forward. Planned Corrective Actions: Management agrees with the finding. The invoice in question was incurred during an emergency response period prior to the implementation of the Acumatica system. While approval was likely obtained at the time, documentation was not retained. With the implementation of the Acumatica AP approval process in June 2020, the System has taken appropriate steps to address the finding and enhance internal controls over invoice approvals. Name of contact person responsible for corrective action: Corrinne Schindler

View Audit 369486

Finding 1157179 (2024-001)

Material Weakness 2024

The Just One Project

NV

Allowable Costs / Cost Principles Eligibility Significant Deficiency

The Just One Project's CSFP team will maintain a filing system organized by service site, alphabetical client name, and month and year of registration. The team will also utilize the Salesforce system to track registered clients, recertification dates, and services provided each day. Effective immed...

The Just One Project's CSFP team will maintain a filing system organized by service site, alphabetical client name, and month and year of registration. The team will also utilize the Salesforce system to track registered clients, recertification dates, and services provided each day. Effective immediately, designated CSFP staff will visit all active distribution sites each business day to collect new registration and recertification forms, cross-check them and previously filed forms against the day's Salesforce distribution list, and file new forms in the designated system. This will ensure every client record is complete and current. In addition, the team will conduct an internal audit at least annually to confirm that all participant files contain required documents and certifications, promptly address any deficiencies, and document corrective steps. Staff will also receive periodic refresher training to reinforce record-keeping standards and sustain compliance.

View Audit 369485

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

Corrective Action Plans

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