Corrective Action Plans

Finding 1158131 (2024-001)

Material Weakness 2024

County of Essex

NJ

Cash Management HUD Housing Programs

N/A

View Audit 370058

Finding 1158131 (2024-001)

Material Weakness 2024

County of Essex

NJ

Cash Management HUD Housing Programs

Recommendation:

View Audit 370058

Finding 1158131 (2024-001)

Material Weakness 2024

County of Essex

NJ

Cash Management HUD Housing Programs

We recomment that management strengthen internal controls to ensure compliance with HUD case management requirements. Drawdowns should be requested only for actual, eligible expenditures submitted in a timely manner after costs are incurred, and not made in advance of need. Procedures should be impl...

We recomment that management strengthen internal controls to ensure compliance with HUD case management requirements. Drawdowns should be requested only for actual, eligible expenditures submitted in a timely manner after costs are incurred, and not made in advance of need. Procedures should be implemented to ensure alliligible expenditures are promptly drawn from the IDIS system. Any funds drawn in error or prematurely should be returned promptly to HUD or the grantee to avoid noncompliance.

View Audit 370058

Finding 1158131 (2024-001)

Material Weakness 2024

County of Essex

NJ

Cash Management HUD Housing Programs

Explanation & Corrective Action:

View Audit 370058

Finding 1158131 (2024-001)

Material Weakness 2024

County of Essex

NJ

Cash Management HUD Housing Programs

The Division has added another member to the financial team, and will revise the review of the transactions between MSI, IDIS and the Financial Summary tio ensure all drawdowns are done timely and correct.

View Audit 370058

Finding 1158131 (2024-001)

Material Weakness 2024

County of Essex

NJ

Cash Management HUD Housing Programs

Implementation Date & Explanation:

View Audit 370058

Finding 1158131 (2024-001)

Material Weakness 2024

County of Essex

NJ

Cash Management HUD Housing Programs

The additional review of trqansactions has been imp0lemented as of this date.

View Audit 370058

Finding 1158130 (2024-003)

Material Weakness 2024

Lansing Economic Area Partnership, Inc.

MI

Reporting Internal Control / Segregation of Duties Significant Deficiency

2024-003 – Grant Reporting Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Program. Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, Small Business Support Hubs Program passed through the Michig...

2024-003 – Grant Reporting Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Program. Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, Small Business Support Hubs Program passed through the Michigan Strategic Fund. Auditor Description of Condition and Effect. Although we were able to review the quarterly reporting due during the fiscal year, we initially noted that the reports quarterly totals did not add up to the year-to-date totals, and total cost for the year reported, as well as quarterly totals, did not agree to the general ledger or the Schedule of Expenditures of Federal Awards. Management was able to subsequently correct these errors. Additionally, it was noted that there was no formal review and approval process over the completion and submission of the grant reports. As a result of this condition, the Organization reported inaccurate amounts to the grant pass-through agency. Auditor Recommendation. We recommend that the Organization base all grant financial reporting on general ledger detail of costs and that the reporting be reconciled to the Schedule of Expenditures of Federal Awards at year-end. In addition, all reports should be reviewed and approved by appropriate personnel prior to submission. Corrective Action. LEAP will be following the recommendation of basing all grant financial reporting on general ledger detail of costs and being more diligent in reconciling that ledger to the Schedule of Expenditures of Federal Awards at year-end. Further all reports moving forward will be reviewed and approved by CFO and COO in addition to the department head who is compiling with their team. LEAP’s modifications to its Grants Management SOP in 2025 are designed to also cover grant reporting process per Uniform Guidance requirements. This grant reporting issue too will be covered in the content of LEAP’s training for all management team members set to occur in August. Responsible Person. Tony Klisch, LEAP CFO Anticipated Completion Date. August 31, 2025

View Audit 370048

Finding 1158129 (2024-002)

Material Weakness 2024

Lansing Economic Area Partnership, Inc.

MI

Procurement, Suspension & Debarment Subrecipient Monitoring

2024-002 – Documentation of Controls over Suspension and Debarment (Repeat Finding) Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Procurement, Suspension and Debarment, Subrecipient Monitoring). Program. Coronavirus State and Local Fiscal Recovery...

2024-002 – Documentation of Controls over Suspension and Debarment (Repeat Finding) Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Procurement, Suspension and Debarment, Subrecipient Monitoring). Program. Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, All Awards. Auditor Description of Condition and Effect. During our testing of suspension and debarment for three vendors and six subrecipients, it was determined that the Organization did not verify that vendors or subrecipients were not suspended, debarred or otherwise excluded when the Organization contracted with them to provide goods or services for five of the nine vendors and subrecipients. The searches at www.sam.gov were done in early 2025 by management, which was well after the date of the applicable contractual agreement and expenditure activity. The failure to monitor suspension and debarment could cause funds to be disbursed to vendors or subrecipients who are not eligible to have goods and services purchased with federal monies. Auditor Recommendation. We recommend that the Organization retain documentation of their procurement process including checking vendors for potential exclusions from federal award work. We further recommend that these checks be done prior to entering into a contractual agreement. Corrective Action. LEAP will be following the recommendation of retaining all documentation of our procurement process including the checking of vendors both at state and federal levels for any potential exclusions from federal award work, and ensuring these checks be done prior to contract execution. LEAP will be substantially modifying its procurement policy that is part of its Grants Management SOP in order to more explicitly detail expectations and procedural steps to meet the requirements of Uniform Guidance with regards to sequence of events leading up to contract execution, including the state and federal checks for exclusion. Further, LEAP’s leadership will be holding a module within the aforementioned internal training for all management team members to walk through a new check list tool that aligns with policy and Uniform Guidance, and case study exercise will also hit on this topic to ensure learning occurs around the internal controls improvements made with policy revamp. Responsible Person. Tony Klisch, LEAP CFO Anticipated Completion Date. August 31, 2025

View Audit 370048

Finding 1158128 (2024-001)

Material Weakness 2024

Lansing Economic Area Partnership, Inc.

MI

Subrecipient Monitoring

2024-001 – Lack of Subrecipient Monitoring Activities Finding Type. Immaterial Noncompliance/Material Weakness in Internal Control over Compliance (Subrecipient Monitoring). Program. Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, All Awards. Auditor Descr...

2024-001 – Lack of Subrecipient Monitoring Activities Finding Type. Immaterial Noncompliance/Material Weakness in Internal Control over Compliance (Subrecipient Monitoring). Program. Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, All Awards. Auditor Description of Condition and Effect. Six subrecipients were selected for testing during the audit procedures. There was no subrecipient agreement noted for one of the subrecipients selected, therefore the required federal award information was not properly communicated. Additionally, no risk assessment was performed, nor was a monitoring plan within documentation of monitoring activities noted for this subrecipient. For the remaining five subrecipients selected for testing, the required federal award information was not properly communicated within the agreements. Lastly, the Organization does not have a procedure requiring the review of subrecipient audits. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Auditor Recommendation. We recommend that management become familiar with the subrecipient monitoring requirements and draft a policy and procedures that provide reasonable assurance that future subrecipient arrangements will be in compliance with the Uniform Guidance. Corrective Action. In an effort for LEAP to become more familiar with the subrecipient monitoring requirements and drafting policy and procedures that provide assurance that future subrecipient arrangements will be in full compliance with the Uniform Guidance federal regulations, LEAP will be modifying its Grants Management SOP to more explicitly detail expectations and procedural steps to meet the requirements of Uniform Guidance. Further, LEAP’s leadership will be holding an internal training for all management team members to discuss this revamped set of policies, go through case study exercises and question and answer session to make sure that all those managing grants or the employees that manage grants have a full understanding of what is expected of them, and their role in various management and oversight processes for the organization. Responsible Person. Tony Klisch, LEAP CFO Anticipated Completion Date. August 31, 2025

View Audit 370048

Finding 1158125 (2024-003)

Material Weakness 2024

Tulsa Community Foundation

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.318 § 200.326

Description of Finding: The Foundation and its affiliates did not ensure proper documentation was retained regarding its procurement process. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will adopt a procurement po...

Description of Finding: The Foundation and its affiliates did not ensure proper documentation was retained regarding its procurement process. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will adopt a procurement policy in accordance with UGG 2 CFR 200.318 through 200.327 and will collaborate more closely with project partners of federal grants to ensure documentation requirements for the procurement process are adhered to and work to centralize grant documentation for all awards. This will be in tandem with establishing effective internal controls as per Uniform Guidance 2 CFR 200.303. To support this corrective action, the Foundation has hired an experienced senior accountant to strengthen internal capacity. The qualified senior accountant will oversee federal grants and ensure ongoing compliance with internal controls and help to prevent recurrence of the issue. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and centralization of grant documentation to be established by December 31, 2025.

View Audit 370045

Finding 1158124 (2024-002)

Material Weakness 2024

Tulsa Community Foundation

OK

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting

Description of Finding: The Foundation and its affiliates did not ensure proper performance reporting was completed for individual grants. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will collaborate more closely ...

Description of Finding: The Foundation and its affiliates did not ensure proper performance reporting was completed for individual grants. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will collaborate more closely with project partners of federal grants to establish reporting deadlines and monitor individual reporting requirements throughout the year. This will be in tandem with establishing effective internal controls as per UGG 2 CFR 200.303. The Foundation will take steps to ensure that all required reports are submitted in a timely manner and all relevant documentation and evidence of reports’ submissions are retained in an effective manner. To support this corrective action, the Foundation has hired an experienced senior accountant to strengthen internal capacity. The qualified senior accountant will oversee federal grants and ensure ongoing compliance with internal controls and help to prevent recurrence of the issue. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by December 31, 2025.

View Audit 370045

Finding 1158123 (2024-001)

Material Weakness 2024

Tulsa Community Foundation

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more ...

Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more in-depth federal award process and collaborate with project partners to ensure their understanding of the compliance requirements as per Uniform Guidance (UGG) 2 CFR 200.303. The Foundation will also begin internal monitoring to ensure project partners are following established policies and procedures through the duration of each award. To support this corrective action, the Foundation has hired an experienced senior accountant to strengthen internal capacity. The qualified senior accountant will oversee federal grants and ensure ongoing compliance with internal controls and help to prevent recurrence of the issue. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by December 31, 2025.

View Audit 370045

Finding 1158094 (2024-003)

Material Weakness 2024

Acupuncture and Integrative Medicine College, Berkeley

CA

Student Financial Aid Reporting Significant Deficiency

As of today, September 29, 2025, the organization has fully implemented procedures in Populi to update enrollments to actual final status within the required 30 days. This data will be reported to our third-party servicer RGM in real-time. The academic and administrative teams review these reports.

View Audit 370038

Finding 1158093 (2024-002)

Material Weakness 2024

Acupuncture and Integrative Medicine College, Berkeley

CA

Student Financial Aid Material Weakness Internal Control / Segregation of Duties

Over the past two months in August and September, the board has reviewed the budget and the organization has sharply reduced staff and facility costs at both the Austin and Berkeley campuses. This will ensure that the organization qualifies for at least a 1.0 on the composite score and qualify for a...

Over the past two months in August and September, the board has reviewed the budget and the organization has sharply reduced staff and facility costs at both the Austin and Berkeley campuses. This will ensure that the organization qualifies for at least a 1.0 on the composite score and qualify for a letter of credit alternative or provisional certification alternative to meet the fiscal responsibility requirements through the 2025 fiscal year audit. As of today, September 29, 2025, expense reductions have been implemented.

View Audit 370038

Finding 1158088 (2024-001)

Material Weakness 2024

Manhattan Housing Authoirty

KS

Reporting Internal Control / Segregation of Duties

Finding 2024-001 Criteria: The Authority did not maintain adequate internal controls over financial reporting. Condition: During audit testing we noted the following:  The Authority recorded a prior period adjustment in order to correct misstatements of deferred inflows of resources and leases rece...

Finding 2024-001 Criteria: The Authority did not maintain adequate internal controls over financial reporting. Condition: During audit testing we noted the following:  The Authority recorded a prior period adjustment in order to correct misstatements of deferred inflows of resources and leases receivable.  Numerous adjusting entries were required to present the Authority's financial statements in accordance with GAAP. Cause: Controls were not fully executed to ensure that the Authority recorded and reported financial data consistently and reliably in accordance with generally accepted accounting principles. Effect: The Authority required an immoderate number of adjustments in order to report accurate results in accordance with generally accepted accounting principles. Auditors' Recommendation: We recommend the Authority implement their internal controls; specifically, the Authority should ensure they are performing monthly procedures whereby financial statements and general ledger accounts are reviewed for accuracy and reconciled to their subsidiary ledgers. Authority Response and Planned Corrective Action: The Authority agrees with the findings and is in process of assessing and modifying internal controls to avoid similar issues. The Authority will reconcile the statement of financial position and other key account balances on an ongoing and periodic basis. The Authority will also reconcile account balances following any large and unusual adjusting entries. Aaron Estabrook, Executive Director, is responsible for implementing this corrective action by December 31, 2025.

View Audit 370029

Finding 1158086 (2024-005)

Material Weakness 2024

Native Village of Point Hope

AK

Allowable Costs / Cost Principles Material Weakness

Finding 2024-005 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Executive Director. Corrective Action Plan: 1. Update and...

Finding 2024-005 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Executive Director. Corrective Action Plan: 1. Update and Disseminate Financial Management Policies: • Action: Formally update and reissue Chapter III (Financial Management) of the Administrative Manual to specifically include the following requirements for all payroll-related actions: o Mandatory use of the payment authorization form for all employee pays rate changes, bonuses, or other non-standard payments. o Verification of all signatories against a current, board-approved signatory list. o A documented review step during each payroll run where the personnel action recommendation form is compared against the actual pay rate being processed. • Responsible Party: Executive Director and Financial Specialist. 2. Implement a Structured Payroll Review Process: • Action: Establish a mandatory, documented two-step review process for every payroll cycle: o Step 1: The Financial Specialist will review all payment authorization forms and verify signatories. o Step 2: The Financial Specialist will compare the pay rates in the payroll system to the approved rates on the personnel action recommendation forms and initial the review for the record. • Responsible Party: Financial Specialist. 3. Conduct Mandatory Training for Staff: • Action: Provide comprehensive and mandatory training for all relevant staff (e.g., payroll clerks, program managers) on the updated financial management policies and payroll review protocols. This training will cover: o Proper use and routing of payment authorization forms. o Verification procedures for pay rates. o The importance of maintaining proper documentation. • Responsible Party: Executive Director, in coordination with the Financial Specialist. 4. Transition to New Permanent Administration: • Action: As part of the onboarding process for the new staff, the following will occur: o The Executive Director will hold a comprehensive "sit-down" session to review and reinforce all financial management and payroll protocols. o The new team will be provided with the updated Administrative Manual and all relevant training materials. o A transition checklist will be used to ensure all key financial controls are properly handed over and understood. • Responsible Party: Executive Director 5. Verification of Effectiveness: • Action: After the new procedures are implemented, the Executive Director and Tribal Council will perform a periodic review of a sample of payroll records to ensure compliance with the new internal controls. • Responsible Party: Tribal Council and Executive Director. Proposed Completion Date: Ongoing, Starting Early 2026.

View Audit 370023

Finding 1158085 (2024-004)

Material Weakness 2024

Native Village of Point Hope

AK

Questioned Costs Cash Management Material Weakness § 200.305

Finding 2024-004 Lack of Internal Control over Cash Management Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Executive Director. Corrective Action Plan: 1. Strengthen the payment review process: • Action: Enforce and d...

Finding 2024-004 Lack of Internal Control over Cash Management Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Executive Director. Corrective Action Plan: 1. Strengthen the payment review process: • Action: Enforce and document a stricter segregation of duties in the payment process. This will ensure the individual requesting a payment is not the same person who authorizes the payment. • Details: All payment requests must be cross-referenced with a corresponding invoice or receipt and reviewed and approved by an authorized department head. This Department Head must not be the one who submitted the initial request. 2. Implement a two-tiered review for cash receipts: • Action: Establish a formal two-tiered cash receipts process to enhance accountability and accuracy. • Details: o Tier 1: The individual receiving and logging cash receipts will immediately perform a preliminary count and documentation. o Tier 2: A separate, authorized staff member will perform a second, independent review of the cash receipt records and verify the funds against the deposit slip before the funds are deposited. 3. Standardize training and onboarding for all staff: • Action: Develop a standardized training curriculum on financial management policies and procedures, including a dedicated section on cash management best practices. • Details: o All new permanent and staff members will undergo mandatory training on the updated policies. o Training will cover the importance of internal controls, specifically emphasizing segregation of duties in cash handling. o The Executive Director will meet with all new finance and administrative staff within their first two weeks to review proper protocols and emphasize the organization's commitment to financial controls. 4. Introduce periodic, surprise cash audits: • Action: Conduct unannounced cash counts and reconciliations to ensure compliance with procedures. • Details: An authorized, independent party will perform these surprise audits quarterly to check cash on hand and compare records against financial systems. 5. Enhance oversight and reporting: • Action: The Executive Director will provide regular updates on the implementation of these corrective actions to the Native Village of Point Hope Tribal Council. • Details: A formal report will be presented quarterly, outlining the progress of the corrective actions and any findings from the new oversight procedures. This provides a clear accountability mechanism. Proposed Completion Date: Ongoing, Starting Early 2026.

View Audit 370023 Questioned Costs: $1

Finding 1158084 (2024-003)

Material Weakness 2024

Native Village of Point Hope

AK

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2024-003 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Executive Director. Corrective Action Plan: 1. Update and formalize policies and procedures: •...

Finding 2024-003 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Executive Director. Corrective Action Plan: 1. Update and formalize policies and procedures: • Action: Conduct a comprehensive review and update of the Administrative Manual Systems, Chapter III: Financial Management, focusing specifically on all sections related to Uniform Guidance (UG) reporting. This includes procurement, reporting, and subrecipient monitoring requirements. • Details: o Develop and document detailed, step-by-step procedures for each UG reporting requirement. o Ensure all policies reflect the most current version of the UG, including the 2024 revisions. o Secure formal approval of the revised manual from tribal leadership. 2. Standardize and conduct mandatory staff training: • Action: Develop and implement a structured, mandatory training program for all staff involved in federal grant management, including finance, administrative, and program personnel. • Details: o Content: The training will cover the revised UG policies, focusing on reporting deadlines, documentation requirements, and proper internal controls. o Onboarding: The Executive Director will meet with all new permanent staff within their first two weeks of employment to review these protocols and emphasize the importance of compliance. o Ongoing Training: Conduct annual refresher training for all relevant staff to address any new changes or best practices. 3. Enhance monitoring and oversight: • Action: Establish a robust system of internal oversight to ensure continuous compliance with UG reporting requirements. • Details: o Regular Reviews: The Executive Director will implement a schedule of regular reviews of financial records to confirm that all supporting documentation for federal awards is correctly attached and reports are filed accurately and on time. o Reporting Checklist: Create and use a standardized checklist for each federal award to ensure all specific reporting requirements are met prior to submission. o Audit Readiness: Perform periodic internal compliance checks or "mock audits" to identify and correct potential issues before an external audit. 4. Strengthen documentation and audit trail: • Action: Improve the organization and accessibility of all documentation required for UG reporting to facilitate a clear and defensible audit trail. • Details: o Centralized Record-keeping: Establish a centralized, secure digital location for all federal award documents, including grant agreements, financial reports, and supporting records. o Documentation Protocol: Implement a protocol requiring all relevant personnel to upload and correctly label all necessary documentation immediately after a transaction is completed. 5. Designate responsibility and accountability: • Action: Clearly assign responsibility for each UG compliance task to specific individuals to eliminate confusion and ensure accountability. • Details: For each grant, a lead financial staff member will be designated as the primary point of contact responsible for ensuring all UG reporting and documentation requirements are met. The Executive Director will oversee this process. Proposed Completion Date: Ongoing, Starting Early 2026.

View Audit 370023

Finding 1158059 (2024-002)

Material Weakness 2024

Stone Lake Woods, Inc.

MI

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Management will implement a formal tracking system and internal calendar reminders to ensure timely submission of audited financial statements in accordance with HUD requirements.

View Audit 370012

Finding 1158057 (2024-001)

Material Weakness 2024

Whitman-Walker Clinic, Inc. Dba Whitman-Walker Health

DC

Procurement, Suspension & Debarment § 200.318 § 200.319 § 200.320 § 200.324

2024-001 – Internal Controls over Compliance and Compliance with Procurement Standards Individual Responsible for Corrective Action Plan: Meghan Davies, Chief Operating Officer Anticipated Completion Date: Effective immediately Corrective Action Plan: WWH’s Chief Operating Officer will be the single...

2024-001 – Internal Controls over Compliance and Compliance with Procurement Standards Individual Responsible for Corrective Action Plan: Meghan Davies, Chief Operating Officer Anticipated Completion Date: Effective immediately Corrective Action Plan: WWH’s Chief Operating Officer will be the single point person responsible for ensuring all federally funded procurements are managed properly and that all documentation is maintained. In addition, an extra step will be taken to duplicate the filing system for all federally funded procurements into the grants management files themselves.

View Audit 370009

Finding 1158056 (2024-001)

Material Weakness 2024

Caap Housing, Inc. Dba Emma O. Johnson Homes 073-11685

IN

Questioned Costs HUD Housing Programs

Auditee: CAAP Housing, Inc. HUD Project Number: 073-11685 Audit Firm: Agresta, Storms & O’Leary PC Audit Period Ended December 31, 2024 Corrective Action Plan Prepared by: Name: Cynthia Norris Position: Housing Asset and Tenant Service Director (Community Action of Greater Indianapolis, Inc.) A. Cur...

Auditee: CAAP Housing, Inc. HUD Project Number: 073-11685 Audit Firm: Agresta, Storms & O’Leary PC Audit Period Ended December 31, 2024 Corrective Action Plan Prepared by: Name: Cynthia Norris Position: Housing Asset and Tenant Service Director (Community Action of Greater Indianapolis, Inc.) A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding No. 2024-001 A. Comments on the Finding and Each Recommendation: Management agrees with the finding that the security deposit cash account was underfunded at December 31, 2024. B. Action Taken or Planned on the Finding: Management will transfer the required funds to the security deposit cash account when the funds are available. B. Status of Corrective Actions on Findings Reported in the Prior Audit Schedule of Findings, Questioned Costs, and Recommendations See Finding No. 2024-001 for status of Finding No. 2023-001. Respectfully Submitted, Terrence White Executive Director/CEO Community Action of Greater Indianapolis, Inc.

View Audit 370008 Questioned Costs: $1

Finding 1158055 (2024-001)

Material Weakness 2024

St Barnabas Hospital

NY

Questioned Costs Procurement, Suspension & Debarment

Finding 2024-001 Material Weakness regarding Procurement Information on the federal program: Grantor: Department of Health and Human Services Program Name: Congressional Directives Assistance Listing No.: 93.493 Views of responsible officials and planned corrective actions: Management acknowledges t...

Finding 2024-001 Material Weakness regarding Procurement Information on the federal program: Grantor: Department of Health and Human Services Program Name: Congressional Directives Assistance Listing No.: 93.493 Views of responsible officials and planned corrective actions: Management acknowledges the finding related to procurement documentation for the installation of equipment purchased under the grant. We recognize the importance of maintaining effective internal controls to ensure compliance with procurement requirements under the Uniform Guidance. The hospital has reviewed the circumstances surrounding this transaction and agrees that documentation supporting either (i) the competitive bidding process or (ii) the justification for noncompetitive procurement was not adequately retained. While the cost was included in the approved budget and was an allowable expense under the grant agreement, we understand that the absence of contemporaneous documentation represents a material weakness in our internal control framework. Subsequent to the procurement in question, the Hospital solicited and obtained an additional bid from another qualified source to validate that the original vendor’s pricing was reasonable and consistent with market expectations. Although this does not substitute for obtaining bids prior to procurement, it provides assurance that the transaction was consistent with the principles of fair and open competition. Management has prepared a Corrective Action Plan to strengthen procurement controls, improve documentation retention, and provide staff training to ensure future compliance with Uniform Guidance requirements. Corrective Action Plan: 1. Policy Enhancement: The hospital is revising its procurement policy to more clearly define documentation requirements for purchases made with federal funds, particularly those exceeding the micro-purchase threshold. 2. Pre-Procurement Checklist: A standardized checklist will be implemented for all federally funded purchases to verify compliance with procurement methods outlined in 2 CFR §200.320, including competitive bidding or justification for noncompetitive procurement. 3. Documentation Retention: Procurement staff will be required to upload and retain all competitive quotes or sole-source justifications in the centralized procurement system prior to final approval. 4. Training: Targeted training will be provided to procurement and grants management staff to reinforce Uniform Guidance requirements and the hospital’s updated procurement policies. 5. Monitoring: The compliance department will conduct quarterly reviews of federally funded procurements above the micro-purchase threshold to ensure adherence to policies and to promptly address any gaps. Name of responsible official: William DiBitetto, Senior Vice President, Finance Projected completion date: The updated policies and procedures will be implemented within 90 days of this response. Staff training and compliance monitoring will begin immediately thereafter.

View Audit 370005 Questioned Costs: $1

Finding 1158054 (2024-002)

Material Weakness 2024

Second Harvest Food Bank of the Mahoning Valley

OH

Reporting

Federal Expenditure Tracking (Emergency Food Assistance Program - Food Commodities) Recommendation: Management should strengthen internal controls over the calculation and tracking of federal expenditures by ensuring commodity weights are accurately applied. This may include implementing a standardi...

Federal Expenditure Tracking (Emergency Food Assistance Program - Food Commodities) Recommendation: Management should strengthen internal controls over the calculation and tracking of federal expenditures by ensuring commodity weights are accurately applied. This may include implementing a standardized calculation process, reconciling records of food received to supporting documentation, and performing supervisory review before amounts are reported on the SEFA. Action Taken: Management has implemented a standardized process for calculating federal expenditures under the Emergency Food Assistance Program (Food Commodities). Amounts reported on the SEFA are reviewed by management and verified annually against the applicable inventory categories used for calculation to ensure accurancy and compliance.

View Audit 370003

Finding 1158053 (2024-001)

Material Weakness 2024

Hannas House

CA

Reporting

Management acknowledges the importance of timely and accurate federal reporting and recognizes that system barriers and internal processes must be addressed to ensure compliance. They are committed to maintaining proactive communication with federal partners and implementing internal controls to pre...

Management acknowledges the importance of timely and accurate federal reporting and recognizes that system barriers and internal processes must be addressed to ensure compliance. They are committed to maintaining proactive communication with federal partners and implementing internal controls to prevent recurrence. The following are the planned correction actions from the Organization: • Establish a comprehensive reporting calendar with automated reminders to ensure all deadlines are met. • Assign multiple staff with responsibility for report submissions to provide redundancy. • Conduct quarterly compliance reviews by finance and executive leadership to verify timely reporting. Personnel responsible for implementation: Connie Franks, Chief Executive Officer and Aaliyah Rajasingam, Chief Operating Officer Date of implementation: September 23, 2025 – All corrective actions are effective immediately and will ensure consistent compliance with federal reporting requirements going forward.

View Audit 370001

Corrective Action Plans

Filters