Corrective Action Plans

Finding 570066 (2024-023)

Significant Deficiency 2024

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

Finding 569990 (2024-003)

Material Weakness 2024

Southeast Valley Community School District

IA

Internal Control / Segregation of Duties

SEE RESPONSE AND CORRECTIVE ACTION PLAN AT 2024-001

View Audit 361259

Finding 569989 (2024-001)

Material Weakness 2024

Van Buren Community Mental Health Authority

MI

Questioned Costs Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.317 § 200.318 § 200.327

SINGLE AUDIT FOR THE YEAR ENDED SEPTEMBER 30, 2024 CORRECTIVE ACTION PLAN FEDERAL AWARD FINDINGS - Fiscal Year 2024 Finding Number: 2024-001 Procurement Assistance Listing Number: 93.696 Assistance Listing Title: Certified Community Behavioral Health Clinics N ame of Federal Agency: Substance Abuse...

SINGLE AUDIT FOR THE YEAR ENDED SEPTEMBER 30, 2024 CORRECTIVE ACTION PLAN FEDERAL AWARD FINDINGS - Fiscal Year 2024 Finding Number: 2024-001 Procurement Assistance Listing Number: 93.696 Assistance Listing Title: Certified Community Behavioral Health Clinics N ame of Federal Agency: Substance Abuse and Mental Health Services Administration Federal Award Identification Number: H79SM089299 Fiscal Year of Initial Finding: 2024 • Name of the contact person: Tina Boyer, CFO • Corrective Action Plan: Management agrees with this recommendation. VBCMH management will review and update policies and procedures to ensure that allfederal requirements are followed. Anticipated Completion Date: Fiscal Year 2025

View Audit 361252 Questioned Costs: $1

Finding 569979 (2024-005)

Material Weakness 2024

Dillard University

LA

Student Financial Aid Subrecipient Monitoring Reporting § 200.512

The late audit submission was a result of significant leadership and staffing turnover, unresolved audit support items, and missing reconciliations from prior months. The University engaged an external firm to stabilize the finance function and has since appointed an interim Controller. Beginning wi...

The late audit submission was a result of significant leadership and staffing turnover, unresolved audit support items, and missing reconciliations from prior months. The University engaged an external firm to stabilize the finance function and has since appointed an interim Controller. Beginning with FY26, the University will adopt a rolling monthly close schedule, establish an internal audit prep calendar, and define internal deadlines for deliverables to external auditors. These steps will support timely completion of future audits. Target: Audit submission by March 31, 2026 for FY25.

View Audit 361246

Finding 569978 (2024-004)

Material Weakness 2024

Dillard University

LA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The University concurs with this finding. Due to turnover in critical roles, the FY24 FISAP contained inaccuracies. The University has appointed an interim Controller to oversee the correction of reporting processes. The new process will require that all FISAP data be supported by reconciled financi...

The University concurs with this finding. Due to turnover in critical roles, the FY24 FISAP contained inaccuracies. The University has appointed an interim Controller to oversee the correction of reporting processes. The new process will require that all FISAP data be supported by reconciled financial records and reviewed collaboratively by Financial Aid and Accounting staff. Process updates and internal review checklists will be developed in time for the FY25 submission, with training and testing of the new approach by June 30, 2026.

View Audit 361246

Finding 569977 (2024-003)

Material Weakness 2024

Dillard University

LA

Questioned Costs Student Financial Aid Subrecipient Monitoring

This finding resulted from a loan disbursement exceeding regulatory limits for one student. The issue was corrected before the audit report was finalized. The University will strengthen its review process prior to disbursement by ensuring additional loan eligibility is validated and documented. The ...

This finding resulted from a loan disbursement exceeding regulatory limits for one student. The issue was corrected before the audit report was finalized. The University will strengthen its review process prior to disbursement by ensuring additional loan eligibility is validated and documented. The Financial Aid Office will receive targeted training on aggregate loan monitoring. Corrective actions will be fully implemented by January 31, 2026.

View Audit 361246 Questioned Costs: $1

Finding 569976 (2024-002)

Material Weakness 2024

Dillard University

LA

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

The University acknowledges the enrollment status reporting errors noted in the audit. This was due to a lack of coordination between departments responsible for enrollment status updates and NSLDS reporting. Under the direction of the interim Controller, the University will work with Registrar, Off...

The University acknowledges the enrollment status reporting errors noted in the audit. This was due to a lack of coordination between departments responsible for enrollment status updates and NSLDS reporting. Under the direction of the interim Controller, the University will work with Registrar, Office of Records and Registrations to implement a monthly reconciliation process and establish clear ownership of status reporting responsibilities. A tracking log will be introduced to monitor timely and accurate submissions. Completion of corrective actions is expected by March 31, 2026.

View Audit 361246

Finding 569970 (2024-003)

Significant Deficiency 2024

City of Marco Island

FL

Subrecipient Monitoring Cash Management Significant Deficiency § 200.302 § 200.303

DEPARTMENT OF HOMELAND SECURITY Disaster Grant Public Assistance (Presidentially Declared Disasters) - Assistance Listing No. 97.036 Recommendation: We recommend that the organization implement a review and approval process for all quarterly progress submissions. This should include: Training sta...

DEPARTMENT OF HOMELAND SECURITY Disaster Grant Public Assistance (Presidentially Declared Disasters) - Assistance Listing No. 97.036 Recommendation: We recommend that the organization implement a review and approval process for all quarterly progress submissions. This should include: Training staff on the importance of the review and approval process. Ensuring adequate staffing levels to handle the review process. Developing clear guidelins and procedures for the review and approval process. Regularly monitoring and auditing the review process to ensure compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The City will implement a review and approval process for all quarterly progress report submissions within it ERP (Enterprise Resource Planning) software system. The City will train its staff on the importance of the review and approval process. The City will ensure adequate staffing levels to handle the review process. The City will develop clear guidelines and procedures for the review and approval process. The City will regularly monitor and audit the reivew process to ensure compliance. Name(s) of the contact person(s) for corrective action: Guillermo Polanco. Planned completion date for corrective action plan: 09/30/2025

View Audit 361239

Finding 569969 (2024-004)

Significant Deficiency 2024

Institute for Population Health, INC

MI

Patients who are eligible for the sliding fee discount will receive the discount based on the current year Sliding Fee schedule. The Sliding Fee Discount will be applied to the each year during a renewal period using the most recent Board approved Sliding Fee Discount.

View Audit 361226

Finding 569968 (2024-003)

Significant Deficiency 2024

Institute for Population Health, INC

MI

During the Budget Period April 1, 2023 to April 30, 2024, Healthy Start Performance Measure (HS 6) the percentage of Father and/or Partner Involvement with child <24 months to 80%. Program performance was 71%. Not achieved. HS 5, the percentage of Father and/or Partner Involvement during pregnancy...

During the Budget Period April 1, 2023 to April 30, 2024, Healthy Start Performance Measure (HS 6) the percentage of Father and/or Partner Involvement with child <24 months to 80%. Program performance was 71%. Not achieved. HS 5, the percentage of Father and/or Partner Involvement during pregnancy to 80%. Program performance was 63%. Not achieved. Father involvement is a challenge while the program staff encourage, teach, and support Father involvement, too many relationships struggle with co-parenting and stress management issues.

View Audit 361226

Finding 569957 (2024-001)

None 2024

Hillside Elderly Housing, Inc.

CT

HUD Housing Programs

Management agrees with the finding. The financial statements were submitted to HUD on May 9, 2025.

View Audit 361199

Corrective Action Plans

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