Corrective Action Plans

Finding 1163356 (2024-002)

Material Weakness 2024

MI

Reporting

Management agrees that additional support was required to prepare a complete and accurate SEFA for the audit period. The need for assistance was largely due to the same staffing vacancy in the accounting department, which delayed the financial close process and limited internal capacity to compile a...

Management agrees that additional support was required to prepare a complete and accurate SEFA for the audit period. The need for assistance was largely due to the same staffing vacancy in the accounting department, which delayed the financial close process and limited internal capacity to compile and review federal expenditure information in a timely manner. To strengthen controls, management is formalizing SEFA preparation procedures, including earlier identification of federal awards, timely reconciliation of expenditures, and improved documentation of grant activity. Cross-training is being implemented to ensure coverage when key roles are vacant, and a second-level review process will be incorporated before the SEFA is finalized. Management anticipates that these measures will ensure accurate and timely SEFA preparation in future periods.

View Audit 372865

Finding 1163355 (2024-001)

Material Weakness 2024

METRO SOLUTIONS, INC. AND SUBSIDIARY

MI

Reporting § 200.512

Management acknowledges the delay in submitting the Single Audit reporting package to the Federal Audit Clearinghouse. The late submission was primarily the result of delays in the year-end financial close process caused by a vacancy within the accounting department and the additional time required ...

Management acknowledges the delay in submitting the Single Audit reporting package to the Federal Audit Clearinghouse. The late submission was primarily the result of delays in the year-end financial close process caused by a vacancy within the accounting department and the additional time required to fill and train for that position. These staffing challenges impacted the timing of the audit and, consequently, the submission deadline. To address this going forward, management has strengthened its close process by reallocating responsibilities during staffing gaps, cross-training existing personnel, and ensuring adequate coverage for key accounting functions. Management has also implemented a compliance calendar and designated responsibility for monitoring all audit-related deadlines to help ensure timely preparation and submission of future reporting packages. All corrective actions will be fully implemented prior to the next audit cycle.

View Audit 372865

Finding 1163340 (2024-012)

Material Weakness 2024

Canadian County

OK

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

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 372861

Finding 1163339 (2024-010)

Material Weakness 2024

Canadian County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compli...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 372861

Finding 1163338 (2024-003)

Material Weakness 2024

Upper Missouri District Health Unit

ND

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

2024-003 - IMMUNIZATION COOPERATIVE GRANT AGREEMENTS - INTERNAL CONTROLS - LACK OF SUPPORT FOR PAYROLL APPROVALS - ALN #93.268 - SIGNIFICANT DEFICIENCY FINDING TYPE: SIGNIFICANT DEFICIENCY Finding 2024-003 Federal Program: FAIN: IMMUNIZATION COOPERATIVE AGREEMENT NH23IP922623 ALN: 93.268 Year(s): 20...

2024-003 - IMMUNIZATION COOPERATIVE GRANT AGREEMENTS - INTERNAL CONTROLS - LACK OF SUPPORT FOR PAYROLL APPROVALS - ALN #93.268 - SIGNIFICANT DEFICIENCY FINDING TYPE: SIGNIFICANT DEFICIENCY Finding 2024-003 Federal Program: FAIN: IMMUNIZATION COOPERATIVE AGREEMENT NH23IP922623 ALN: 93.268 Year(s): 2024 Federal Agency: U.S. Department of Health and Human Services Pass Through Agency: North Dakota Department of Health Questioned Cost: $0 Condition: Upper Missouri District Health Unit does not have documented approval of the payroll transactions to ensure that the expenditures are allowable to the Immunization Cooperative Agreements program and are coded to the proper grant. Corrective Action Plan: We agree, UMDHU will be adding proper approval processes regarding payroll transactions. Anticipated Completion Date: FY 2026

View Audit 372860

Finding 1163322 (2024-001)

Material Weakness 2024

Koinonia, Inc. 053-11202

NC

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties § 200.302 § 200.303

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN October 31, 2025 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Koinonia, Inc. respectfully submits the following Corrective Action Plan for the...

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN October 31, 2025 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Koinonia, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The finding from the year ended December 31, 2024 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - Financial Statement Audit and Federal Award Program Audit Finding 2024-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 223(f)/207) Recommendation: We recommend management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2024-001 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will review the accounting and financial procedures, system of internal controls and policies. If HUD has questions regarding this corrective action plan, please call 828-758-2617. Sincerely yours, Chassidy Triplett Project Administrator Koinonia, Inc.

View Audit 372842 Questioned Costs: $1

Finding 1163321 (2024-001)

Material Weakness 2024

People's Housing+, Inc.

LA

Reporting § 200.512

Response: The Organization realized its Single Audit requirement in September of 2025 and immediately made plans to fulfill its requirements. Going forward, the Organization will track federal expenditures contemporaneously in order to determine when a reporting threshold is tripped. This should all...

Response: The Organization realized its Single Audit requirement in September of 2025 and immediately made plans to fulfill its requirements. Going forward, the Organization will track federal expenditures contemporaneously in order to determine when a reporting threshold is tripped. This should allow the Organization enough time to comply with the applicable laws and regulations.

View Audit 372834

Finding 1163310 (2024-001)

Material Weakness 2024

Heading Home

NM

Reporting § 200.512

Heading Home management is in agreement with this finding. After years of turnover in key management positions steps have been taken to address staffing challenges and these positions have been successfully staffed with high-quality individuals who bring extensive knowledge and expertise to their ro...

Heading Home management is in agreement with this finding. After years of turnover in key management positions steps have been taken to address staffing challenges and these positions have been successfully staffed with high-quality individuals who bring extensive knowledge and expertise to their roles. These positions include a new Chief Executive Officer, Director of Operations, Chief Financial Officer, and Director of Human Services. To address challenges in accounting and finance Heading Home had contracted with a local CPA firm specializing in nonprofit accounting and financial reporting to assist the CFO with daily accounting tasks, the monthly close, financial reporting to management and the board of directors, and to facilitate and ensure audits are completed timely each year. The new management group is committed to maintaining a skilled and competent team in key financial roles. The FY23 audit was completed in May 2025 and the Heading Home’s accounting team anticipates the FY24 audit to be completed by November 2025. While this will once again result in a late filing, the new management team has made significant strides in a short amount of time and anticipates that the 2025 and all future audits will be submitted on or before the March 31st due date. Management anticipates the above corrective action plan to be fully implemented by November 30, 2025. Personnel responsible for ensuring implementation include Connie Chavez, Executive Director, and Debbie Brickman, Chief Financial Officer.

View Audit 372829

Finding 1163308 (2024-002)

Material Weakness 2024

Heading Home

NM

Allowable Costs / Cost Principles Reporting Significant Deficiency

Heading Home management is in agreement with this finding. After years of turnover in key management positions steps have been taken to address staffing challenges and these positions have been successfully staffed with high-quality individuals who bring extensive knowledge and expertise to their ro...

Heading Home management is in agreement with this finding. After years of turnover in key management positions steps have been taken to address staffing challenges and these positions have been successfully staffed with high-quality individuals who bring extensive knowledge and expertise to their roles. These positions include a new Chief Executive Officer, Director of Operations, Chief Financial Officer, and Director of Human Services. To address challenges in accounting and finance Heading Home had contracted with a local CPA firm specializing in nonprofit accounting and financial reporting to assist the CFO with daily accounting tasks, the monthly close, financial reporting to management and the board of directors, and to facilitate and ensure audits are completed timely each year. The new management group is committed to maintaining a skilled and competent team in key financial roles. Due to the backlog of billings at the opening of FY23, the billing submissions and quarterly reports for the first quarter were submitted late. With the new staff and assistance, these billings and quarterly reports were brought current as quickly as possible. They are now current and being submitted in a timely manner. Management’s corrective action plan was fully implemented by June 30, 2025, and anticipate that there will be no further issues. Personnel responsible for ensuring implementation include Connie Chavez, Executive Director, and Debbie Brickman, Chief Financial Officer.

View Audit 372829

Finding 1163295 (2024-001)

Material Weakness 2024

Genesis Community Health, Inc.

FL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.302

Additional preventive internal control procedures will be implemented, designating a secondary individual responsible for submission should the primary individual leave or be terminated. These procedures and internal controls have been implemented as of the date of this report.

View Audit 372818

Finding 1163279 (2024-005)

Material Weakness 2024

Alameda Point Collaborative

CA

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking

1-Develop a reconciliation process for excess cash reserves to ensure compliance with loan agreements 2-Implement procedures to obtain and maintain documentation for qualifying low-income housing individuals. 3-Train staff on compliance requirements for loan agreements and reconciliation processes.

View Audit 372806

Finding 1163275 (2024-002)

Material Weakness 2024

Youthcare

WA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Corrective Action Plan For the Year Ended December 31, 2024 Contact Person(s): De Angelo Jones, Finance Director Deangelo.jones@youthcare.org Finding 2024-002 Significant deficiency in internal controls over compliance related to reporting. Explanation and specific reasons for disagreement with the ...

Corrective Action Plan For the Year Ended December 31, 2024 Contact Person(s): De Angelo Jones, Finance Director Deangelo.jones@youthcare.org Finding 2024-002 Significant deficiency in internal controls over compliance related to reporting. Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective action planned:  Develop a contract expenditure compliance review process created with final review and approval by Finance Director. Anticipated completion date: Fixed January 1, 2025

View Audit 372803

Finding 1163270 (2024-002)

Material Weakness 2024

Wingo Elderly Housing Corporation D/b/a Locust Ridge Apartments

KY

Questioned Costs

Management will make sure the audited financial statements are filed into the REAC system 90 days after the fiscal year-end in future years.

View Audit 372786 Questioned Costs: $1

Finding 1163269 (2024-001)

Material Weakness 2024

Wingo Elderly Housing Corporation D/b/a Locust Ridge Apartments

KY

Questioned Costs Cash Management HUD Housing Programs

Management will deposit required amounts.

View Audit 372786 Questioned Costs: $1

Finding 1163268 (2024-003)

Material Weakness 2024

Middle Georgia Community Action Agency, Inc.

GA

THE AGENCY AGREES WITH THE FINDING AND IS IN THE PROCESS OF PROVIDING ADDITIONAL TRAINING FOR THE PROGRAM STAFF.

View Audit 372782

Finding 1163267 (2024-002)

Material Weakness 2024

Middle Georgia Community Action Agency, Inc.

GA

THE AGENCY AGREES WITH THE FINDING AND IS IN THE PROCESS OF PROVIDING ADDITIONAL TRAINING FOR THE PROGRAM STAFF.

View Audit 372782

Finding 1163241 (2024-002)

Material Weakness 2024

East Valley Community Health Center, Inc.

CA

Special Tests & Provisions

Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. Planned Corrective Actions: To strengthen compliance with ou...

Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. Planned Corrective Actions: To strengthen compliance with our sliding fee discount policy, East Valley Community Health Center has implemented several corrective measures. Re-training for intake and billing staff began in April 2025 and is ongoing as part of our quarterly training cycle, In addition, we are currently reviewing our sliding fee discount policy and procedures to ensure they are clear, consistently applied, and aligned with HRSA guidance and the Health Center Program Compliance Manual. Monthly audits of patient encounters involving sliding fee adjustments began in October 2024 by the billing department and are now a permanent component of our internal compliance process. Audit results are reviewed by the Revenue Cycle Manager and shared with Clinic Managers, Front Office Leads, and Senior Leadership to ensure accountability and prompt corrective action when needed. The CFO is responsible for overseeing these processes and ensuring that all compliance measures are implemented effectively.

View Audit 372749

Finding 1163234 (2024-002)

Material Weakness 2024

Benton Franklin Community Action Committee

WA

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

BFCAC made a change in personnel during 2024. Subsequently, BFCAC has emphasized the need to maintain supporting documentation for all charges, including changes to timesheets, and supporting documentation for manual adjustments. The Executive Director and the Finance Manager are responsible for thi...

BFCAC made a change in personnel during 2024. Subsequently, BFCAC has emphasized the need to maintain supporting documentation for all charges, including changes to timesheets, and supporting documentation for manual adjustments. The Executive Director and the Finance Manager are responsible for this corrective action.

View Audit 372721 Questioned Costs: $1

Finding 1163222 (2024-007)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Allowable Costs / Cost Principles

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization follow policies and procedures put in place in regard to the approval of cash disbursements. Explanation of disagreement with audit fin...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization follow policies and procedures put in place in regard to the approval of cash disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: GHN has implemented policies and provided additional training to new staff to ensure compliance. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163221 (2024-006)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.945 Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Exp...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.945 Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will implement policies and procedures to implement subrecipient monitoring. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31. 2025.

View Audit 372710

Finding 1163220 (2024-005)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Reporting § 200.329

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization create and or update policies and procedures to ensure all required reports are submitted timely and accurately. Explanation of disagre...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization create and or update policies and procedures to ensure all required reports are submitted timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: GHN has developed and is in the process of implementing a tracking system for compliance deadlines, including report submissions. Name of the contact person responsible for corrective action: Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163219 (2024-004)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization create proper policies and procedures to ensure indirect costs are properly calculated and tracked. Explanation of disagreement with au...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization create proper policies and procedures to ensure indirect costs are properly calculated and tracked. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: GHN has developed a procedure as well as hired additional staff to correctly track, calculate, and review indirect costs. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163218 (2024-003)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Special Tests & Provisions

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreemen...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are reviewing our current policies and procedures in these areas to determine if any changes should be implemented. Greater Health Now has increased trainings for staff members in terms of the documentation required to purchase goods and services with grant funds. Furthermore, to strengthen our oversight of sole-source contracts awarded with program and non-program funds, we will introduce stringent measures requiring thorough documentation of the vendor’s or contractor’s qualifications. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163217 (2024-002)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Subrecipient Monitoring § 200.305

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request ...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have established a process to review and track accounts payable, including monthly reviews of outstanding bills, partner invoices, and partner compliance. Furthermore, we have added additional accounting staff focused on disbursements for subrecipients involved in federal grant programs. Finally, we have a process in place to document the receipt of partner invoices submitted to GHN for payment as well as a record of payment approval and/or revisions necessary. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163215 (2024-001)

Material Weakness 2024

New Jersey Coalition for Inclusive Education

NJ

§ 200.512

Recommendation: We recommend that the Organization put controls in place to ensure timely filing of the audit package to the Federal Audit Clearinghouse. Organization's Response: The Organization agrees with the auditors' recommendation.

View Audit 372705

Corrective Action Plans

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