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Corrective Action Plans

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Finding 1218328 (2025-001)
Material Weakness 2025
City of Lake Lillian
MN
Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure he is aware of financial statement requirements and new pronouncements.
Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure he is aware of financial statement requirements and new pronouncements.
View Audit 404564
Finding 1218328 (2025-001)
Material Weakness 2025
City of Lake Lillian
MN
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
View Audit 404564
Finding 1218323 (2025-004)
Material Weakness 2025
Housing Authority of the City of Greenville
NC
HUD Housing Programs
Finding 2025-004 – Section 8 Waiting List – Eligibility – Internal Control over Waiting List – Noncompliance and Significant Deficiency – Section 8 Housing Assistance Cluster Program – ALNs 14.871, 14.879, and 14.EHV 1. Standardized Waiting List Procedures The agency will establish and enforce stand...
Finding 2025-004 – Section 8 Waiting List – Eligibility – Internal Control over Waiting List – Noncompliance and Significant Deficiency – Section 8 Housing Assistance Cluster Program – ALNs 14.871, 14.879, and 14.EHV 1. Standardized Waiting List Procedures The agency will establish and enforce standardized procedures for: • Application intake (date/time stamping) • Placement order and preference verification • Updating applicant status • Removal and reinstatement processes All procedures will align with program regulations and be clearly documented. 2. Waiting List Management System Controls The agency will implement or strengthen controls within its waiting list system to ensure: • Automatic date/time tracking of applications • Secure user access with role-based permissions • Audit trails showing all changes (additions, updates, removals) Manual logs will be maintained if system functionality is limited. 3. Periodic Waiting List Updates & Purging The waiting list will be updated regularly to maintain accuracy: • Scheduled update notices (e.g., annually or biannually) • Proper documentation of applicant responses • Removal of ineligible or unresponsive applicants with documented justification 4. Supervisory Review & Oversight A supervisor will conduct routine reviews of waiting list activities, including: • Verification of proper placement and preferences • Review of removals and selections • Approval of any deviations from standard procedures 5. Staff Training All HCV staff involved in waiting list management will receive training on: • HUD and agency requirements • Preferences and ranking procedures • Proper documentation and recordkeeping • Fair housing compliance Refresher training will be conducted periodically. 6. Internal Quality Control Monitoring The agency will conduct periodic internal audits of the waiting list to ensure: • Compliance with policies • Accurate applicant ranking • Proper documentation of all actions Findings will be documented, and corrective actions will be implemented promptly. 7. Policy & Administrative Plan Updates The agency has revise its Administrative Plan to include: • Detailed waiting list procedures • Internal control measures • Selection and preference verification processes All updates will be approved and communicated to staff. 8. Documentation Retention The agency will maintain complete documentation for: • Applications received • Preferences verified • Correspondence with applicants • Reasons for removal or denial Files will be retained in accordance with recordkeeping requirements. Person Responsible- Consuela Knight, Director of HCV Programs Anticipated Completion Date - September 30, 2026
View Audit 404556
Finding 1218320 (2025-003)
Material Weakness 2025
Housing Authority of the City of Greenville
NC
HUD Housing Programs
Finding 2025-003 – Section 8 Participant Files – Eligibility – Internal Control over Participant Files – Noncompliance and Material Weakness – Section 8 Housing Assistance Cluster Program – ALNs 14.871, 14.879, and 14.EHV 1. Standardized Eligibility Checklist A comprehensive eligibility checklist wi...
Finding 2025-003 – Section 8 Participant Files – Eligibility – Internal Control over Participant Files – Noncompliance and Material Weakness – Section 8 Housing Assistance Cluster Program – ALNs 14.871, 14.879, and 14.EHV 1. Standardized Eligibility Checklist A comprehensive eligibility checklist will be developed and required for all participant files. This checklist will ensure all required documents (income verification, identification, citizenship status, etc.) are obtained, reviewed, and properly filed before approval. Please see the above attachment regarding the checklist. 2. File Review & Approval Process All participant files will undergo a two-tier review process: • Initial review by the assigned staff member • Secondary review and approval by a supervisor prior to final eligibility determination No file will be approved without documented supervisory sign-off. 3. Staff Training All staff responsible for eligibility determinations will receive mandatory training on: • Program eligibility requirements • Proper documentation standards • File organization and recordkeeping procedures Refresher training will be conducted annually or as regulations change. 4. Internal Quality Control Audits Monthly random file audits will be conducted to ensure compliance with eligibility requirements and documentation standards. Findings will be documented, and corrective feedback will be provided to staff. 5. Written Policies & Procedures Update The agency has update its written policies and procedures manual to include: • Step-by-step eligibility determination processes • Documentation requirements • File retention and organization standards • Quality control measures All staff will be required to acknowledge and follow updated procedures. 6. File Organization Standardization All participant files (physical and/or electronic) will follow a uniform structure to ensure consistency, accessibility, and completeness. 7. Tracking & Monitoring System A tracking system (manual log or software-based) will be implemented to monitor: • Missing documents • Pending verifications • File status (intake, review, approved) Person Responsible- Consuela Knight, Director of HCV Programs Anticipated Completion Date - September 30, 2026
View Audit 404556
Finding 1218317 (2025-002)
Material Weakness 2025
Housing Authority of the City of Greenville
NC
HUD Housing Programs Questioned Costs Subrecipient Monitoring
Finding 2025-002 – Public and Indian Housing Participant Files – Eligibility – Internal Control over Participant Files – Noncompliance and Material Weakness – Public and Indian Housing Program – ALN 14.850 1. Standardized Eligibility Checklist A comprehensive eligibility checklist will be developed ...
Finding 2025-002 – Public and Indian Housing Participant Files – Eligibility – Internal Control over Participant Files – Noncompliance and Material Weakness – Public and Indian Housing Program – ALN 14.850 1. Standardized Eligibility Checklist A comprehensive eligibility checklist will be developed and required for all participant files. This checklist will ensure all required documents (income verification, identification, citizenship status, etc.) are obtained, reviewed, and properly filed before approval. Please see the above attachment regarding the checklist. 2. File Review & Approval Process All resident files will undergo a two-tier review process: • Initial review by the assigned staff member • Secondary review and approval by a supervisor prior to final eligibility determination No file will Be approved without documented supervisory sign-off. 3. Staff Training All staff responsible for eligibility determinations will receive mandatory training on: • Program eligibility requirements • Proper documentation standards • File organization and recordkeeping procedures Refresher training will be conducted annually or as regulations change. 4. Internal Quality Control Audits Monthly random file audits will be conducted to ensure compliance with eligibility requirements and documentation standards. Findings will be documented, and corrective feedback will be provided to staff by supervisor. 5. Written Policies & Procedures Update The agency has updated its written policies and procedures manual to include: • Step-by-step eligibility determination processes • Documentation requirements • File retention and organization standards • Quality control measures All staff will be required to acknowledge and follow updated procedures. 6. File Organization Standardization All resident files (physical and/or electronic) will follow a uniform structure to ensure consistency, accessibility, and completeness. 7. Tracking & Monitoring System A tracking system (manual log or software-based) will be implemented to monitor: • Missing documents • Pending verifications • File status (intake, review, approved) Person Responsible- Shanetta Moye, Deputy Director/COO Anticipated Completion Date - September 30, 2026
View Audit 404556
Finding 1218316 (2025-001)
Material Weakness 2025
Housing Authority of the City of Greenville
NC
HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions
Finding 2025-001 - Internal Controls and Accounting for Capital Fund Grants – Cash Management and Special Tests and Provisions – Noncompliance and Significant Deficiency Capital Fund Grant Program ALN #14.872 Public and Indian Housing ALN #14.850 Corrective Action Plan: The Housing Authority of the ...
Finding 2025-001 - Internal Controls and Accounting for Capital Fund Grants – Cash Management and Special Tests and Provisions – Noncompliance and Significant Deficiency Capital Fund Grant Program ALN #14.872 Public and Indian Housing ALN #14.850 Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year September 30, 2026: a. Accounting staff will be sent to Capital Fund Training. b. Funds will be drawn and paid within 3 days of receipt. c. Funds will be drawn from appropriate BLI and distributed to the eligible line number. d. Grant end dates will be monitored to prevent loss of funding. Person Responsible: Joseph L Regan, Chief Financial Officer Anticipated Completion Date: September 30, 2026
View Audit 404556
Finding 1218314 (2025-002)
Material Weakness 2025
American Academy McAllister Institute of Funeral Service, Inc.
NY
Student Financial Aid Questioned Costs Special Tests & Provisions
In May of 2026, the Institute amended its procedures to (1) require the printing of a schedule of student balances after application of Federal Pell Grant and Loan receipts and (2) for all students with a credit balance within 12 days of the Pell receipt indicating the check number and date of the r...
In May of 2026, the Institute amended its procedures to (1) require the printing of a schedule of student balances after application of Federal Pell Grant and Loan receipts and (2) for all students with a credit balance within 12 days of the Pell receipt indicating the check number and date of the refund to the student on this schedule. This schedule is then to be reviewed for adherence to the required 14-day refund requirement under the Pell program by another staff member.
View Audit 404554
Finding 1218313 (2025-001)
Material Weakness 2025
American Academy McAllister Institute of Funeral Service, Inc.
NY
Student Financial Aid Questioned Costs Special Tests & Provisions
As reported in the Institutes fiscal 2024 Corrective Action Plan, in May 2025, the Institute revised its current procedures to include having an employee independent from the exit conference process review that any student not enrolled in a new semester or that is enrolled at less than half time sta...
As reported in the Institutes fiscal 2024 Corrective Action Plan, in May 2025, the Institute revised its current procedures to include having an employee independent from the exit conference process review that any student not enrolled in a new semester or that is enrolled at less than half time status has received proper exit conferencing and that exit conferencing has been properly documented. Two of the findings in the current fiscal 2025 occurred prior to the May revision by the Institute of its procedures. The third finding occurred during a period that the independent party performing the review function was on leave due to a death in the family. The Institute recognizes the importance of ensuring that exit conferences are performed timely and properly documented. Management has met with its staff involved in this process to emphasize its importance. Additionally, an additional staff member has been assigned to perform the review procedures if the staff member responsible is not available to timely perform the procedures.
View Audit 404554
Finding 1218312 (2025-002)
Material Weakness 2025
Asi - Austin Texas, Inc.
MN
HUD Housing Programs Questioned Costs Cash Management
FINDING 2025-002: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: A Due From Sponsor exists on the financial statements at year-end. Recommendation: The Sponsor should reimburse the Project immediately. Action Taken: The Project agrees with the finding. The Project's sponsor will reimburse ...
FINDING 2025-002: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: A Due From Sponsor exists on the financial statements at year-end. Recommendation: The Sponsor should reimburse the Project immediately. Action Taken: The Project agrees with the finding. The Project's sponsor will reimburse the Project as soon as possible. If the Department of Housing and Urban Development has questions regarding these plans, please call Ling Han at 651-645-7271.
View Audit 404552
Finding 1218311 (2025-001)
Material Weakness 2025
Asi - Austin Texas, Inc.
MN
HUD Housing Programs Questioned Costs
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: In 1 of 28 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before pa...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 Condition: In 1 of 28 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment. The finding was corrected in March 2026.
View Audit 404552
Finding 1218310 (2025-004)
Material Weakness 2025
Dona Ana County
NM
Subrecipient Monitoring
Views of Responsible Officials and Planned Corrective Action The grant administrator for this project retired last year and the current Jetport staff were unable to locate past reports for the requested timeframe. DFA did not respond with any pertinent information. This project was completed in Marc...
Views of Responsible Officials and Planned Corrective Action The grant administrator for this project retired last year and the current Jetport staff were unable to locate past reports for the requested timeframe. DFA did not respond with any pertinent information. This project was completed in March 2025, and all drawdowns were completed by June 30, 2025. The County agrees with the recommendation that Jetport strengthen its internal controls over grant compliance by implementing formal procedures to ensure timely preparation, review, and submission of all required reports. Current Jetport staff have reviewed the process of submitting these reports and will help ensure this does not occur in the future. Management recognizes its responsibility to establish and maintain centralized record retention practices for all grant documentation and implement cross-training or supervisory review processes to mitigate the risk of noncompliance due to staff turnover. We agree with the recommendation and are establishing a centralized grant office and will consistently train the grant administrators that will affect grant accounting reconciliations and oversight. Finding resolution timeline: December 1, 2026 Designation of employee position responsible for meeting this deadline: Jetport Manager, Grants Manager, Grant Accountant
View Audit 404551
Finding 1218307 (2025-003)
Material Weakness 2025
Dona Ana County
NM
Questioned Costs Reporting § 200.512
Views of Responsible Officials and Planned Corrective Action Doña Ana County implemented Workday as new ERP system for the year ended June 30, 2025. There are several configuration issues and as a result, there has been a significant increase in the amount of time the county staff requires to provid...
Views of Responsible Officials and Planned Corrective Action Doña Ana County implemented Workday as new ERP system for the year ended June 30, 2025. There are several configuration issues and as a result, there has been a significant increase in the amount of time the county staff requires to provide information related to the audit. We posted RFP for Workday re-implementation, and the contract will go to the Board of County Commissioners for approval in April 2026. We will contract with an audit and accounting firm and will use their services to correct the implementation issues. That will help resolve the issues we faced in 2025 audit. The County’s Finance department had retirements and turnover in key audit-related positions. We will continue training and professional development of employees in current auditing and accounting standards. The County is establishing a centralized grant office and will consistently train the grant administrators that will affect grant accounting reconciliations and oversight. These steps will improve the timeliness and accuracy of financial reporting for audits and enable timely submission of reports. Finding resolution timeline: December 1, 2026 Designation of employee position responsible for meeting this deadline: Controller, Financial Services Director, Grants Manager, and IT Assistant Director
View Audit 404551
Finding 1218302 (2025-101)
Material Weakness 2025
Mount Desert Island Biological Laboratory
ME
Internal Control / Segregation of Duties Procurement, Suspension & Debarment Allowable Costs / Cost Principles
INVOICE CODING - Criteria: Costs are necessary and reasonable for the performance of the federal award and allocable under the principles of 2 CFR 200, Subpart E. Condition: One invoice charged to the grant in the amount of $1,955 should have been allocated to a different grant. Context: Internal co...
INVOICE CODING - Criteria: Costs are necessary and reasonable for the performance of the federal award and allocable under the principles of 2 CFR 200, Subpart E. Condition: One invoice charged to the grant in the amount of $1,955 should have been allocated to a different grant. Context: Internal control review procedures did not correctly identify that the invoice was charged to the incorrect grant. Effect: Cost was charged to the wrong grant. Cause: Error in invoice coding. Recommendation: Review procedures should be enhanced to ensure approved costs are charged to the appropriate grant. Corrective Action: This mistake of grant attribution was subsequently corrected completely. The issue was attributable to a manual process that has been replaced by electronic processing. The electronic procurement system significantly reduces and in most cases eliminates data entry and manual translation between procurement and posting to a particular grant. Adequate review and oversight processes are in place and this issue does not reflect a systemic failure. Responsible Party: Claudine Lurvey, VP of Finances.
View Audit 404546
Finding 1218301 (2025-002)
Material Weakness 2025
Kentucky Refugee Ministries, Inc.
KY
Recommendation: KRM should have future audits completed and filed timely with the Federal Audit Clearinghouse. Action Taken: KRM continues to take steps to increase efficiencies within the finance department and due to the decrease in the number of refugees served the finance department is on schedu...
Recommendation: KRM should have future audits completed and filed timely with the Federal Audit Clearinghouse. Action Taken: KRM continues to take steps to increase efficiencies within the finance department and due to the decrease in the number of refugees served the finance department is on schedule to have the September 30, 2025 audit completed and filed timely.
View Audit 404545
Finding 1218296 (2025-001)
Material Weakness 2025
Miami-Dade Aviation Department
FL
HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions
Action Taken: The Department has taken immediate corrective action to address the deficiencies identified in the files audited. All noted discrepancies are being reviewed and are in the process of being corrected, and revised Form HUD-50058 submissions will be completed and transmitted, where requir...
Action Taken: The Department has taken immediate corrective action to address the deficiencies identified in the files audited. All noted discrepancies are being reviewed and are in the process of being corrected, and revised Form HUD-50058 submissions will be completed and transmitted, where required. The Department maintains established procedures, systems, and internal controls designed to support compliance with applicable HUD requirements. To further strengthen these controls, enhancements are currently underway to improve the timeliness of processing activities, ensure accurate and thorough income verification, and enforce proper application of abatements. Additionally, the Department is implementing more robust quality control (QC) measures to verify that all required documentation is consistently obtained, reviewed, and retained. To reinforce oversight, the Department is expanding its existing QC and Housing and Community Development (HCD) review processes. This includes the implementation of a front-line supervisory review of a representative sample of recertifications prior to the submission of Form HUD-50058. This added layer of review is intended to proactively identify and correct potential errors, ensuring accuracy, completeness, and full regulatory compliance. If the Department of Housing and Urban Development has questions regarding this plan, please call Nathan Kogon, Director at (786) 469-4120. The process to start correcting the issue discussed above is currently underway, and significant progress is expected for the next fiscal year end audit.
View Audit 404539
Finding 1218293 (2025-005)
Material Weakness 2025
Resilience: Advocates for Ending Violence
MI
Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring
Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and...
Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should expand its financial reporting review procedures to require the documented review and approval of all performance reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: During the fiscal year, the Organization properly implemented procedures that require the documented review of the monthly financial reports, including the corresponding indirect cost calculations. The Organization will expand these policies and procedures to require the documented review and approval of all performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.
View Audit 404531
Finding 1218292 (2025-004)
Material Weakness 2025
Resilience: Advocates for Ending Violence
MI
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles
Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00...
Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should establish and maintain written internal control procedures that cover the required five components of internal control for each area of compliance for each of its federal programs. The Organization should educate all employees working with federal programs of the Organization’s procedures and monitor compliance with them. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.
View Audit 404531
Finding 1218272 (2025-006)
Material Weakness 2025
TOWN OF HOPKINTON
RI
Allowable Costs / Cost Principles Questioned Costs Cash Management
Corrective Action: All vouchers require Town Manager and Finance Director to approve and sign all vouchers prior to payment. Efforts are in place to make this a high priority even in busy times. The number of transactions processed greatly increased relative to Federal dollars, but the Town is commi...
Corrective Action: All vouchers require Town Manager and Finance Director to approve and sign all vouchers prior to payment. Efforts are in place to make this a high priority even in busy times. The number of transactions processed greatly increased relative to Federal dollars, but the Town is committed to internal controls. Anticipated Completion Date: Immediately Contact Person: Elizabeth Draper and Brian Rosso
View Audit 404527
Finding 1218269 (2025-005)
Material Weakness 2025
TOWN OF HOPKINTON
RI
Questioned Costs Reporting
Corrective Action: Future reports relative to Federal agencies will rely solely upon general ledger details at the time of the reporting. Effort will be made to be as inclusive as possible. Anticipated Completion Date: Next reporting period Contact Person: Elizabeth Draper
Corrective Action: Future reports relative to Federal agencies will rely solely upon general ledger details at the time of the reporting. Effort will be made to be as inclusive as possible. Anticipated Completion Date: Next reporting period Contact Person: Elizabeth Draper
View Audit 404527
Finding 1218268 (2025-004)
Material Weakness 2025
TOWN OF HOPKINTON
RI
Procurement, Suspension & Debarment
Corrective Action: For all future RFP's utilizing Federal funds, the town will include a certification form in the RFP for bidders to provide proof of suspension or disbarment. It will be required with bid submittals, or bids will not be considered. Proof of active UEI needs to be sought from Sam.go...
Corrective Action: For all future RFP's utilizing Federal funds, the town will include a certification form in the RFP for bidders to provide proof of suspension or disbarment. It will be required with bid submittals, or bids will not be considered. Proof of active UEI needs to be sought from Sam.gov or vendor prior to awarding bids or received within 10-day grace period of bid packet receipt. Anticipated Completion Date: Immediately Contact Person: Brian Rosso, Procurement Office
View Audit 404527
Finding 1218265 (2025-003)
Material Weakness 2025
Five-Town Health Alliance, Inc. D/b/a Mountain Health Center
VT
Procurement, Suspension & Debarment § 200.214
Condition Found: The Organization did not have adequately designed internal controls to ensure compliance with Federal suspension and debarment requirements. Specifically, the Organization did not perform SAM.gov exclusion screenings for all employees and contractors. SAM.gov checks were performed o...
Condition Found: The Organization did not have adequately designed internal controls to ensure compliance with Federal suspension and debarment requirements. Specifically, the Organization did not perform SAM.gov exclusion screenings for all employees and contractors. SAM.gov checks were performed only for certain clinical providers and were aligned with the Organization’s credentialing cycle (approximately every two years), rather than being performed for all applicable individuals upon hire and/or on a recurring basis. As a result, the Organization’s exclusion screening process was not consistently applied to all individuals whose compensation is charged, in whole or in part, to Federal awards. Individual(s) Responsible for Corrective Action: Heidi Melbostad, Chief Executive Officer and Compliance Officer (process design and oversight). Nancy Kusner, Human Resources Director (screening execution and documentation). Planned Corrective Action: This finding has been remediated. The Organization has implemented exclusion screening covering all employees, contractors, and Board members whose compensation may be charged, in whole or in part, to Federal awards. Screening is performed against both the SAM.gov Exclusions List and the Office of Inspector General List of Excluded Individuals and Entities (LEIE) at the time of hire or engagement and on a recurring monthly basis. The Organization built this control in phases, conducting screening runs on 2026-04-22 and 2026-05-09 as it expanded coverage and refined the process, and completing its first comprehensive entity-wide screening, covering all current staff and Board members and including review of known names and aliases against the current roster, on 2026-06-01, with all individuals returning clear results. The Organization retains documented evidence of each screening, including the roster comparison and alias check, to support compliance with 2 CFR 200.214. Management is finalizing a written protocol documenting these steps to ensure the control is sustained. Anticipated Completion Date: Control built in phases over April and May 2026 (screening runs 2026-04-22 and 2026-05-09); first comprehensive entity-wide screening completed 2026-06-01, all results clear. SAM.gov and LEIE screening of all staff, contractors, and Board members continues on a recurring monthly basis. Written protocol documenting the control to be finalized by 2026-06-30.
View Audit 404523
Finding 1218262 (2025-002)
Material Weakness 2025
Five-Town Health Alliance, Inc. D/b/a Mountain Health Center
VT
Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs
Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a disco...
Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a discount but did not have an active sliding fee application for the service date the sliding fee discount was applied. Individual(s) Responsible for Corrective Action: Lori Slicer, Revenue Cycle Manager (organization-wide sliding fee discount monitoring procedure across the medical and dental service lines). Crystal Kinsman, Dental Practice Manager (dental-specific monitoring, with increased sampling of the Dental system given its higher level of manual processing). Heidi Melbostad, Chief Executive Officer and Compliance Officer (sliding fee discount schedule redesign and oversight). Planned Corrective Action: Management is addressing this finding through both an immediate interim action and a comprehensive redesign, together with an ongoing monitoring control. Interim action (completed): the Board approved revised nominal fee levels on 2026-04-27, effective 2026-04-28, establishing Category A as the most favorable discount category, consistent with Section 330(k)(3)(G) of the Public Health Service Act. Full corrective action: management will complete a comprehensive redesign of the Sliding Fee Discount Program, including separate schedules for the medical and dental service lines, data-driven evaluation of tier thresholds and fee levels, and replacement of the percentage-based payment option with a clearer flat-fee structure, for Board review and approval. Ongoing monitoring control: management will establish a documented monitoring procedure over sliding fee discount application across both the medical and dental service lines, including a defined monthly sample drawn from each service line with increased sampling of the Dental system given its higher level of manual processing, verification that an active sliding fee application is on file for each service date, documented review results, timely correction of identified errors, and supervisory sign-off, with error rates reviewed at least quarterly. Anticipated Completion Date: Interim nominal fee revision effective 2026-04-28 (completed). Comprehensive Sliding Fee Discount Program redesign and ongoing monitoring procedure to be Board-approved and operational by 2026-08-24.
View Audit 404523
Finding 1218250 (2025-002)
Material Weakness 2025
SOUTH FEATHER WATER AND POWER AGENCY
CA
Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.320
Finding 2025-002 – Significant Deficiency Award No.: 21.027 Federal Grantor: U.S. Department of Treasury, Passed-through the County of Butte, Pass-through Grantor’s Number X25534. Compliance Requirement: Procurement, Suspension and Debarment. Condition: The Agency’s procurement policy does not adequ...
Finding 2025-002 – Significant Deficiency Award No.: 21.027 Federal Grantor: U.S. Department of Treasury, Passed-through the County of Butte, Pass-through Grantor’s Number X25534. Compliance Requirement: Procurement, Suspension and Debarment. Condition: The Agency’s procurement policy does not adequately document procurement requirements under the Uniform Guidance or contract provisions under Appendix II to Part 200 of the Uniform Guidance. Criteria: Uniform Guidance, Section 200.318(a) indicates “the recipient or subrecipient must maintain and use documenting procedures for procurement transactions under a Federal award or subaward, including for acquisition of property or services. These documented procurement procedures must be consistent with State, local, and tribal laws and regulations and the standards identified in §§ 200.317 through 200.327”. Required contracting provisions are documented in Appendix II to Part 200 – Contract Provisions for Non-federal Entity Contracts Under Federal Awards. Cause: The Agency’s procurement policy needs to be updated to document the requirements of the Uniform Guidance. Effect: The Agency’s procurement policy does not comply with the requirements of the Uniform Guidance, which could result in procurements that do not comply with the Uniform Guidance and the awarding agency disallowing the federal award and requesting the return of the award. Context: The Agency’s procurement policy complies with many requirements of the Uniform Guidance, but the policy does not comply with certain required provisions, including the thresholds for micro purchases, simplified acquisition threshold and full public procurements and the requirements for sole sourcing procurements under section 200.320. The procurements tested were found to comply with procurement requirements under Uniform Guidance even though the policy did not include all of the required provisions. Recommendation: The Agency should update its procurement policy to reference Uniform Guidance §§ 200.317 through 200.327 and should reference contracting provisions under Appendix II to Part 200 to be in compliance with Uniform Guidance prior to procurements being made under future federal awards. Views of Responsible Officials and Planned Corrective Actions: The procurement policy will be updated to include procurement guidance under Uniform Guidance §§ 200.317 through 200.327 and contracting provisions under Appendix II to Part 200 – Contract Provisions for Non-federal Entity Contracts Under Federal Awards. Title of Responsible Party: Finance Manager Implementation Date: By September 22, 2026
View Audit 404498
Finding 1218248 (2025-001)
Material Weakness 2025
Valorus
CA
Reporting Internal Control / Segregation of Duties § 200.510
Finding 2025-001 – Accuracy of Schedule of Expenditures of Federal Awards (SEFA) The ALN numbers identified as incorrect were on 16.588 & 16.575 under the Violence Against Women Formula Grant. These two numbers were inadvertently transposed during preparation of the SEFA. Out of the 20 ALN numbers r...
Finding 2025-001 – Accuracy of Schedule of Expenditures of Federal Awards (SEFA) The ALN numbers identified as incorrect were on 16.588 & 16.575 under the Violence Against Women Formula Grant. These two numbers were inadvertently transposed during preparation of the SEFA. Out of the 20 ALN numbers reported, only these two were inaccurate. All expenditures reported on the SEFA were based on actual expenditures incurred consistent with prior guidance provided by the auditor. During the previous audit cycle, VALOR’s accountant sought clarification regarding whether expenditures should be reported based on actual expenditures or reimbursement amounts and was instructed to use actual expenditures incurred. In accordance with 2 CFR 200.510(b), auditees must prepare a SEFA that accurately identifies programs by the correct ALN and reports expenditures based on actual amounts expended from federal awards. Except for the inadvertent transposition of the two ALN numbers noted above, the SEFA was prepared in compliance with these requirements. As a corrective action, beginning with the next SEFA report for the 2025-2026 fiscal year, the SEFA will be prepared by the Senior Accountant, Karen Sayers, and reviewed by both the Director of Operations, Rosemary Gonzales, and the organization’s CPA, Kim Jones, prior to submission to verify the accuracy of all ALN numbers and reported amounts.
View Audit 404493
Finding 1218247 (2025-002)
Material Weakness 2025
Valorus
CA
Subrecipient Monitoring § 200.332 § 200.510
Finding 2025-002 – Incomplete Subrecipient Agreements and Inaccurate Subrecipient SEFA Reporting Subrecipient agreements were executed based on California’s State Administrator of federal funds (CalOES) requirements applicable to second-tier subawards. Based on guidance provided during Federal Grant...
Finding 2025-002 – Incomplete Subrecipient Agreements and Inaccurate Subrecipient SEFA Reporting Subrecipient agreements were executed based on California’s State Administrator of federal funds (CalOES) requirements applicable to second-tier subawards. Based on guidance provided during Federal Grants Advanced Training and the 2025 CalOES Subrecipient Handbook (page 65), entities receiving pass-through funding from the state are required to follow CalOES second-tier subaward requirements. Accordingly, VALOR’s agreements include the elements required for second-tier subawards. Elements of a Second-Tier Subaward (From the 2025 CalOES Subrecipient Handbook) The following elements must be included in a Second-Tier Subaward: • Name of the Subrecipient Organization and the participating agency/organization, • The titles and contact information for the individuals that will serve as the primary contacts,• The timeframe of the agreement (this must cover the Grant Subaward performance period), • The roles and responsibilities (as they relate to the specific Grant Subaward) of the Subrecipient Organization and the participating agency/organization, • Specific information concerning all non-fiscal resources shared between the Subrecipient Organization and the participating agency/organization, • Reporting requirements necessary for the Subrecipient Organization to meet Cal OES reporting requirements, • Signatures of the chief executive or designee of the Subrecipient Organization and the participating agency/organization, including the dates of those signatures, and • Specific information concerning the transfer of any Grant Subaward funds from the Subrecipient Organization to the participating agency/organization. At a minimum, this information must include the total amount of Grant Subaward funds that will be transferred, the process for transferring the Grant Subaward funds (e.g., monthly invoices, payment based on deliverables), what the Grant Subaward funds will be used for, and any match contribution provided by the participating agency/organization. Any funds included in the Second-Tier Subaward must be clearly designated (not itemized) in the Grant Subaward Budget Pages (Cal OES Form 2-106a or b). Additionally, second tier subrecipients are prohibited from charging indirect costs; therefore, indirect cost provisions were not included in the agreements. Based on the above, management believes the subrecipient agreements substantially complied with applicable CalOES requirements. Any omissions identified were administrative in nature and did not impact program performance, allowability of costs, or oversight of subrecipient activities. To strengthen internal controls and ensure full compliance with all applicable grant requirements, beginning January 1, 2027, VALOR’s Director of Operations, Rosemary Gonzales, will include all required elements identified in the finding in future subrecipient agreements. In addition, VALOR will review subrecipient Single Audit reports to verify that applicable grant funding is properly reported on the SEFA. VALOR will also notify subrecipients of the requirement to include these amounts in their future SEFA reporting. Contracts for the current year, 2026, have already been signed.
View Audit 404493
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