Corrective Action Plans

Finding 570439 (2024-001)

Material Weakness 2024

Deerfield Twp School District

NJ

METHOD OF IMPLEMENTATION: Review Audit and Account Software reports for Fund 20.

View Audit 361397

Finding 570101 (2024-001)

Significant Deficiency 2024

City of Ely, Minnesota

MN

Internal Control / Segregation of Duties

Finding Number: 2024-001 Name of Contact Person: Harold Langowski, City Clerk-Treasurer Corrective Action Planned: Clerk-Treasurer will attempt to monitor transactions and structure the duties of office personnel to help ensure as much segregation of duties as possible within the City’s staffin...

Finding Number: 2024-001 Name of Contact Person: Harold Langowski, City Clerk-Treasurer Corrective Action Planned: Clerk-Treasurer will attempt to monitor transactions and structure the duties of office personnel to help ensure as much segregation of duties as possible within the City’s staffing limitations and funding constraints. Anticipated Completion Date: Management has been monitoring transactions and reviewing the duties of office personnel on an ongoing basis.

View Audit 361379

Finding 570093 (2024-017)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Reporting § 200.302 § 200.510

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement internal control procedures to reconcile federal awards with the expenditures and revenue received to ensure completeness and accuracy in financial rep...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement internal control procedures to reconcile federal awards with the expenditures and revenue received to ensure completeness and accuracy in financial reporting. The Group will prepare and maintain an accurate SEFA in accordance with 2 CFR 200.510 to ensure proper documentation and compliance with federal reporting requirements. Group staff are trained on the requirements related to federal award reconciliations and SEFA preparation which mitigates the risk of noncompliance in the future.

View Audit 361368

Finding 570081 (2024-014)

Material Weakness 2024

West Central Mental Health Center, Inc.

CO

Reporting § 200.302 § 200.510

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement internal control procedures to reconcile federal awards with the expenditures and revenue received to ensure completeness and accuracy in financial rep...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement internal control procedures to reconcile federal awards with the expenditures and revenue received to ensure completeness and accuracy in financial reporting. The Group will prepare and maintain an accurate Schedule of Expenditures of Federal Awards (SEFA) in accordance with 2 CFR Part 200.510 to ensure proper documentation and compliance with federal reporting requirements. Group staff are trained on the requirements related to federal award reconciliations and SEFA preparation which mitigates the risk of noncompliance in the future.

View Audit 361368

Finding 570078 (2024-029)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Allowable Costs / Cost Principles

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will revise the current written cost allocation policy to clearly define how fringe benefits are to be accounted for, allocated and applied across all federal programs. The poli...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will revise the current written cost allocation policy to clearly define how fringe benefits are to be accounted for, allocated and applied across all federal programs. The policy will ensure consistency, compliance with 2 CFR Part 200, and equitable allocation based on actual benefit expended.

View Audit 361368

Finding 570077 (2024-028)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that documentation of all required reports are submitted in a timely manner in accordance with grant terms and conditions,...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that documentation of all required reports are submitted in a timely manner in accordance with grant terms and conditions, including evidential support of timing of submission of required reports such as submission confirmations or logs. These internal controls ensure oversight of reporting requirements that are outsourced to vendors.

View Audit 361368

Finding 570075 (2024-027)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles § 200.403 § 200.405

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Unif...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Uniform Guidance.

View Audit 361368 Questioned Costs: $1

Finding 570074 (2024-026)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.403

agreement, the Group will implement grant monitoring internal controls and procedures to ensure that expenditures comply with all earmarking limitations specified in grant agreements and approved budgets. These procedures will track expenditures by budget category and verify compliance prior to subm...

agreement, the Group will implement grant monitoring internal controls and procedures to ensure that expenditures comply with all earmarking limitations specified in grant agreements and approved budgets. These procedures will track expenditures by budget category and verify compliance prior to submitting reimbursement requests.

View Audit 361368 Questioned Costs: $1

Finding 570072 (2024-025)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.403

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance wi...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance with regard to the period of performance requirements.

View Audit 361368 Questioned Costs: $1

Finding 570070 (2024-024)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.430

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate calculation of payroll costs incurred under the federal programs, including r...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate calculation of payroll costs incurred under the federal programs, including review and monitoring of process and procedures. In addition, documentation ensuring accurate payroll costs allocated to federal programs, along with support of review and approval of such expenses, will be retained in accordance with federal regulations.

View Audit 361368 Questioned Costs: $1

Finding 570066 (2024-023)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.305

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will ensure that all reimbursable costs are submitted for reimbursement in a timely manner. The Group has significant experience in submitting for reimbursement for federal, sta...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will ensure that all reimbursable costs are submitted for reimbursement in a timely manner. The Group has significant experience in submitting for reimbursement for federal, state, and similar types of grants and contracts.

View Audit 361368

Finding 570062 (2024-022)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.302 § 200.329

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to design and implement internal controls related to federal program grant management, including assignment of responsibility for grant oversight to sp...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to design and implement internal controls related to federal program grant management, including assignment of responsibility for grant oversight to specific individuals or departments.

View Audit 361368

Finding 570061 (2024-021)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.302 § 200.430

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to implement internal controls over tracking of expenditures related to federal award grants, especially personnel costs, and the related reimbursed co...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to implement internal controls over tracking of expenditures related to federal award grants, especially personnel costs, and the related reimbursed cost to ensure compliance with federal requirements.

View Audit 361368

Finding 570058 (2024-020)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Allowable Costs / Cost Principles Cash Management Eligibility § 200.334

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently ...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently reviewed, approved, submitted, retained and retrievable for the required retention period. This includes quarterly reports, expense reimbursement packets submitted to the grantors, project expenditure reports, or other grant-related records necessary to demonstrate compliance with federal reporting and record retention standards under the federal programs.

View Audit 361368

Finding 570055 (2024-019)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Procurement, Suspension & Debarment

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to revise the procurement policy to include a formal procedure requiring suspension and debarment verification for all covered transactions prior to ve...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to revise the procurement policy to include a formal procedure requiring suspension and debarment verification for all covered transactions prior to vendor engagement. This process will include retaining documentation (e.g., dated SAM.gov search results or signed vendor certifications) in the procurement file for regulatory compliance.

View Audit 361368

Finding 570054 (2024-018)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Allowable Costs / Cost Principles Reporting § 200.302

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement internal control procedures to establish separate accounts, classification, use of cost centers and project codes to clearly distinguish expenditures by funding s...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement internal control procedures to establish separate accounts, classification, use of cost centers and project codes to clearly distinguish expenditures by funding source, especially federal and state funds, as well as revenues received.

View Audit 361368

Finding 570053 (2024-016)

Material Weakness 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Gro...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Group will reconcile budgeted and actual fringe benefit costs regularly to ensure continued compliance.

View Audit 361368 Questioned Costs: $1

Finding 570052 (2024-015)

Material Weakness 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.430

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate accounting of payroll costs incurred under the federal programs, including re...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate accounting of payroll costs incurred under the federal programs, including review and monitoring of processes and procedures. Documentation ensuring accurate payroll costs allocated to federal programs, along with support of review and approval of such charges, will be retained in accordance with federal regulations.

View Audit 361368 Questioned Costs: $1

Finding 570038 (2024-006)

Significant Deficiency 2024

Passage Home

NC

Questioned Costs Allowable Costs / Cost Principles Cash Management

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend the Corporation review the expenditures submitted to sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findin...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend the Corporation review the expenditures submitted to sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Within 60 days of audit issuance, the Interim CFO will conduct training for finance staff regarding accounts payable invoices and sales tax requirements and coding. Updated accounts payable policies and procedures include a process to ensure that the CFO reviews and codes sales tax when checks are prepared, approved and signed. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 09/30/2025

View Audit 361326 Questioned Costs: $1

Finding 570037 (2024-005)

Material Weakness 2024

Passage Home

NC

Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.403

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation strengthen its internal controls over cash disbursements. This should include retention of payments supported by valid invoices and proof of payment documentation as well as peri...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation strengthen its internal controls over cash disbursements. This should include retention of payments supported by valid invoices and proof of payment documentation as well as periodic internal audits to ensure compliance with the documentation requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All purchase-related supporting documentation will be transitioned to paper files to eliminate confusion created by the electronic record-keeping system, and to ensure that all staff requiring access to such documentation can immediately and easily retrieve them. Records will be maintained in the Finance Department office for seven years. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 06/12/2025

View Audit 361326 Questioned Costs: $1

Finding 570036 (2024-004)

Material Weakness 2024

Passage Home

NC

Questioned Costs Allowable Costs / Cost Principles § 200.403

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation implement internal controls over the reconciliation of payroll reports to grant expenditures. This should include regular reconciliations and reviews to ensure that all payroll c...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation implement internal controls over the reconciliation of payroll reports to grant expenditures. This should include regular reconciliations and reviews to ensure that all payroll costs charged to the grant are adequately supported by detailed payroll records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A payroll salary reconciliation report will be completed after each payroll issued and will be verified against the grant reports, accounting system class coding and employee-specific payroll file(s). Printed reports will be maintained on file in the Finance Department for historical reference. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 06/12/2025

View Audit 361326 Questioned Costs: $1

Finding 570035 (2024-003)

Material Weakness 2024

Passage Home

NC

Eligibility Material Weakness Internal Control / Segregation of Duties

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing intake forms, provide training to staff on the importance of maintaining proper documentation and the pr...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing intake forms, provide training to staff on the importance of maintaining proper documentation and the procedures for completing and reviewing eligibility determinations, and implement periodic internal audits to ensure compliance with documentation requirements and to identify any areas needing improvement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In fiscal year 2025, Passage Home implemented new programmatic policies and procedures ensuring that a Program Manager or the Program Director reviews and approves (by signature) all new client enrollments prior to case manager assignment. The Program Director will conduct related training for all program staff and will administer quarterly client record audits (peer or supervisor review) to verify ongoing compliance. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 03/26/2025

View Audit 361326

Finding 570034 (2024-002)

Material Weakness 2024

Passage Home

NC

Material Weakness Internal Control / Segregation of Duties

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing forms, provide training to staff on the importance of maintaining proper documentation and the procedure...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing forms, provide training to staff on the importance of maintaining proper documentation and the procedures for completing and reviewing compliance requirements, and implement periodic internal audits to ensure compliance with documentation requirements and to identify any areas needing improvement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During 2024, Passage Home experienced unprecedented change, including extensive staff turnover and extended vacancies in key positions. Of note, the entire leadership team transitioned out, the Supportive Services for Veteran Families Program Manager (SSVF) left, and 4 new SSVF program team members were onboarded within the year. Additionally, the finance department migrated to a new accounting system that ultimately proved to be unsatisfactory for the organization's needs. Management appreciates and agrees with the auditors' recommendations and has implemented and/or initiated the indicated operational adjustments. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 03/26/2025

View Audit 361326

Finding 570025 (2024-007)

Material Weakness 2024

City of Osceola, Iowa

IA

Procurement, Suspension & Debarment

THIS WILL BE IMPLEMENTED ON FUTURE PROJECTS.

View Audit 361308

Finding 569994 (2024-008)

Material Weakness 2024

Greene County Board of Education

NC

Equipment & Real Property Management Procurement, Suspension & Debarment Material Weakness

Finding: 2024-008 Name of Contact Person: Jessica Gregory, Finance Officer Corrective Action: Personnel will receive adequate training to ensure duties are completed in a timely and accurate manner. Procedures will be developed as necessary. Proposed Completion Date: Immediately.

View Audit 361261

Corrective Action Plans

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