Corrective Action Plans

Finding 1175220 (2023-005)

Material Weakness 2023

Cooperstown Medical Center D/b/a Dakota Regional Medical Center

ND

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking

Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Acco...

Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Account) were reconciled on a timely basis. This increases the possibility that errors related to the USDA Accounts and other accounts impacted by the USDA Accounts, including construction in progress, are not properly stated in the financial statements. In addition, there could be amounts expended from the USDA Accounts that do not meet the requirements and those expenditures would not be identified in a timely manner. Corrective Action Plan Internal controls will be updated to have a formalized process established to ensure timely reconciliation of the USDA Accounts as well as a review process of those reconciliations each month Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO; Jasen Walker, Controller Anticipated Completion Date Complete.

View Audit 388912

Finding 1175219 (2023-004)

Material Weakness 2023

Cooperstown Medical Center D/b/a Dakota Regional Medical Center

ND

Reporting Material Weakness Matching / Level of Effort / Earmarking

Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Cli...

Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Clinics Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.301 Program Name COVID 19 Small Rural Hospital Improvement Grants Finding Summary Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Corrective Action Plan It is not cost effective to have an internal control system designed to provide for a complete and accurate schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the schedule of expenditures. We have designated a member of management to review the drafted schedule of expenditures. Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO Anticipated Completion Date Ongoing

View Audit 388912

Finding 1174960 (2023-001)

Material Weakness 2023

Cmsu Behavorial Health and Development Services

PA

Matching / Level of Effort / Earmarking

CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR

View Audit 388558

Finding 1174905 (2023-003)

Material Weakness 2023

Count of Penobscot, Maine

ME

2023-003 Other Matter Name of contact person: Blair Tinkham, County Administrator Corrective Action: The Organization is aware of the filing deadline and will ensure that future audits are completed on a timely basis. Controls are being implemented to ensure that the year end reporting can be comple...

2023-003 Other Matter Name of contact person: Blair Tinkham, County Administrator Corrective Action: The Organization is aware of the filing deadline and will ensure that future audits are completed on a timely basis. Controls are being implemented to ensure that the year end reporting can be completed within a period of time that will allow timely completion of the audit and submission to the audit clearinghouse. Proposed implementation date: The corrective actions will be implemented as soon as possible.

View Audit 388461

Finding 1174808 (2023-001)

Material Weakness 2023

First Step of Wichita Falls, Inc

TX

Subrecipient Monitoring Reporting

First Step of Wichita Falls, Inc. agrees with this recommendation and is implementing the following actions to address it: 1. Development of a Grant Monitoring System o We are implementing a centralized grant tracking system to record key grant requirements, reporting timelines, and deliverables. o ...

First Step of Wichita Falls, Inc. agrees with this recommendation and is implementing the following actions to address it: 1. Development of a Grant Monitoring System o We are implementing a centralized grant tracking system to record key grant requirements, reporting timelines, and deliverables. o The Executive Director and Finance Director will oversee the development and maintenance of this system. 2. Creation of a Compliance and Reporting Calendar o A detailed compliance calendar will be developed to track all financial and progranunatic reporting deadlines for each grant. o The calendar will be reviewed monthly by program and finance staff to ensure all deliverables are submitted on time. 3. Staff Training and Accountability o Staff responsible for grant management will receive training on Uniform Guidance requirements and the use of the new tracking system. o Roles and responsibilities related to compliance and reporting will be clearly defined in updated internal procedures. We believe these corrective actions will strengthen our internal controls, improve oversight of grant activities, and ensure compliance with all Uniform Guidance reporting requirements.

View Audit 388365

Finding 1174703 (2023-014)

Material Weakness 2023

City of Woonsocket

RI

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current ...

Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current staff has completed HUD training modules on monitoring to ensure that monitoring that takes place will follow all guidelines. With the updated catalogue of all HOME loans, the division of housing and community development can have an accurate list of properties that are in the period of affordability and subject to monitoring. Staff will refer to monitoring files from previous years to create documents and letters to be sent to homeowners. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174702 (2023-013)

Material Weakness 2023

City of Woonsocket

RI

Procurement, Suspension & Debarment Eligibility HUD Housing Programs

Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The depar...

Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program Compliance Officer after thorough review. Written agreement documentation will be revised to include the requirements from the new compliance manual. The City of Woonsocket plans to procure grant management software which will streamline the application process and allow for improved recordkeeping to ensure compliance with all policies and procedures. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174701 (2023-012)

Material Weakness 2023

City of Woonsocket

RI

Allowable Costs / Cost Principles Reporting Special Tests & Provisions

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued ...

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174700 (2023-011)

Material Weakness 2023

City of Woonsocket

RI

Allowable Costs / Cost Principles § 200.403 § 200.405

Reference Number: 2023-011 Finding: Improve Controls and Compliance with Approval of Allowable Costs Name of Contact Person: Lorina Esposito Corrective Active Plan: The City will implement a policy mandating documented approval for all invoices before they are paid or charged to federal programs. In...

Reference Number: 2023-011 Finding: Improve Controls and Compliance with Approval of Allowable Costs Name of Contact Person: Lorina Esposito Corrective Active Plan: The City will implement a policy mandating documented approval for all invoices before they are paid or charged to federal programs. In addition, the City will conduct regular, scheduled reviews of invoice processing to verify compliance with allowable cost procedures and address any deviations promptly. Training will be provided to staff involved in invoice approval and payment processes to ensure understanding and adherence to these internal control requirements. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174698 (2023-010)

Material Weakness 2023

City of Woonsocket

RI

Material Weakness Reporting Internal Control / Segregation of Duties § 200.328 § 200.329

Reference Number: 2023-010 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Lorina Esposito Corrective Active Plan: In the past year, the City has fully staffed the division of housing and community development which has led to the successful submission of the 2024 CAP...

Reference Number: 2023-010 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Lorina Esposito Corrective Active Plan: In the past year, the City has fully staffed the division of housing and community development which has led to the successful submission of the 2024 CAPER. The staff worked diligently to find all required data for the report and participated in training courses to prepare for future CAPERs. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174696 (2023-009)

Material Weakness 2023

City of Woonsocket

RI

Equipment & Real Property Management § 200.313

Reference Number: 2023-009 Finding: Improve Controls and Compliance with Equipment and Real Property Management Name of Contact Person: Lorina Esposito Corrective Active Plan: Over the past year staff has ensured that the inventory is up-to-date and accurate. Inventories were performed in 2024 in pr...

Reference Number: 2023-009 Finding: Improve Controls and Compliance with Equipment and Real Property Management Name of Contact Person: Lorina Esposito Corrective Active Plan: Over the past year staff has ensured that the inventory is up-to-date and accurate. Inventories were performed in 2024 in preparation for the single audit. Now that the division of housing and community development is fully staffed, the inventory can be shared amongst staff as well as uploaded to the shared drive to ensure it can be accessed in the event of staff turnover. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174694 (2023-008)

Material Weakness 2023

City of Woonsocket

RI

Material Weakness Reporting Internal Control / Segregation of Duties § 200.328 § 200.329

Reference Number: 2023-008 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement formal written procedures for preparing, submitting, and retaining all required quarterly performance and evalu...

Reference Number: 2023-008 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement formal written procedures for preparing, submitting, and retaining all required quarterly performance and evaluation reports in compliance with program requirements. Designated staff will be responsible for tracking reporting deadlines, ensuring timely submissions, and maintaining thorough documentation of all reports. Management will conduct regular reviews to monitor compliance and address any deficiencies promptly. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174693 (2023-007)

Material Weakness 2023

City of Woonsocket

RI

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.318 § 200.327

Reference Number: 2023-007 Finding: Improve Controls and Compliance with Procurement Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement standardized procurement procedures specifically for federally funded purchases, ensuring that all transactio...

Reference Number: 2023-007 Finding: Improve Controls and Compliance with Procurement Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement standardized procurement procedures specifically for federally funded purchases, ensuring that all transactions are fully documented in accordance with applicable procurement policies. Staff will be trained on these procedures, and a central repository will be established to maintain executed contracts and all supporting documentation. Regular audits will be conducted to verify compliance and that all required records are retained and readily accessible. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174692 (2023-006)

Material Weakness 2023

City of Woonsocket

RI

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303

Reference Number: 2023-006 Finding: Improve Segregation of Duties over Expenditure Approvals Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will establish formal procedures to ensure that the responsibilities for approving purchase orders and invoices are assigned to ...

Reference Number: 2023-006 Finding: Improve Segregation of Duties over Expenditure Approvals Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will establish formal procedures to ensure that the responsibilities for approving purchase orders and invoices are assigned to different individuals, thereby maintaining effective segregation of duties. In instances where staffing limitations make segregation impractical, management will implement compensating controls, including independent review and approval of these transactions. Documentation of all reviews and approvals will be maintained for audit purposes. Training will be provided to relevant staff to ensure understanding and compliance with these procedures. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174686 (2023-005)

Material Weakness 2023

City of Woonsocket

RI

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

Reference Number: 2023-005 Finding: Update Documented Policies amt Procedures Over Federal Awards Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement comprehensive policies and procedures specifically addressing the management and oversight of fe...

Reference Number: 2023-005 Finding: Update Documented Policies amt Procedures Over Federal Awards Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement comprehensive policies and procedures specifically addressing the management and oversight of federal awards to ensure compliance with the Uniform Guidance. Designated staff will be tasked with drafting these documents, which will be reviewed and approved by senior management. Training sessions will be conducted for all relevant personnel to ensure consistent application of the new policies and procedures. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174673 (2023-004)

Material Weakness 2023

City of Woonsocket

RI

Reporting Matching / Level of Effort / Earmarking Significant Deficiency

Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is ...

Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is both complete and accurate. This will include establishing a formal process for reconciling all reported federal expenditures with supporting documentation such as the general ledger and grant reports. Additionally, the SEFA will undergo a documented review by a qualified individual who was not involved in its preparation prior to finalization and submission. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174298 (2023-007)

Material Weakness 2023

County of Lassen

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: CLA recommends the County implement procedures to ensure that federal guidance is followed relating to suspension and debarment and provide training on these procedures. Explanation of disagreement with audit finding: ...

Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: CLA recommends the County implement procedures to ensure that federal guidance is followed relating to suspension and debarment and provide training on these procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We were unaware we needed to capture the date showing the contractor was in good standing. We now have updated our procedures to include this in contract check-lists. Name(s) of the contact person(s) responsible for corrective action: Pete Heimbigner Planned completion date for corrective action plan: September 18, 2025

View Audit 388041

Finding 1174289 (2023-008)

Material Weakness 2023

County of Lassen

CA

Internal Control / Segregation of Duties

Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: We recommend that the County of Lassen strengthen its internal controls to ensure that all required documentation supporting the implementation of its Quality Assurance Program is retained and readily available for aud...

Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: We recommend that the County of Lassen strengthen its internal controls to ensure that all required documentation supporting the implementation of its Quality Assurance Program is retained and readily available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We were unaware the auditor’s office needed documentation for the quality assurance program. We have notified public works to forward us the information. Name(s) of the contact person(s) responsible for corrective action: Pete Heimbigner Planned completion date for corrective action plan: September 18, 2025

View Audit 388041

Finding 1174281 (2023-010)

Material Weakness 2023

County of Lassen

CA

Reporting

Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) – Assistance Listing No. 21.027 Recommendation: The County should implement enhanced review procedures to ensure accurate and timely reporting of CSLFRF expenditures. This includes reconciling reported amounts with actual expenditures record...

Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) – Assistance Listing No. 21.027 Recommendation: The County should implement enhanced review procedures to ensure accurate and timely reporting of CSLFRF expenditures. This includes reconciling reported amounts with actual expenditures recorded in the financial system prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: At this time, all funds have been spent however, our new financial system will help track future expenditures. Name(s) of the contact person(s) responsible for corrective action: Stephanie Hranac Planned completion date for corrective action plan: July 1, 2024

View Audit 388041

Finding 1174280 (2023-009)

Material Weakness 2023

County of Lassen

CA

Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: We recommend that the County of Lassen implement procedures to ensure that all required wage rate documentation is obtained and retained for all applicable federally funded projects. This includes certified payrolls an...

Highway Planning and Construction – Assistance Listing No. 20.205 Recommendation: We recommend that the County of Lassen implement procedures to ensure that all required wage rate documentation is obtained and retained for all applicable federally funded projects. This includes certified payrolls and evidence of wage rate verification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We were unaware the auditor’s office needed documentation for the wage rate documentation. We have notified public works to forward us the information. Name(s) of the contact person(s) responsible for corrective action: Pete Heimbigner Planned completion date for corrective action plan: September 18, 2025

View Audit 388041

Finding 1174193 (2023-001)

Material Weakness 2023

Gbapp, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

Description of Finding: GBAPP, Inc. was unable to prepare financial statements, a schedule of federal awards and a schedule of state financial assistance that complied with Generally Accepted Accounting Principles (GAAP) and governmental professional standards on a timely basis. Significant adjustme...

Description of Finding: GBAPP, Inc. was unable to prepare financial statements, a schedule of federal awards and a schedule of state financial assistance that complied with Generally Accepted Accounting Principles (GAAP) and governmental professional standards on a timely basis. Significant adjustments, subsequent to year end, were required to conform the financial statements and schedules to professional standards in all material respects. Accordingly, the Federal Data Collection Form and the Connecticut EARS filings were not submitted timely. Statement of Concurrence or Nonconcurrence: GBAPP, Inc. concurs with this audit finding. Corrective Action: Management has since retained additional personnel to assist in performing these duties and is in the process of implementing additional policies and procedures. GBAPP supplemented its accounting personnel with an external CPA with extensive experience in accounting and reporting for non-profit organizations that receive federal and state funding, and who also possesses the suitable skills, knowledge and experience in financial, government and grants management reporting to ensure that this finding will not be repeated. Name of Contact Person: Nancy Kingwood President/Executive Director 203-366-8255 nkingwood@gbapp.org Projected Completion Date: Immediately

View Audit 387906

Finding 1174136 (2023-002)

Material Weakness 2023

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Subrecipient Monitoring HUD Housing Programs Material Weakness

During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...

During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.

View Audit 387791

Finding 1174135 (2023-001)

Material Weakness 2023

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Subrecipient Monitoring Eligibility HUD Housing Programs

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedure...

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedures to ensure all required actions are taken when a tenant becomes over-income.

View Audit 387791

Finding 1174132 (2023-003)

Material Weakness 2023

Norman County

MN

Cash Management Reporting Significant Deficiency § 200.303

Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification sinc...

Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification since 2024 and has been reporting since receiving notification. Anticipated Completion Date: 1/1/2024

View Audit 387778

Finding 1174131 (2023-002)

Material Weakness 2023

Norman County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/train...

Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/trainings for staff Anticipated Completion Date: Quarterly internal audits anticipated start date: April 2026 Anticipated completion date of ongoing program training: July 2026

View Audit 387778

Corrective Action Plans

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