Corrective Action Plans

Finding 1230160 (2025-007)

Material Weakness 2025

FL

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Controls over Reporting Recommendation: The City should strengthen its internal controls over federal reporting by establishing formal procedures to monitor reporting deadlines, assigning responsibility for report preparation and review, maintaining a reporting calendar, and performing periodic supe...

Controls over Reporting Recommendation: The City should strengthen its internal controls over federal reporting by establishing formal procedures to monitor reporting deadlines, assigning responsibility for report preparation and review, maintaining a reporting calendar, and performing periodic supervisory reviews to ensure all required reports are submitted accurately and timely. Management Response: Management concurs with the recommendation. The Management Analyst will ensure accurate and timely grant reporting. Anticipated Completion Date: September 30, 2026 Responsible Party: GIna Sherman, Management Analyst

View Audit 411372

Finding 1230159 (2025-006)

Material Weakness 2025

CITY OF INDIAN HARBOUR BEACH

FL

Procurement, Suspension & Debarment Significant Deficiency § 200.303

Suspesion and Debarment Recommendation: The City should perform SAM checks for all vendors or contracors prior to entering into covered transactions and retain docuentation of these processes. Management Response: Management concurs with the finding. As part of the federal grant award process, City ...

Suspesion and Debarment Recommendation: The City should perform SAM checks for all vendors or contracors prior to entering into covered transactions and retain docuentation of these processes. Management Response: Management concurs with the finding. As part of the federal grant award process, City Management will ensure SAM checks are performed prior to contracting with vendors. Anticipated Completion Date: Septembe 30, 2026 Responsibnle Party: Gina Sherman, Management Analyst

View Audit 411372

Finding 1230156 (2025-001)

Material Weakness 2025

Pierce County

WA

Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Pierce County January 1, 2025 through December 31, 2025 This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CF...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Pierce County January 1, 2025 through December 31, 2025 This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The County did not have adequate internal controls for ensuring compliance with federal subrecipient monitoring requirements. Name, address, and telephone of County contact person: Jackie Ota 1501 Market Street, Suite 102 Tacoma, WA 98402 (253) 798-7231 Corrective action the auditee plans to take in response to the finding: Internal controls have been strengthened to ensure compliance with federal program requirements. Anticipated date to complete the corrective action: 09/09/2026

View Audit 411362

Finding 1230155 (2025-001)

Material Weakness 2025

Partnership to End Addiction

NY

Procurement, Suspension & Debarment Subrecipient Monitoring

Management concurs with the finding above and recognizes the importance of maintaining compliance with federal award requirements. To address the matter, management will implement the following corrective actions: Update procurement policies and procedures to properly document suspension and debarme...

Management concurs with the finding above and recognizes the importance of maintaining compliance with federal award requirements. To address the matter, management will implement the following corrective actions: Update procurement policies and procedures to properly document suspension and debarment verification through SAM.gov for all applicable vendors and contracts receiving federal funds. If vendors or contractors are not verifiable through SAM.gov, additional procedures will be performed to ensure vendors and contractors are not suspended or debarred. Implement a standardized checklist to ensure all compliance requirements are met Management will perform semi-annual monitoring of federal award transactions and compliance requirements throughout the year Management believes these actions will adequately address the condition noted and reduce the likelihood of recurrence. The Chief Financial Officer is responsible for implementing and monitoring these corrective actions, which are expected to be fully implemented by December 31, 2026

View Audit 411360

Finding 1230149 (2025-001)

Material Weakness 2025

Trinity Church, INC

FL

Reporting Internal Control / Segregation of Duties § 200.302 § 200.328

FINDING 2025-001 Reporting – Late Submission of SF-425 Federal Program / ALN: 93.092 / Personal Responsibility Education Innovative Strategies (PREIS) Type of Finding: Significant Deficiency in Internal Control over Compliance (Reporting) Questioned Costs: N/A Repeat Finding: No Corrective Action Pl...

FINDING 2025-001 Reporting – Late Submission of SF-425 Federal Program / ALN: 93.092 / Personal Responsibility Education Innovative Strategies (PREIS) Type of Finding: Significant Deficiency in Internal Control over Compliance (Reporting) Questioned Costs: N/A Repeat Finding: No Corrective Action Planned: Management will implement the following corrective actions: establish and maintain a formal federal grant reporting calendar that identifies all SF-425 due dates for Assistance Listing Number 93.092 and other federal awards; assign primary responsibility for the preparation and submission of SF-425 reports to designated grants personnel, with mandatory review and approval by the Fiscal Manager prior to submission; and incorporate SF-425 reporting deadlines into the monthly grant compliance checklist, with documentation of actual submission dates. Official Responsible for Corrective Action: Latisha Kenon, Fiscal Manager Anticipated Completion Date: The planned completion date is December 31, 2026. Views of Responsible Officials: Management agrees with the finding. The late submissions of the required SF-425 Federal Financial Reports resulted from insufficient awareness of the specific reporting deadlines. Management will implement a formal federal grant reporting calendar and assign monitoring responsibility to designated grants compliance personnel. The corrective actions will be fully implemented by the Organization and will be monitored on an ongoing basis.

View Audit 411358

Finding 1230060 (2025-002)

Material Weakness 2025

City of Cedarburg

WI

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214

City Response and Corrective Action Plan: Management agrees with the recommendation. Moving forward the City will check vendors in SAM.gov before awarding contracts and will recheck them at least once a year for multi year agreements. Each check will be recorded in a central log, and supporting docu...

City Response and Corrective Action Plan: Management agrees with the recommendation. Moving forward the City will check vendors in SAM.gov before awarding contracts and will recheck them at least once a year for multi year agreements. Each check will be recorded in a central log, and supporting documentation will be kept in our contract and grant files. When needed, the City will collect a vendor certification at the time of award and review compliance annually. The City expects full implementation of these procedures within 60 days, with ongoing monitoring after that.

View Audit 411346

Finding 1230059 (2025-003)

Material Weakness 2025

Maine Sate Housing Authority

ME

Subrecipient Monitoring Reporting

2025-003: Reporting – Temporary Assistance for Needy Families Name of Contact Person(s): Bobbie Crooker, Director of Energy and Housing Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees that for 2025 the Program Delivery Report,...

2025-003: Reporting – Temporary Assistance for Needy Families Name of Contact Person(s): Bobbie Crooker, Director of Energy and Housing Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees that for 2025 the Program Delivery Report, the Program Projections Report, and many of the Monthly Household reports did not have evidence of submission and that the Closeout Report was not filed timely. This issue occurred due to staff turnover within the LIHEAP Team, within the Fiscal Team, and within the EHS Department overall, as well as due to an insufficient monitoring process regarding reporting requirements. The State of Maine DHHS verbally informed MaineHousing that all 2025 reporting requirements have been satisfied. EHS is in the process of developing and implementing the use of an up-to-date report tracking spreadsheet for the Department. As part of the training for newly onboarded staff, such as the new department Director, the newly hired Quality Control Specialist, and the newly hired Fiscal Compliance Coordinator, EHS has also identified who is responsible for maintaining the tracking spreadsheet, identified who is responsible for the information contained in specific reports, identified who is responsible for submitting each report, and identified who is responsible for updating the department calendar with reminders for report due dates. This spreadsheet will help ensure that all reports for all programs are submitted accurately and in a timely manner in accordance with state guidelines for report submission. Additionally, EHS walked through the process and what is required with a representative from Maine DHHS. For TANF, this process and tracking has been fully implemented. This program was administered as part of a subrecipient agreement with the Maine Department of Health and Human Services (DHHS). Due to structural and fiscal changes at DHHS, MaineHousing concluded its administration of these TANF funds effective July 1, 2026. Proposed Completion Date: Completed in fall of 2025

View Audit 411338

Finding 1230058 (2025-002)

Material Weakness 2025

Maine Sate Housing Authority

ME

Eligibility Subrecipient Monitoring § 200.516

Finding 2025-002: Eligibility – Temporary Assistance for Needy Families Name of Contact Person: Bobbie Crooker, Director of Energy and Housing Services Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees with the finding. The elig...

Finding 2025-002: Eligibility – Temporary Assistance for Needy Families Name of Contact Person: Bobbie Crooker, Director of Energy and Housing Services Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees with the finding. The eligibility determination error occurred because the applicant initially presented a qualifying dependent child that met program requirements. However, the applicant subsequently failed to provide the required verification documentation. Although the applicant should have been deemed ineligible due to noncompliance, the system did not update accordingly to adjust the benefit level. The system has since been corrected to address this issue. Application intake and approval are performed by Community Action Agencies (CAAs) on behalf of MaineHousing. To provide greater assurance that CAAs accurately determine and document participant eligibility, MaineHousing has strengthened its oversight and monitoring procedures. As part of this corrective action, MaineHousing enhanced its monitoring procedures to include additional supervisory review of CAA applications and eligibility determinations. These procedures supplement the annual required risk monitoring performed for each CAA and better enable MaineHousing to identify and address determination errors or related control weaknesses in a timely manner. EHS has reviewed the circumstances surrounding the specific case identified and has determined that it appears that the known questioned costs did not exceed reportable federal thresholds and no further recovery action is necessary. This program was administered as part of a subrecipient agreement with the Maine Department of Health and Human Services (DHHS). Due to structural and fiscal changes at DHHS, MaineHousing concluded its administration of these TANF funds effective July 1, 2026. Proposed Completion Date: Completed

View Audit 411338

Finding 1230057 (2025-001)

Material Weakness 2025

Maine Sate Housing Authority

ME

Reporting Subrecipient Monitoring HUD Housing Programs

Finding 2025-001: Reporting – Community Development Block Grant/State’s Program and Non- Entitlement Grants in Hawaii Name of Contact Person: Ashley Carson, Chief Counsel Management’s Views and Corrective Action Plan: The Legal & Compliance Department is responsible for the submission of the Annual ...

Finding 2025-001: Reporting – Community Development Block Grant/State’s Program and Non- Entitlement Grants in Hawaii Name of Contact Person: Ashley Carson, Chief Counsel Management’s Views and Corrective Action Plan: The Legal & Compliance Department is responsible for the submission of the Annual Performance Report for the Recovery Housing Program and agree with the finding. For 2025, MaineHousing was experiencing an error in HUD’s Disaster Recovery Grant Reporting (DRGR) system with submission of the report and reached out to HUD for assistance. HUD was non-responsive to the first two requests for assistance, and a third request was not made until after the report filing deadline. HUD responded to the third request and assisted by providing technical assistance which allowed the report to be submitted. The report was not filed in a timely manner due to the DRGR system errors and the elapsed time between follow-ups with HUD. As system errors for DRGR are a common issue, the following corrective action will ensure that MaineHousing is proactive in the submission of Annual Performance Report for Recovery Housing. The Annual Performance Report for the Recovery Housing Program is due on October 30th. No later than September 15th each year, MaineHousing will attempt to verify any issues with the DRGR system ahead of the reporting deadline and immediately reach out to HUD for technical assistance with any issues found. MaineHousing will gather the information for the Recovery Housing Annual Performance Report at least 45 days ahead of the October 30th deadline (if available) and attempt submission of that report no later than October 5th. If errors occur in DRGR in submitting the report, MaineHousing will immediately contact HUD and continue to follow up weekly until the issue is resolved, attempting other modes of contact if HUD is unresponsive. If the report cannot be submitted in a timely manner, MaineHousing will request that HUD confirm in writing that late submission is acceptable given the circumstances. Proposed Completion Date: Completed

View Audit 411338

Finding 1230056 (2025-004)

Material Weakness 2025

Maine Sate Housing Authority

ME

HUD Housing Programs

Finding 2025-004: Eligibility – Housing Choice Vouchers Name of Contact Person(s): Allison Gallagher, Director of Housing Choice Vouchers Management’s Views and Corrective Action Plan: The Housing Choice Voucher (HCV) Department at MaineHousing agrees with the finding. The error occurred during the ...

Finding 2025-004: Eligibility – Housing Choice Vouchers Name of Contact Person(s): Allison Gallagher, Director of Housing Choice Vouchers Management’s Views and Corrective Action Plan: The Housing Choice Voucher (HCV) Department at MaineHousing agrees with the finding. The error occurred during the Annual Recertification process on September 1, 2025. While an interim recertification on January 1, 2025 correctly noted the removal of a household member and indicated that the voucher would be downsized, this information was not correctly carried forward and processed during the annual recertification. During the annual recertification, the household’s voucher size was correctly downsized, but the payment standard of $1,801 was mistakenly retained instead of applying the correct one-bedroom standard of $1,383. While the difference in payment standards is $418, the actual HUD subsidy calculation resulted in a Housing Assistance Payment (HAP) overpayment of $335 per month for four months or $1,340 in total. Upon identification of the error, HCV provided the tenant with the required 30-day notice and processed the necessary corrections to the voucher calculation. To prevent recurrence and ensure compliance with HUD regulations, the HCV Department has strengthened its annual recertification quality control procedures. The department has transitioned from a 75% monthly sample review to a mandatory 100% Quality Assurance (QA) review of all monthly processed Annual Recertifications. Proposed Completion Date: Completed

View Audit 411338

Finding 1230052 (2025-002)

Material Weakness 2025

HENRY HEYWOOD MEMORIAL HOSPITAL

MA

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Condition Found: The Organization expended federal funds in excess of the applicable Uniform Guidance audit threshold for the fiscal years 2021 through 2024; however, a Uniform Guidance audit was not completed for these years. Individual Responsible for Corrective Action: John Bujak, Chief Financial...

Condition Found: The Organization expended federal funds in excess of the applicable Uniform Guidance audit threshold for the fiscal years 2021 through 2024; however, a Uniform Guidance audit was not completed for these years. Individual Responsible for Corrective Action: John Bujak, Chief Financial Officer Planned Corrective Action: Management acknowledges the finding. Beginning with fiscal year 2026, the Organization will implement procedures to monitor federal expenditures throughout the year and as part of the annual financial reporting process. Responsibility for tracking federal awards and cumulative federal expenditures will be assigned to designated finance personnel, with oversight provided by the Chief Financial Officer. As part of the year end close process, management will perform a formal assessment of total federal expenditures to determine whether the Organization meets the requirements for a Uniform Guidance audit. The results of this assessment will be reviewed and documented annually. In addition, management will communicate with applicable funding agencies and advisors, as necessary, regarding prior-year federal expenditures and any actions that may be appropriate to address historical noncompliance with Uniform Guidance audit requirements. Anticipated Completion Date: September 30, 2026

View Audit 411332

Finding 1230045 (2025-002)

Material Weakness 2025

Boys & Girls Club of Truckee Meadows

NV

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Finding 2025-002 Corrective Action: Management concurs with the finding. The Organization will implement a formal review and approval process over monthly CACFP requests for reimbursement. Prior to submission, the Grant Manager, who is independent of the preparation process, will review the monthly ...

Finding 2025-002 Corrective Action: Management concurs with the finding. The Organization will implement a formal review and approval process over monthly CACFP requests for reimbursement. Prior to submission, the Grant Manager, who is independent of the preparation process, will review the monthly request for reimbursement and supporting documentation, including payroll and nonpayroll costs allocated to the CACFP to verify that costs are appropriately allocated to the program and are allowable under the applicable federal requirements. Evidence of the review and approval will be documented and retained with the monthly reimbursement documentation. Anticipated Completion Date: September 2026 Personnel Responsible for Corrective Action: Alison Elder, CFO

View Audit 411318

Finding 1230038 (2025-001)

Material Weakness 2025

County of Essex, New York

NY

Eligibility

Management agrees with the finding and plans to reinforce eligibility review procedures, provide additional staff training, and perform periodic supervisory reviews to ensure eligibility determinations are properly supported before benefits are authorized.

View Audit 411286

Finding 1230037 (2025-001)

Material Weakness 2025

Blackbelt Unincorporated Wastewater Program

AL

Procurement, Suspension & Debarment § 200.317 § 200.320 § 200.327

Management's Response: The Program will develop an internal procurement policy with reference to the appropriate Federal, State, and local laws, regulations, and standards. The documented policy will be used when initiating and approving purchases under Federal grant programs, so they can ensure tha...

Management's Response: The Program will develop an internal procurement policy with reference to the appropriate Federal, State, and local laws, regulations, and standards. The documented policy will be used when initiating and approving purchases under Federal grant programs, so they can ensure that they are in compliance with Uniform Guidance. Until it is written, procurement standards will be reviewed and followed. Completion Date: Discussion is ongoing regarding the plan.

View Audit 411284

Finding 1230019 (2025-001)

Material Weakness 2025

Southwest Washington Regional Health Alliance

WA

Allowable Costs / Cost Principles Cash Management HUD Housing Programs

Management will enhance its review of grant reimbursement requests by comparing billed amounts to supporting expense detail before submission and resolving any differences timely. Additional billing review training has been implemented, and management will continue working with the funding agency to...

Management will enhance its review of grant reimbursement requests by comparing billed amounts to supporting expense detail before submission and resolving any differences timely. Additional billing review training has been implemented, and management will continue working with the funding agency to resolve the overpayment.

View Audit 411267

Finding 1230018 (2025-001)

Material Weakness 2025

Trumbull County

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

The County will enhance its internal controls over reporting and review federal guidance for reporting under the Coronavirus State and Local Fiscal Recovery Funds.

View Audit 411256

Finding 1230016 (2025-011)

Material Weakness 2025

St. Mary Parish Water and Sewer Commission No. 4

LA

Internal Control / Segregation of Duties

See response to finding 2025-010

View Audit 411244

Finding 1230015 (2025-010)

Material Weakness 2025

St. Mary Parish Water and Sewer Commission No. 4

LA

Reporting § 200.512

The Commission will implement policies and procedures to ensure that the audit is completed and submitted in a timely manner.

View Audit 411244

Finding 1230007 (2025-010)

Material Weakness 2025

Area Xv Multi-County Housing Agency

IA

Allowable Costs / Cost Principles HUD Housing Programs

Finding 2025-010: Noncompliance and Significant Deficiency – Allowable Activities and Allowable Costs Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will establish written cost-allocation procedures to ensure that expenditures are charged only to...

Finding 2025-010: Noncompliance and Significant Deficiency – Allowable Activities and Allowable Costs Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will establish written cost-allocation procedures to ensure that expenditures are charged only to the program receiving the benefit and that all allocations are reasonable, equitable, consistently applied, and adequately supported. The Agency will take the following actions: Cost-Allocation Procedures • Review all methodologies used to allocate shared costs among the Public Housing, Housing Choice Voucher, and other Agency programs. • Establish written procedures identifying allowable costs, allocation methods, required supporting documentation, and approval responsibilities. • Ensure costs directly benefiting one program are charged entirely to that program. • Allocate shared costs using a reasonable and documereplacented basis that reflects the benefit received by each program. • Review and update allocation methodologies whenever programs, staffing, services, or operating conditions change. Property Insurance and Prior Allocations • Review property insurance expenses to ensure costs associated with Public Housing properties are not charged to the Housing Choice Voucher Program. • Verify and correct the $14,202.98 property insurance allocation identified during fiscal year 2025. • Review the approximately $24,964.76 in similar allocation errors identified during the two preceding fiscal years. • Record all necessary correcting entries in accordance with applicable accounting requirements and guidance from the Agency’s auditor. • Retain documentation supporting the review, calculations, correcting entries, and final disposition of the prior-period amounts. Documentation and Supervisory Review • Require invoices, allocation calculations, and supporting documentation to be reviewed before expenditures are charged to a federal program. • Implement a supervisory approval process for shared costs and expenditures affecting multiple programs. • Document the allocation basis, calculation, programs charged, reviewer, and date of approval. • Periodically review significant expense accounts to identify allocation errors and ensure corrections are made promptly. • Reconcile financial reports and general-ledger activity to supporting invoices and allocation documentation. Training and Ongoing Monitoring • Provide training to accounting and administrative personnel regarding federal cost principles, allowable costs, and allocability requirements. • Ensure staff understand that federal program funds may only be used for costs that benefit that program. • Conduct periodic internal reviews of expenditures charged to the Housing Choice Voucher Program. • Report the results of monitoring activities and any unresolved allocation issues to the Executive Director and Board of Commissioners. • Provide additional training or corrective guidance when errors or inconsistencies are identified. Management will periodically evaluate compliance with the cost-allocation procedures and report the results and any unresolved deficiencies to the Board of Commissioners. Estimated Completion Date: Written cost-allocation procedures and supervisory review requirements will be implemented by October 31, 2026. The review and correction of the fiscal year 2025 property insurance allocation and prior-year allocation errors will be completed by December 31, 2026, with quarterly monitoring thereafter. Responsible Parties: Executive Director, financial and accounting personnel, applicable program staff, contracted accounting professionals, and Board of Commissioners.

View Audit 411231

Finding 1230006 (2025-009)

Material Weakness 2025

Area Xv Multi-County Housing Agency

IA

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

Finding 2025-009: Noncompliance – Special Tests and Provisions Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will establish written procedures and a compliance calendar addressing waiting-list administration, annual utility allowance reviews, an...

Finding 2025-009: Noncompliance – Special Tests and Provisions Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will establish written procedures and a compliance calendar addressing waiting-list administration, annual utility allowance reviews, and required inspection quality-control reviews. The Agency will take the following actions: Waiting-List Administration • Review existing waiting-list records and procedures. • Maintain documentation supporting applications, preferences, applicant selections, withdrawals, removals, updates, and offers of assistance. • Ensure applicants are selected in accordance with the Administrative Plan and documented waiting-list order. • Restrict and monitor access to waiting-list records. • Periodically reconcile system-generated waiting-list reports to supporting documentation. • Conduct and document periodic waiting-list purges in accordance with the Administrative Plan. Utility Allowances • Complete and document an annual review of the Voucher program’s utility allowance schedules. • Retain utility rates, consumption information, calculations, conclusions, and supporting documentation. • Present revisions to the Board for approval when an adjustment is warranted. • Document the review even when no change to the utility allowance schedule is required. Inspection Quality Control • Establish procedures for selecting and completing the required number of quality-control inspections. • Ensure the quality-control sample is selected in accordance with applicable HUD requirements. • Use a qualified individual other than the original inspector to perform the quality-control review. • Document the units reviewed, deficiencies identified, comparison to the original inspection, and corrective action taken. • Apply the HUD inspection standard in effect for the Voucher program at the time of the inspection. • Use quality-control results to identify training needs and improve inspection consistency. Management will review compliance with these requirements periodically and report the results and any unresolved deficiencies to the Board of Commissioners. Estimated Completion Date: Written procedures and the compliance calendar will be implemented by October 31, 2026. The outstanding utility allowance review and initial inspection quality-control review will be completed by December 31, 2026, with annual and periodic monitoring thereafter. Responsible Parties: Executive Director, Housing Choice Voucher program staff, designated inspection personnel, and Board of Commissioners.

View Audit 411231

Finding 1230005 (2025-008)

Material Weakness 2025

Area Xv Multi-County Housing Agency

IA

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Finding 2025-008: Material Weakness in Internal Control Over Compliance – Housing Choice Voucher Program Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will develop and implement a comprehensive system of written internal controls and compliance ...

Finding 2025-008: Material Weakness in Internal Control Over Compliance – Housing Choice Voucher Program Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will develop and implement a comprehensive system of written internal controls and compliance procedures for the Housing Choice Voucher Program. The Agency will also: • Develop standardized tenant-file checklists covering eligibility, income, assets, deductions, citizenship or eligible immigration status, Social Security numbers, EIV documentation, rent reasonableness, inspections, leases, HAP contracts, annual and interim reexaminations, portability, and other applicable requirements. • Require the checklist to be completed and maintained in each participant file. • Establish and document supervisory or quality-control reviews of an appropriate sample of applicant and participant files. • Correct deficiencies identified during supervisory reviews and document the corrective action taken. • Update the Administrative Plan to incorporate applicable HOTMA provisions and current HUD guidance. • Establish procedures for reviewing HUD notices, regulations, handbooks, and other program guidance. • Provide regular training to employees responsible for administering the Voucher program. • Clearly assign program responsibilities and develop written procedures to reduce dependence on the knowledge of individual employees. • Maintain a compliance calendar for recurring program responsibilities and reporting deadlines. • Provide the Board with periodic reports regarding compliance reviews, deficiencies identified, and corrective actions completed. Estimated Completion Date: Checklists and supervisory-review procedures will be implemented by October 31, 2026. Written procedures, policy updates, and initial staff training will be completed by December 31, 2026, with ongoing monitoring thereafter. Responsible Parties: Executive Director, Housing Choice Voucher program staff, designated supervisory staff, and Board of Commissioners.

View Audit 411231

Finding 1230004 (2025-006)

Material Weakness 2025

Papa Ola Lokahi

HI

Cash Management Subrecipient Monitoring Internal Control / Segregation of Duties § 200.305

Material Weakness Finding No. 2025-006: Cash Management Views of Responsible Officials and Planned Corrective Action The Organization acknowledges the importance of compliance with 2 CFR §200.305, rules for federal payments; and understood and concurred with the prior year finding (2024-006) and cur...

Material Weakness Finding No. 2025-006: Cash Management Views of Responsible Officials and Planned Corrective Action The Organization acknowledges the importance of compliance with 2 CFR §200.305, rules for federal payments; and understood and concurred with the prior year finding (2024-006) and current year renumbered recommendation (2025-006). A. U.S. Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. The Organization received this award from the HHS, Substance Abuse and Mental Health Services Administration (SAMHSA), via the State of Hawaii, Department of Health (DOH). In other words, SAMHSA awarded federal dollars to the DOH, who then sub-awarded federal dollars to the Organization. The Organization further sub-awarded to eligible community-based organizations (CBOs), for the purpose of SAMHSA emergency response grants (SERG), as a result of the impacts of the Lahaina wildfires in August 2023. Payments from the DOH, is based on the Organization’s meeting the billing parameters as established by the DOH at the time of contracting. Actual billing by the Organization to the DOH, includes the aggregation of eligible expenditures incurred by sub-recipient CBOs, that are subject to reimbursement from the Organization via the DOH reimbursement. Sub-recipient CBO invoices are reviewed and validated by the Organization’s program staff prior to submission for the Organization’s aggregation and invoicing to DOH. 1. The Organization notes the following process in place as of the June 30, 2025 fiscal year end: Process & Review Controls – Finance Committee & Full Board. The Organization’s monthly Board process and review controls includes the review of the Organization’s: Statement of Financial Position, Statement of Revenues and Expenditures, Statement of Revenues and Expenditures – Net Income/(Loss) by Fund, Fund Details – Additional Information and Statistics, Active Subcontract Summary, Active Subcontract Listing Related to Funds. This monthly process and review controls functioned to mitigate any internal control non-compliance. 2. The Organization also notes the following processes implemented after the June 30, 2025 fiscal year end: Internal Control Environment Policy – July 2025, Updated August 2026. Established and updated the following policies: Internal Control Environment; Implementation of Significant Accounting Policies; Revenue Recognition Policy, Including Federal Draws; and Implementation of Health Resources & Services Administration (HRSA) Related Policies, including cash management processes and procedures. Effective September 2026, the Organization will implement an internal control review of the federal funds to ensure compliance with 2 CFR §200.305 for Federal Assistance Listing Number 93.243. B. U.S. Department of Health and Human Services (HHS) Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. This federal award is referred to as either Public Health Services (PHS) or the Native Hawaiian Healthcare Improvement Act (Act) federal dollars. For context, the Organization’s progressive and corrective actions as of the fiscal year ended (FYE) June 30, 2024 report included the following: 1. System, Process & Review Controls In Practice. a. System Controls. Continued to operate in an environment in which system, process & review controls of the United States Department of Health and Human Services (HHS) are practiced in processing cash (draw) transactions in both the Electronic Handbook (EHB) and Payment Management System (PMS) systems, operated by HHS. Only the director of administrative operations and the CEO have system access to the EHB and PMS systems. b. Process & Review Controls – Finance Committee & Full Board. The Organization’s monthly Board process and review controls includes the review of the Organization’s: Statement of Financial Position, Statement of Revenues and Expenditures, Statement of Revenues and Expenditures – Net Income/(Loss) by Fund, Fund Details – Additional Information and Statistics, Active Subcontract Summary, Active Subcontract Listing Related to Funds, and Native Hawaiian Health Program (Fund 007V), and Native Hawaiian Health Scholarship Program (Fund 017V). This monthly process and review controls functioned to mitigate any internal control non-compliance. c. HHS Drawdown Restriction. The Organization remained on HHS imposed drawdown restriction as of June 30, 2024 and June 30, 2025. The restriction was removed by HHS in July 2026. 2. The Organization also notes the following processes implemented after the June 30, 2025 fiscal year end: a. Internal Control Environment Policy – July 2025, Updated August 2026. Implemented and updated the following policies: Internal Control Environment; Implementation of Significant Accounting Policies; Revenue Recognition Policy, Including Federal Draws; and Implementation of Health Resources & Services Administration (HRSA) Related Policies, including cash management processes and procedures. b. Additional Process & Review Controls – EHB & PMS. Effective March 1, 2026, the Organization implemented, federal draws, process and review of internal controls implemented, via the chief of staff’s review of the director of administrative operations cash management analyses, federal grant receivable composition, reconciliation and related federal grant revenue computations, prior to any director of administrative operations and chief executive officer action in EHB and PMS, respectively. Finding No. 2025-006: Cash Management Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations, and Sylvia Hussey, Ed.D., Chief of Staff.

View Audit 411216

Finding 1230003 (2025-005)

Material Weakness 2025

Papa Ola Lokahi

HI

Subrecipient Monitoring

Material Weakness Finding No. 2025-005: Document Retention Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Feder...

Material Weakness Finding No. 2025-005: Document Retention Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…”, and recommendation made. The Organization further refers to the corrective action plan of Finding No. 2025-002: Subrecipient Monitoring, which describes the Organization’s implemented changes re: Subrecipient Monitoring and Management, Retroactive Subrecipient Portfolio Risk Assessment and Correction(s), and Subrecipient Policies and Procedures. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work by the Organization: A. Contractor Performance Collection and Substantiation – November 2024. Incorporated specific review procedures to ensure the timely collection and substantiation of contractor performance deliverables (e.g., products, goods, services, activities, reports), consistent with the terms and conditions of the contract. B. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. C. Discussed with respective program director(s), the implementation of initiation, consideration, decision, documentation and monitoring phased activities. D. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. E. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date. Finding No. 2025-005: Document Retention Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations, and Sylvia Hussey, Ed.D. Chief of Staff.

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Finding 1230002 (2025-004)

Material Weakness 2025

Papa Ola Lokahi

HI

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.512 § 200.514

Significant Deficiency Finding No. 2025-004: Reporting Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2024-004) and current year renumbered recommendation (2025-004), acknowledging that the unexpected resignation of the former independent...

Significant Deficiency Finding No. 2025-004: Reporting Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2024-004) and current year renumbered recommendation (2025-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a delay in securing a new independent auditor (April 2023) and completion of single audits continued to challenge the Organization through the fiscal year ended June 30, 2025. The Organization notes the following: A. Status and Progress of Single Audits 1. Single Audit as of fiscal year ended (FYE) June 30, 2022, filed in the Federal Audit Clearinghouse (FAC) on February 20, 2025. 2. Single Audit as of FYE June 30, 2023, filed in the FAC on March 9, 2026. 3. Single Audit as of FYE June 30, 2024, filed in the FAC on June 20, 2026. 4. Single Audit as of FYE June 30, 2025, projected for filing in the FAC no later than September 30, 2026. Note: Once the FYE June 30, 2025, single audit is filed, the Organization will no longer be delinquent in filing its single audit in the FAC. 5. Single Audit as of FYE June 30, 2026, engagement letter signed with scheduled field work to commence after the June 30, 2025, FAC filing (e.g., November 2026); with a projected on-time FAC filing no later than March 31, 2027, in compliance with 2 CFR §200.514 – Standards and scope of audit; and 2 CFR §200.512 – Report submission via Form SF-SAC: Data Collection Form, nine months after year end of the audit period. B. Policy, Process and Communications re: Single Audits, the Organization implemented the following policy, process and communications practices: 1. Financial Policies: Internal Control Environment Policy, Implementation of Significant Accounting Policies. 2. Process: Review and Approve Audit Report, including Financial Statements. 3. Communication of the status of the single audit(s) via Memo to the Board occurred in February, March, May, June and August 2026; and as a continuing practice will be completed for each Board meeting.Finding No. 2025-004: Reporting Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations and Sylvia Hussey, Ed.D., Chief of Staff.

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Finding 1230001 (2025-003)

Material Weakness 2025

Papa Ola Lokahi

HI

Procurement, Suspension & Debarment § 200.318 § 200.320

Finding No. 2025-003: Procurement Policies Views of Responsible Officials and Corrective Action The Organization acknowledges incorporation of the procurement standards of the Uniform Guidance to its policies and procedures to ensure compliance with Federal standards, including 2 CFR §200.318(h). Th...

Finding No. 2025-003: Procurement Policies Views of Responsible Officials and Corrective Action The Organization acknowledges incorporation of the procurement standards of the Uniform Guidance to its policies and procedures to ensure compliance with Federal standards, including 2 CFR §200.318(h). The Organization concurs with the prior year (2024-003) and current year renumbered recommendation (2025-003),and highlights its ongoing progressive and corrective implementation of policy and process actions. For context, the Organization’s progressive and corrective actions as of the fiscal year ended (FYE) June 30, 2024 report included the following: A. Financial Policies – May 2025. Completed financial policies related to: implementation of significant accounting policies, internal control environment, cash and banking, cash disbursements and check issuance, payroll processes, procure to pay and revenue recognition policies, processes and procedures. In addition, when applicable, documenting procurement circumstances, processes, decisions and CEO approval was implemented via memo(s) to the procurement file (MTPF). B. Procurement Related Processes – May 2025. Initiated use of MTPF, and process implementation of Request(s) for Professional Services Qualifications, Request(s) for Professional Services, Request(s) for Proposal. C. HRSA Policies – July 2025. Developed HRSA related policies re: implementation of HRSA policies; executive performance evaluation, non-executive performance evaluation, executive compensation, non-executive compensation, timesheets, suspension & debarment procedure, financial management system, legislative mandates, legislative mandates process & procedure and cash management for federal draws and return of funds. D. Board Policy Provision & Awareness – August 2025. Informed the Board about the progress of the Organization’s policy framework, including the above policies. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work by the Organization: A. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. B. Discussed with respective program director(s), the application of initiation, consideration, decision, documentation and monitoring phased activities. C. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. D. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). E. Updated procurement processes for emergency disaster recovery and support of community needs, including MTF documentation. Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date Finding No. 2025-003: Procurement Policies Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations, and Sylvia Hussey, Ed.D., Chief of Staff.

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Corrective Action Plans

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