Corrective Action Plans

Finding 1157487 (2024-004)

Material Weakness 2024

OH

Allowable Costs / Cost Principles Cash Management

Allowable Costs Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure the draw down requests and related support are formally reviewed and approved by the Executive Director for allowability before submitting...

Allowable Costs Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure the draw down requests and related support are formally reviewed and approved by the Executive Director for allowability before submitting the request to the awarding agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization has implemented a formal review and approval process, as outlined in the board-approved Financial Management Policy & Procedure Manual, to ensure all draw down requests and supporting documentation are reviewed and approved by the Executive Director for allowability prior to submission to the awarding agency, with all approved support retained on file. This process is in practice as of the date of this letter, with corrective actions continuing as needed to ensure effectiveness. Name of the contact person responsible for corrective action: Megan Mattimoe, Executive Director Planned completion date for corrective action plan: December 31, 2025

View Audit 369706

Finding 1157486 (2024-003)

Material Weakness 2024

Ao: Advocating Opportunity, Inc.

OH

Cash Management

Cash Management Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure the draw down requests and related support are formally reviewed and approved by the Executive Director before submitting the request to t...

Cash Management Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure the draw down requests and related support are formally reviewed and approved by the Executive Director before submitting the request to the awarding agency and that the support is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization has implemented a formal review and approval process, as outlined in the board-approved Financial Management Policy & Procedure Manual, to ensure all draw down requests and supporting documentation are reviewed and approved by the Executive Director prior to submission to the awarding agency, with all approved support retained on file. This process is in practice as of the date of this letter, with corrective actions continuing as needed to ensure effectiveness. Name of the contact person responsible for corrective action: Megan Mattimoe, Executive Director Planned completion date for corrective action plan: December 31, 2025

View Audit 369706

Finding 1157485 (2024-002)

Material Weakness 2024

Ao: Advocating Opportunity, Inc.

OH

Material Weakness Reporting Internal Control / Segregation of Duties

Reporting Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure reports are prepared and reviewed by separate individuals and that the information gathered to prepare the report is retained. Explanation of di...

Reporting Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure reports are prepared and reviewed by separate individuals and that the information gathered to prepare the report is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization has implemented a formal review process, as outlined in the board-approved Financial Management Policy & Procedure Manual, to ensure reports are prepared and reviewed by separate individuals before submission to the Federal Agency, and all supporting documentation is retained in accordance with the policy. This process is in practice as of the date of this letter, with corrective actions continuing as needed to ensure effectiveness. Name of the contact person responsible for corrective action: Megan Mattimoe, Executive Director Planned completion date for corrective action plan: December 31, 2025

View Audit 369706

Finding 1157456 (2024-002)

Material Weakness 2024

Housing Authority of Mayfield

KY

Cash Management HUD Housing Programs

2024-002 Capital Fund Drawdowns Federal Program: Public and Indian Capital Fund Program, Federal Assistance Listing No. 14.872 Criteria: Under federal guidelines, the capital fund program operates as a reimbursement grant. As such, all amounts must be committed or spent prior to their drawdown. Cond...

2024-002 Capital Fund Drawdowns Federal Program: Public and Indian Capital Fund Program, Federal Assistance Listing No. 14.872 Criteria: Under federal guidelines, the capital fund program operates as a reimbursement grant. As such, all amounts must be committed or spent prior to their drawdown. Condition: The entity is required to expend funds as they are drawn down from its capital fund program. As of the end of the fiscal year, drawdowns exceeded recorded expenses by $82,043. As of the end of the fiscal year, this amount is showing as unearned revenue and has not been expended. Questioned Costs: None Effect: Amounts were drawn down in an amount that exceeded the documented expenses for the capital fund program. Cause: The PHA drew down funds in anticipation of spending them but they were not spent at year end. Recommendation: The PHA should ensure that all funds are expended prior to being drawn down. Views of responsible officials and planned corrective actions: We will ensure that all future draws are supported by documentation and are spent as the funds are received. Expected correction date is December 31, 2025.

View Audit 369705

Finding 1157455 (2024-001)

Material Weakness 2024

Housing Authority of Mayfield

KY

HUD Housing Programs Eligibility

Department of Housing and Urban Development 2024-001 Public Housing Tenant Files Federal Program: Public and Indian Housing, Federal Assistance Listing No. 14.850 Criteria: The PHA is required to conduct re-examinations of tenant eligibility on an annual basis. The PHA can elect to conduct complete ...

Department of Housing and Urban Development 2024-001 Public Housing Tenant Files Federal Program: Public and Indian Housing, Federal Assistance Listing No. 14.850 Criteria: The PHA is required to conduct re-examinations of tenant eligibility on an annual basis. The PHA can elect to conduct complete re-examinations every three years using the streamline method. When using the streamline method, the tenant must be on a fixed income and certify that there have been no additional sources of income. The tenant income is adjusted by a cost of living adjustment (COLA) factor. Condition: During our review of twenty-two public housing tenant files, we noted the following: • Seven files were participating in the streamline re-examination process. On these seven files, the income was not adjusted for the COLA. Questioned Costs: None Context: Under 24 CFR 982.16, the PHA is required to adjust the income used in the rental computation by a COLA. The PHA thought that the rent did not have to be adjusted annually under the streamline method. They were adjusting the rent at the end of the three-year period. Effect: Rent amounts charged to the tenants that were participating in the streamline process were incorrect. Cause: The PHA thought that the rent did not have to be adjusted annually under the streamline method. They were adjusting the rent at the end of the three-year period. Recommendation: The PHA should adjust the amounts used in the rental computation on an annual basis. A complete re-examination is not required but the COLA should be reviewed and the rent amount adjusted if required. View of responsible officials and planned actions: We will modify our procedures to adjust the rent as required on an annual basis. Expected correction date is December 31, 2025.

View Audit 369705

Finding 1157454 (2024-004)

Material Weakness 2024

Urban Sustainability Directors Network

NC

Reporting § 200.510

The Organization acknowledges that one Federal grant was omitted from the original SEFA submitted for audit, requiring a restatement. To correct this issue, management will implement a reconciliation process that compares all grant revenue accounts and funding agreements to the draft SEFA prior to s...

The Organization acknowledges that one Federal grant was omitted from the original SEFA submitted for audit, requiring a restatement. To correct this issue, management will implement a reconciliation process that compares all grant revenue accounts and funding agreements to the draft SEFA prior to submission. The Organization will also designate a member of the finance team to perform an independent review of the SEFA for completeness and accuracy. These procedures will help ensure that all Federal awards are properly identified, included, and reported in the SEFA in future reporting periods.

View Audit 369704

Finding 1157453 (2024-003)

Material Weakness 2024

Urban Sustainability Directors Network

NC

Subrecipient Monitoring § 200.332

The Organization recognizes that subrecipient agreements must include all elements required by 2 CFR 200.332(b)(1). To address this, management will update the standard subrecipient agreement template to incorporate each required element and will adopt a checklist to be used during the agreement dra...

The Organization recognizes that subrecipient agreements must include all elements required by 2 CFR 200.332(b)(1). To address this, management will update the standard subrecipient agreement template to incorporate each required element and will adopt a checklist to be used during the agreement drafting and review process to ensure completeness. Staff responsible for preparing and executing subrecipient agreements will receive training on Uniform Guidance requirements. These steps will ensure that all subrecipient agreements fully comply with Federal regulations going forward.

View Audit 369704

Finding 1157448 (2024-003)

Material Weakness 2024

Advisewell, Inc. Formerly Known As Eqhealth Qio, Inc.

LA

Questioned Costs Allowable Costs / Cost Principles § 200.403 § 200.405 § 200.414

Corrective Action Plan: Management is in the process of working with HHS to renew the Provisional Rate agreements. The anticipation is that the agreement will be completed by the end of 2025. Anticipated Completion Date: December 31, 2025

View Audit 369691 Questioned Costs: $1

Finding 1157447 (2024-005)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Cash Management Subrecipient Monitoring § 200.303 § 200.305

U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...

U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25

View Audit 369689

Finding 1157446 (2024-004)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25

View Audit 369689

Finding 1157438 (2024-003)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Reporting HUD Housing Programs Significant Deficiency § 200.303

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25

View Audit 369689

Finding 1157430 (2024-006)

Material Weakness 2024

Anamosa Senior Citizens Housing INC

IA

Cash Management

Recommendation: We recommend that all invoices are paid timely to avoid late fees. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: December 31, 2025

View Audit 369688

Finding 1157429 (2024-005)

Material Weakness 2024

Anamosa Senior Citizens Housing INC

IA

Internal Control / Segregation of Duties

Recommendation: We recommend that board members are found, and a board meeting is held. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: December 31, 2025

View Audit 369688

Finding 1157428 (2024-004)

Material Weakness 2024

Anamosa Senior Citizens Housing INC

IA

Reporting

Recommendation: We recommend that the Corporation file the MINC reports timely. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: March 31, 2026

View Audit 369688

Finding 1157424 (2024-003)

Material Weakness 2024

Anamosa Senior Citizens Housing INC

IA

Recommendation: We recommend that the Corporation discuss with the USDA the required minimum amounts in the reserve funds and determine what the annual payments should be for each apartment building. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completi...

Recommendation: We recommend that the Corporation discuss with the USDA the required minimum amounts in the reserve funds and determine what the annual payments should be for each apartment building. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: December 31, 2025

View Audit 369688

Finding 1157423 (2024-002)

Material Weakness 2024

Anamosa Senior Citizens Housing INC

IA

Recommendation: We recommend the Corporation create a checklist to ensure that tenant files are properly documented. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: December 31, 2025

View Audit 369688

Finding 1157422 (2024-001)

Material Weakness 2024

Anamosa Senior Citizens Housing INC

IA

Internal Control / Segregation of Duties Reporting

Recommendation: While we do recognize that the Corporation is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Corporation be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will impl...

Recommendation: While we do recognize that the Corporation is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Corporation be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional controls where possible. Anticipated Date of Completion: December 31, 2025

View Audit 369688

Finding 1157418 (2024-001)

Material Weakness 2024

Christian Military Academy, Inc.

PR

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.327

Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was d...

Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was due on January 30, 2025, was submitted late on February 7, 2025. Corrective Action Plan Christian Military Academy, Inc. acknowledges this finding and has implemented corrective measures to ensure compliance with future reporting deadlines: 1. Enhanced Monitoring of PMS Submissions – A reporting calendar with reminders has been established to track all SF-425 deadlines and submission confirmations through the Payment Management System (PMS). 2. Secondary Reviewer – A second staff member has been assigned to review and confirm timely report submissions before each deadline. 3. System Contingency Plan – In the event of PMS malfunctions or access issues, management will immediately notify DHHS/ACF program officers in writing and retain evidence of the communication on or before the due date. 4. Staff Training – Fiscal staff responsible for federal reporting have been trained on the importance of timely submission and the procedures to follow in case of technical issues. Responsible Official Maribel Batista Marrero Christian Military Academy, Inc. Anticipated Completion Date The corrective actions have been implemented as of October 2025 and will remain in place on an ongoing basis.

View Audit 369684

Finding 1157417 (2024-002)

Material Weakness 2024

Early Education and Care, Inc.

FL

Equipment & Real Property Management § 200.439

Condition: During testing it was noted that the Inventory tracking sheet was not updated to reflect items that were abandoned when EEC moved out of a leased property. Cause: EEC did not properly update the fixed asset schedule for disposals, which resulted in items included on the listing and deprec...

Condition: During testing it was noted that the Inventory tracking sheet was not updated to reflect items that were abandoned when EEC moved out of a leased property. Cause: EEC did not properly update the fixed asset schedule for disposals, which resulted in items included on the listing and depreciation calculation that were disposed of previously. Corrective Action: We have implemented the following corrective actions: - The finance department has reviewed and will uphold the methods set forth in its capital asset management plan. - All information required by Uniform Guidance has been consolidated into a central tracking system. - Proper asset disposal forms have been completed and will be reviewed by EEC’s Board of Directors at their next meeting to be approved for proper disposal Corrective Responsible Party: Gary Cox/CFO and Finance Department Estimated completion date: 06/30/2025.

View Audit 369678

Finding 1157416 (2024-002)

Material Weakness 2024

Hale County Housing Authority

TX

Questioned Costs HUD Housing Programs Allowable Costs / Cost Principles

Corrective Action Plan - ACH payment not supported. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The PHA will review the ACH payment and obtain supporting documentation. Anticipated completion date - Within the next fiscal year.

View Audit 369677 Questioned Costs: $1

Finding 1157415 (2024-001)

Material Weakness 2024

Hale County Housing Authority

TX

HUD Housing Programs Reporting

Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reconciled with the FDS. Anticipated completion date - Within the nex...

Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reconciled with the FDS. Anticipated completion date - Within the next fiscal year.

View Audit 369677

Finding 1157414 (2024-001)

Material Weakness 2024

Partnership4health Community Health Board

MN

Subrecipient Monitoring Cash Management Significant Deficiency § 200.303 § 200.305

Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal poli...

Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal policy where any payment remittance advices' must be responded to and completed within two weeks of receipt to ensure that payments are deposited, and member counties of the CHB are reimbursed for the expenses that were submitted for in a prompt manner. Anticipated Completion Date: August 15, 2025

View Audit 369676

Finding 1157413 (2024-001)

Material Weakness 2024

Spokane Valley Hub

WA

Internal Control / Segregation of Duties Reporting Significant Deficiency

FINDING 2024-001 – Reporting; Significant Deficiency in Internal Control Over Compliance and Noncompliance Condition and context: Supporting documentation for the quarterly financial reports required by the grant did not include documentation of a review process or filing could not be verified for t...

FINDING 2024-001 – Reporting; Significant Deficiency in Internal Control Over Compliance and Noncompliance Condition and context: Supporting documentation for the quarterly financial reports required by the grant did not include documentation of a review process or filing could not be verified for timely submission. We noted for two of the three reports selected; submission support was not retained by the client. The grantor confirmed submission of all required reports however, the date of submission could not be verified. As such, both reports were determined to have been submitted late. Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all quarterly reports. Calendar reminders will be added to the task list for the compiler of the report information as well as the reviewer/signer of the report. These reminders will be implemented in the work calendars of the employees responsible at the onset of the grant. Reports required by the grant must be submitted timely and must have two levels of documented review. The bookkeeper and project manager will compile the information needed for the grant. The project manager and executive director will review and sign off on the grant report prior to each reporting date. Additionally, report backup and proof of timely submission will be retained by the bookkeeper and project manager. Contact Persons: Phil Champlin – Executive Director Mary Pat Davoren – Bookkeeper

View Audit 369666

Finding 1157412 (2024-001)

Material Weakness 2024

Denver Health and Hospital Authority

CO

Matching / Level of Effort / Earmarking Subrecipient Monitoring Eligibility § 200.303

FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a man...

FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025

View Audit 369665

Finding 1157411 (2024-010)

Material Weakness 2024

Heart City Health Center, Inc.

IN

Reporting

Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-010: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City H...

Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-010: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City Health Center, Inc. has already started the process to file the reports with HRSA to resolve this request

View Audit 369664

Corrective Action Plans

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