Corrective Action Plans

Finding 575829 (2024-001)

Significant Deficiency 2024

City of Lake Lillian

MN

Name of Contact Person: Casey Ochs, City Clerk

View Audit 365805

Finding 575829 (2024-001)

Significant Deficiency 2024

City of Lake Lillian

MN

Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure he is aware of financial statement requirements and new pronouncements.

View Audit 365805

Finding 575829 (2024-001)

Significant Deficiency 2024

City of Lake Lillian

MN

Proposed Completion Date: The City Council will implement the above procedures immediately.

View Audit 365805

Finding 575821 (2024-001)

Material Weakness 2024

Beacon, Inc.

IN

Internal Control / Segregation of Duties Material Weakness Reporting

2024 CORRECTIVE ACTION PLAN July 30, 2025 Beacon, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Blue & Co., LLC 720 E Pete Rose Way, Suite 100 Cincinnati, OH 45202 Audit period: January 0...

2024 CORRECTIVE ACTION PLAN July 30, 2025 Beacon, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Blue & Co., LLC 720 E Pete Rose Way, Suite 100 Cincinnati, OH 45202 Audit period: January 01, 2024 - December 31, 2024 Beacon, Inc.’s response to the findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Financial Statement Findings 2024-001 Finding: Preparation of Financial Statements Management’s response: Management concurs with the above finding and, accordingly, has engaged the auditors to assist with the preparation of the 2024 year-end external financial statements. Action planned: Engagement of the auditors to assist with the preparation of the 2024 year-end external financial statements. Management is currently reviewing the procedures and controls in place to address the preparation and review of external year-end financial statements and will revise and enhance as warranted. Implementation Date: Ongoing Responsible Person: Rev Forrest Gilmore, Executive Director Respectfully submitted, _________________________________________________________ Rev. Forrest Gilmore Executive Director

View Audit 365803

Finding 575820 (2024-001)

Significant Deficiency 2024

Genesis Nonprofit Housing Corporation

MI

Eligibility HUD Housing Programs Significant Deficiency

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.

View Audit 365801

Finding 575819 (2024-002)

Significant Deficiency 2024

Anita Moreau "food Program Specialist"

TX

Subrecipient Monitoring Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has assigned an employee charged with ensuring monitored visits occur in compliance with 4337 of the Texas Department of Agriculture - Child and Adult Care Food Program - Child Care Centers Handbook. This employee ensures mo...

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has assigned an employee charged with ensuring monitored visits occur in compliance with 4337 of the Texas Department of Agriculture - Child and Adult Care Food Program - Child Care Centers Handbook. This employee ensures monitored visists occur and meals monitored do not include snacks. Monitored visits are based on the meal times with the greatest number of meals served at the centers. These were discovered before the audit and procedures were implemented to rectify these two instances before year-end. Twinkle Wonders Rice: This facility was formely called Kaleidoscope. Because of the change in management, the facility did not have a full program year to be monitored. This is where confusion emerged regarding amount of monitors and monitoring events needed versus what actually occured. Top Leaders: This facility was monitored three times during the year. Two of these monitors were PM snacks. There were monitored August 2024 and a follow-up was scheduled for September 2024. The facility must be given enough time to correct its recommendations. Because the issue was so close to the end fo the program year, there was not enough time to proceed with the follow-up and another monitoring of an additional meal. The facility's next monitoring event was a meal, but it was visited in the following program year.

View Audit 365800

Finding 575812 (2024-005)

Significant Deficiency 2024

City of Ellsworth

ME

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.317 § 200.318 § 200.327

Finding 2024-005 – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Nate Moore, Finance Director Corrective Action: The Finance Department will regularly ensure that the procurement policy for the City is followed, and will be sure that it is reviewed often ...

Finding 2024-005 – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Nate Moore, Finance Director Corrective Action: The Finance Department will regularly ensure that the procurement policy for the City is followed, and will be sure that it is reviewed often to be sure that no modifications or adjustments need to be made. Anticipated Completion Date: June 30, 2026

View Audit 365798

Finding 575809 (2024-004)

Significant Deficiency 2024

City of Ellsworth

ME

Allowable Costs / Cost Principles § 200.303

Finding 2024-004 – Allowable Cost/Cost Principles Contact Person Responsible for Corrective Action: Nate Moore, Finance Director Corrective Action: All invoices paid by the City will appear on the weekly warrant ensuring that all monies paid are first reviewed by City Manager and finally overseen by...

Finding 2024-004 – Allowable Cost/Cost Principles Contact Person Responsible for Corrective Action: Nate Moore, Finance Director Corrective Action: All invoices paid by the City will appear on the weekly warrant ensuring that all monies paid are first reviewed by City Manager and finally overseen by the Finance Committee. Anticipated Completion Date: June 30, 2026

View Audit 365798

Finding 575802 (2024-001)

Material Weakness 2024

Mary Lee Community

TX

Eligibility HUD Housing Programs Reporting

Recommendation: The Cornerstone and Legacy projects were disposed of by sale and contribution, respectively, and all HOME-related loans and related compliance requirements were assumed by Foundation Communities (an unrelated nonprofit organization) or one of its affiliates during May 2024. Therefore...

Recommendation: The Cornerstone and Legacy projects were disposed of by sale and contribution, respectively, and all HOME-related loans and related compliance requirements were assumed by Foundation Communities (an unrelated nonprofit organization) or one of its affiliates during May 2024. Therefore, we have no recommendation for this finding. Action taken: Management agrees with the finding. No action is needed.

View Audit 365790

Finding 575800 (2024-003)

Significant Deficiency 2024

Cherokee Hills Utility District

TN

As of this date I was unaware of Section 6-56-lll(a) and To Whom It May Concern rest assure all receipts will be deposited in a timely matter.

View Audit 365778

Finding 575799 (2024-002)

Significant Deficiency 2024

Cherokee Hills Utility District

TN

The District will consider the recommendation and explore options for implementation.

View Audit 365778

Finding 575798 (2024-001)

Significant Deficiency 2024

Cherokee Hills Utility District

TN

Internal Control / Segregation of Duties

Due to the size of the District's administration and limited number of employees, total segregation of duties is not feasible at this time. The Board of Commissioners will continue to be closely involved in financial reporting and will continue to provide oversight in order to mitigate risk of misap...

Due to the size of the District's administration and limited number of employees, total segregation of duties is not feasible at this time. The Board of Commissioners will continue to be closely involved in financial reporting and will continue to provide oversight in order to mitigate risk of misappropriation of assets.

View Audit 365778

Finding 575797 (2024-001)

Significant Deficiency 2024

Rockingham Planning Commission

NH

Allowable Costs / Cost Principles Significant Deficiency

Planned Corrective Action: Assistant Director to review and initial all Executive Director's timesheets. Planned Implementation Date of Corrective Action: July 2024 Person Responsible for Corrective Action: Annette Pettengill

View Audit 365777

Finding 575796 (2024-005)

Material Weakness 2024

Union County Fiscal Court

KY

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness

Prepared by: Lissa Gibson, Union County Treasurer Date Prepared: 6-20-2025 Person Responsible for Corrective Action Plan: Jill Hunley or Kim Nance Anticipated Completion Date: Already jmplemented Official's Response: This is a rollover comment from FY 22 and 23 regarding expenditures in general....

Prepared by: Lissa Gibson, Union County Treasurer Date Prepared: 6-20-2025 Person Responsible for Corrective Action Plan: Jill Hunley or Kim Nance Anticipated Completion Date: Already jmplemented Official's Response: This is a rollover comment from FY 22 and 23 regarding expenditures in general. If purchase orders are not issued on the day of purchase they were dated the date the invoices were received. This has been corrected to match the date of invoice.

View Audit 365767

Finding 575782 (2024-001)

Material Weakness 2024

Overdose Lifeline, Inc.

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Finding 2024-01 Financial Close Process Condition: The auditors noted a lack of a strong financial close process which led to several material audit adjustments that were proposed during the audit and recorded by the client to properly reflect various financial statement accounts. Corrective Actio...

Finding 2024-01 Financial Close Process Condition: The auditors noted a lack of a strong financial close process which led to several material audit adjustments that were proposed during the audit and recorded by the client to properly reflect various financial statement accounts. Corrective Actions Taken or Planned: The Organizations’ Board and Executive Team consisting of the CEO, COO and key Organization staff to include the independent bookkeeper and Grant and Finance Manager recognize the need to further significantly improve on the oversight and reconciliation of the financial statement process. The team will develop processes to include but not limited to. - A comprehensive financial close process will be formalized and documented. This process will include clear timelines, task ownership, and internal controls to ensure the timely and accurate reconciliation of all accounts prior to audit submission. - Beginning in 2025, all financial transactions and balances will undergo rigorous monthly reviews to ensure proper classification in the correct financial statement accounts, reducing the likelihood of errors. - Quarterly meetings will occur to review entries and approval of entry assignment will occur.

View Audit 365764

Finding 575781 (2024-001)

Significant Deficiency 2024

City of Chisholm

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency

The City Clerk-Treasurer will attempt to monitor transactions and structure the duties of the office personnel to ensure as much segregation of duties as possible within the City's staffing limitations and funding constraints.

View Audit 365757

Finding 575780 (2024-001)

None 2024

Town of Foxborough, Massachusetts

MA

Internal Control / Segregation of Duties

July 28, 2025 The Town of Foxborough, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Robert E. Brown II, CPA 25 Cemetery Street P.O. Box 230 Mendon, Massachusetts 01756 Audit perio...

July 28, 2025 The Town of Foxborough, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Robert E. Brown II, CPA 25 Cemetery Street P.O. Box 230 Mendon, Massachusetts 01756 Audit period: The finding from the June 30, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule of expenditures of federal awards. Finding 2024-001 – Education Stabilization Fund – AL No. 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Other Matters Related to Internal Control over Compliance of the Major Program Criteria: Where employees work solely or partially on a single Federal program or cost objective, their salaries or wages must be supported by periodic certification that the employee worked on this program for the period covered by the program. The certifications should be prepared at least semi-annually, and should be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Condition: During our test of controls over compliance with time and effort certifications the Town was not able to provide evidence that the required certifications of time and effort for those employees whose time was spent either completely or partially spent on this program was performed as required by Uniform Guidance. Questioned Costs: Unknown Context: During our test of payroll transactions of the major program (Education Stabilization Fund) it was noted that 2 of the employees charged to this major program had time and effort certifications that were only completed annually as opposed to being prepared at least semi-annually. Effect: The Town was not in compliance with the time and effort certification requirements. Cause: In Fiscal Year 2024, the employee in charge of grant management was under the assumption that annual time and effort certifications were sufficient. Individuals involved with the grants were informed in Fiscal Year 2025 that semi-annual time and effort certifications were required. Identification as a Repeat Finding: N/A Recommendation: We recommend the Town of Foxborough follow procedures to ensure that semi-annual certifications and/or monthly certifications are prepared and signed by either the employees and/or supervisory official having first-hand knowledge of the work performed by the employees in a timely manner in order to comply with the time and effort certification requirement. Responsible for Corrective Plan: Karin Sheridan, School Business Administrator Estimated Completion Date: This process of semi-annually began with Fiscal Year 2025. Action Taken: Individuals involved with grant management began the process of semi-annual certifications in Fiscal Year 2025.

View Audit 365754

Finding 575779 (2024-003)

Significant Deficiency 2024

Town of Mountain Village

CO

Procurement, Suspension & Debarment Subrecipient Monitoring

COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The Town should update all contracts to include a suspension and debarment paragraph to verify status with every renewal or collecting certification from the proposed entity. Additionally, th...

COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The Town should update all contracts to include a suspension and debarment paragraph to verify status with every renewal or collecting certification from the proposed entity. Additionally, the Town should update procedures to ensure that a vendor’s status is checked in SAM.gov prior to contracting with a vendor. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The Town will require all contracts related to federal awards to include a suspension and debarment paragraph to verify status with every renewal or collecting certification from the proposed entity. Additionally, procedures have been updated to ensure that a vendor’s status is checked in SAM.gov prior to contracting with a vendor. Name of the Contact Person Responsible for Corrective Action: Lizbeth Lemley, Finance Director Planned Completion Date for Corrective Action Plan: Procedure updates will be complete by September 30, 2025, and these actions will be implemented upon execution of the next contract related to a federal award.

View Audit 365751

Finding 575778 (2024-004)

Material Weakness 2024

St. Jude's Ranch for Children, Inc.

NV

Subrecipient Monitoring § 200.332

System of Internal Controls Over Compliance: Subrecipient Monitoring; U.S. Department of Treasury, Assistance Listing #21.027, Coronavirus State and Local Fiscal Recovery Funds, Passed Through State of Nevada Criteria: In accordance with 2 CFR 200.332, the auditee must maintain a system of internal ...

System of Internal Controls Over Compliance: Subrecipient Monitoring; U.S. Department of Treasury, Assistance Listing #21.027, Coronavirus State and Local Fiscal Recovery Funds, Passed Through State of Nevada Criteria: In accordance with 2 CFR 200.332, the auditee must maintain a system of internal control over compliance to ensure they provide each subrecipient within the required appropriate document the performance of internal controls over the compliance for subrecipient monitoring. Condition: The Organization did not appropriately implement internal controls necessary to ensure appropriate documentation was available to support the performance of controls in compliance with 2 CFR 200.332. Context: The Organization did not identify funds being passed through from one subsidiary of the Organization to a second subsidiary in a timely manner and based on this timing did not appropriately document the performance of internal controls over the compliance of subrecipient monitoring. Cause: The Organization did not identify its only subrecipient for this award in a timely manner. Effect: The Organization was not able to properly document its performance of internal controls over most of the requirements outlined in 2 CFR 200.332 for the award based on untimely identification of its subrecipient. Recommendation: We recommend management design and implement a system of internal controls over compliance where consideration of possible subrecipients is considered when the award is being applied for and that well documented and supportable internal controls over subrecipient monitoring are implemented when there are subrecipients identified under an award. Views of Responsible Officials and Planned Corrective Actions: SJRC NV Region is addressing its missing controls related to the requirements of 2 CFR 200.332. We acknowledge that SJRC must ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the information required under 2 CFR 200.332 at the time of the subaward all requirements. This includes that every subaward is clearly identified to the subrecipient as a subaward and includes at the time of the subaward and if any data elements change, that there must be an approved subaward modification. We will also ensure we meet the requirements under 2 CFR 200.332 to include our obligations to risk assess and monitor any subrecipients. The timeframe for correction is immediate and full accounting system control improvements will be implemented as part of our 2025 fiscal year-end close. Submitted by: Dr. Christina Vela, DPP Chief Executive Officer St. Jude's Ranch for Children, Inc. and its subsidiaries cvela@stjudesranch.org

View Audit 365748

Finding 575775 (2024-002)

Material Weakness 2024

Community Action Team, Inc.

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

2024-002 Federal Award Special Reporting - Federal Funding Accountability and Transparency Act (FFATA)- Material Non-Compliance and Material Weakness in Internal Controls over Compliance (Repeat of finding 2023-003} Recommendation: The Organization should establish written policies and procedures r...

2024-002 Federal Award Special Reporting - Federal Funding Accountability and Transparency Act (FFATA)- Material Non-Compliance and Material Weakness in Internal Controls over Compliance (Repeat of finding 2023-003} Recommendation: The Organization should establish written policies and procedures regarding review of grant agreements for compliance requirements along with written policies and procedures for first-tier subawards including tracking and proper internal control procedures. Action Taken: Management concurs with the finding and has defined corrective action to address it. We understand a material weakness is identified in the internal control over special reporting. We have identified gaps in our reporting processes and worked to implement changes to ensure compliance with special reporting requirements. The responsibility for reporting under the Federal Funding Accountability and Transparency Act (FFATA) will be within the Fiscal Department. Policies and procedures will be updated regarding special reporting requirements. The Fiscal department will also be responsible for reviewing all contracts to identify all compliance requirements. Tracking procedures will be implemented to ensure reports are filed timely. The above identified corrective action was implemented in July 2024. Stacey Wilson, Fiscal Director, has implemented a tracking system for the FFATA.

View Audit 365745

Finding 575774 (2024-002)

Material Weakness 2024

North Valley Caring Services

CA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302

Management concurs with the finding and will revise procedures to ensure detailed, timely recording of USDA Foods distributions. Staff will receive training on documentation requirements, and management will implement periodic compliance reviews. These corrective actions are expected to be complet...

Management concurs with the finding and will revise procedures to ensure detailed, timely recording of USDA Foods distributions. Staff will receive training on documentation requirements, and management will implement periodic compliance reviews. These corrective actions are expected to be completed by March 1, 2025.

View Audit 365739

Finding 575773 (2024-001)

Material Weakness 2024

North Valley Caring Services

CA

Subrecipient Monitoring Eligibility

Management concurs with the finding. NVCS was followed guidance received from the pass‐through entity but did not fully implement the required proxy documentation format. Management will revise procedures to ensure that the “Volunteer Proxy: [Name]” designation is clearly included where applicable...

Management concurs with the finding. NVCS was followed guidance received from the pass‐through entity but did not fully implement the required proxy documentation format. Management will revise procedures to ensure that the “Volunteer Proxy: [Name]” designation is clearly included where applicable and will provide training to distribution staff. Internal monitoring will be implemented to ensure future compliance. The corrective action is expected to be fully implemented by March 1, 2025.

View Audit 365739

Finding 575769 (2024-002)

Material Weakness 2024

Catherine's Health Center

MI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a ...

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.

View Audit 365733

Finding 575731 (2024-003)

Material Weakness 2024

City of Rhinelander

WI

Procurement, Suspension & Debarment § 200.318 § 200.320

Reference: 2024-003 Corrective Action: The City will work on updating the procurement policy to include clearer expectations. Responsible Person: Kristopher Hanus Frederickson, Mayor; Patrick Reagan, City Administrator; Wendi Bixby, Finance Director/Treasurer Anticipated Completion Date: 12/31/2...

Reference: 2024-003 Corrective Action: The City will work on updating the procurement policy to include clearer expectations. Responsible Person: Kristopher Hanus Frederickson, Mayor; Patrick Reagan, City Administrator; Wendi Bixby, Finance Director/Treasurer Anticipated Completion Date: 12/31/2025

View Audit 365725

Finding 575730 (2024-003)

Material Weakness 2024

Parkview Services

WA

Reporting Matching / Level of Effort / Earmarking § 200.502

Management agrees with this finding. Parkview Services will implement a formal SEFA preparation checklist by December 31st, 2025 that requires Finance Director to review federal loan agreements, program-specific compliance supplements, and prior year SEFAs to ensure all applicable programs are repor...

Management agrees with this finding. Parkview Services will implement a formal SEFA preparation checklist by December 31st, 2025 that requires Finance Director to review federal loan agreements, program-specific compliance supplements, and prior year SEFAs to ensure all applicable programs are reported. The checklist will include a step to verify whether any federal loans with ongoing compliance requirements, including EIDL, must be included even if no new funds were expended during the audit period. The Finance Director will find and take trainings and seek out updates on federal reporting requirements, including any programspecific guidance for all federal awards held by the organization. Finance Director will monitor and idetntify of continuing compliance requirements for loans, as well as the treatment of federal loans in the SEFA. Before finalizing the SEFA each year, the Finance Director will perform a documented review of the draft against the checklist and supporting loan documentation. The Executive Director will provide a secondary review to confirm completeness before submission to the auditors. This dual review process will begin with the preparation of the 2025 SEFA.

View Audit 365724

Corrective Action Plans

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