Corrective Action Plans

Finding 573439 (2023-005)

Material Weakness 2023

OH

Allowable Costs / Cost Principles HUD Housing Programs § 200.403 § 200.430

Finding Number: 2023-005 Planned Corrective Action: The Authority has updated our allocation plan and added actual percentages to the plan. A/P was unaware that all employee benefits were at a different percentage; has since then been remedied. Anticipated Completion Date: April 15, 2025 Responsible...

Finding Number: 2023-005 Planned Corrective Action: The Authority has updated our allocation plan and added actual percentages to the plan. A/P was unaware that all employee benefits were at a different percentage; has since then been remedied. Anticipated Completion Date: April 15, 2025 Responsible Contact Person: Sherrie Boudinot

View Audit 364184

Finding 573259 (2023-004)

Significant Deficiency 2023

Crisis Call Center, Inc. Dba Crisis Support Services of Nevada

NV

Allowable Costs / Cost Principles § 200.400

Corrective Action Plan (CAP) – FY 2023 Single Audit Finding 1: Material Adjustments to Recognize Balances in Accordance with U.S. GAAP Planned Corrective Action / Views of Responsible Officials: Management acknowledges the need for a formalized process to ensure that all general ledger balances are...

Corrective Action Plan (CAP) – FY 2023 Single Audit Finding 1: Material Adjustments to Recognize Balances in Accordance with U.S. GAAP Planned Corrective Action / Views of Responsible Officials: Management acknowledges the need for a formalized process to ensure that all general ledger balances are reviewed and accurate prior to audit. A third-party accounting firm has been engaged to conduct quarterly reviews and reconciliations of the general ledger to ensure proper documentation and recognition in accordance with U.S. GAAP. Management plans to develop and implement a structured internal review process before submitting the General Ledger balance for audit to ensure alignment with U.S. GAAP. We recognize that this may continue as a finding in the FY 2024 audit; however, the corrective action is in place as of this Single Audit in July 2025. Expected Completion Date: In progress with full implementation as of October 2025 or expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 2: Completeness of SEFA and Data Collection Form Filing Timeliness Planned Corrective Action / Views of Responsible Officials: We recognize the deficiencies in our prior SEFA submission process. As of July 2025, the organization has engaged a third-party accounting firm to conduct quarterly reconciliations of federal grant activity and maintain a rolling SEFA throughout the fiscal year. Management turnover has stabilized, and processes are now in place to maintain an up-to-date general ledger with accuracy to support a complete and timely SEFA. A documented checklist and timeline have been implemented to ensure timely and accurate reporting. Expected Completion Date: In progress, with full implementation expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 3: Employee Loan Documentation Planned Corrective Action / Views of Responsible Officials: New leadership has implemented a strict no-loan policy. Any loan or advance to staff must now receive prior written approval from the Executive Board. A formal Employee Loan and Advance Policy is being adopted to ensure any future considerations are properly documented, authorized, and compliant with internal controls. Payment-processing staff will be trained to enforce the new policy and ensure all reimbursements and advances meet approval requirements. Expected Completion Date: September 30, 2025 or expected prior to commencement of FY 2025 Single Audit. Responsible Official: Amee Ivie, MSW Chief Executive Officer Finding 4: Internal Controls Over Compliance – Timesheet Approval and Allowable Costs Planned Corrective Action / Views of Responsible Officials: As of April 2024, the organization implemented a new electronic timekeeping system (SwipeClock) in partnership with a third-party payroll provider. This system includes: • Supervisor approval of all time entries. • A final review by a member of the executive team (CEO, Operations Manager, or Accounting Coordinator). This three-tiered approval process ensures accuracy and accountability in payroll allocation to federal grants. Expected Completion Date: Fully implemented as of April 2024 Responsible Official: Amee Ivie, MSW Chief Executive Officer, AmeeI@cssnv.org

View Audit 364057

Finding 573255 (2023-002)

Significant Deficiency 2023

Westerly Area Rest Meals (warm) INC

RI

Allowable Costs / Cost Principles § 200.430

2023-002 Payroll Costs Contact Person – Erin Metcalf, Finance Director Description of Corrective Action – Training has been provided and currently the payroll allocations are matched to weekly payroll reports from outside payroll company. Allocations of vacation and sick time are done according to...

2023-002 Payroll Costs Contact Person – Erin Metcalf, Finance Director Description of Corrective Action – Training has been provided and currently the payroll allocations are matched to weekly payroll reports from outside payroll company. Allocations of vacation and sick time are done according to actual payroll reports and entered into accounting software based on true numbers instead of tracked on a spreadsheet. Completion Date – June 30, 2025 Root Cause – Outdated procedures in place.

View Audit 364054

Finding 573254 (2023-001)

Significant Deficiency 2023

Westerly Area Rest Meals (warm) INC

RI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.302 § 200.403

2023-001 Supporting Documentation and Approval of Disbursements Contact Person – Erin Metcalf, Finance Director Description of Corrective Action – Since that time, the organization has developed an invoice and payment process. This ensures proper disbursement and approval processes and supporting ...

2023-001 Supporting Documentation and Approval of Disbursements Contact Person – Erin Metcalf, Finance Director Description of Corrective Action – Since that time, the organization has developed an invoice and payment process. This ensures proper disbursement and approval processes and supporting documentation are obtained for expenses incurred. We will ensure that the expenses for the grants are reviewed monthly and will make the correct adjustments on a timely basis to ensure that the funds are approved and paid in accordance with the grant documents. Completion Date – June 30, 2025 Root Cause – New program procedures were not in place

View Audit 364054

Finding 573150 (2023-002)

Material Weakness 2023

American Museum of Science and Energy Foundation, Inc.

TN

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.400

As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final a...

As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final agreement, the budgeted requested salaries were not updated. We will attempt to have the sponsoring office of the federal program to retroactively amend the Assistance Agreement to remove the compensation limitation. The Assistance Agreement has been modified to remove any such limitation prospectively beginning with Modification 0015 April 2024.

View Audit 363969 Questioned Costs: $1

Finding 573012 (2023-001)

None 2023

Town of Hopedale, Massachusetts

MA

Questioned Costs Allowable Costs / Cost Principles Reporting

Finding 2023-001 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Other Matters Related to Internal Control over Compliance of the Major Program Condition: During our test of contr...

Finding 2023-001 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Other Matters Related to Internal Control over Compliance of the Major Program Condition: During our test of controls over compliance it was noted that an expense charged to the major program (High Quality Summer Learning) was not included as part of the approved budget for the “Contracted Services” budget line. Criteria: Costs charged to the major program should meet the requirements as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles). Context: During our review of expenditures posted to the major program (High Quality Summer Learning) it was noted that costs that were originally budgeted to “Stipends” was charged to “Contracted Services”, thus overspending the “Contracted Services” budget line by $8,475.04 or 214.78% which would have required an Amendment. Effect: The Town of Hopedale was not in compliance with the allowable costs/ cost principals requirement as set forth by the Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles). Questioned Costs: $8,475.04 Cause: honest mistake in reporting Identification as a Repeat Finding: N/A Recommendation: We recommend the Town of Hopedale follow procedures to ensure that expenditures charged to the grants are allowable costs as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles) Responsible for Corrective Plan: Lynne Davis Estimated Completion Date: 7/1/24 Action Taken: Going forward, we will ensure that contracted services are recorded as contracted services and not stipends.

View Audit 363880 Questioned Costs: $1

Finding 573000 (2023-002)

Significant Deficiency 2023

New Hampshire Children's Trust

NH

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.318

Planned Corrective Action: Revise Financial Policies to require prior written approval from the Executive Director prior to entering into any agreement for expenditures between $10,000 and $49,999. If it is a sole source, written justification must be submitted and approved by the Executive Director...

Planned Corrective Action: Revise Financial Policies to require prior written approval from the Executive Director prior to entering into any agreement for expenditures between $10,000 and $49,999. If it is a sole source, written justification must be submitted and approved by the Executive Director prior to the execution of agreement. If multiple bids were obtained, these must also be submitted and the selected vendor approved by the Executive Director prior to the execution of agreement. Planned Implementation Date of Corrective Action: 2/5/2025 Person Responsible for Corrective Action: Director of Finance

View Audit 363863

Finding 572980 (2023-003)

Significant Deficiency 2023

Fremont County, Colorado

CO

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.205

RE: 2023-003 Federal Award – Procurement, Suspension and Debarment Fremont County was assessed a Federal Awards Finding for the 2023 Audit year by Certified Public Accountants, Logan and Associates, LLC, for Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, C...

RE: 2023-003 Federal Award – Procurement, Suspension and Debarment Fremont County was assessed a Federal Awards Finding for the 2023 Audit year by Certified Public Accountants, Logan and Associates, LLC, for Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 200.505 and Appendix II to 200. This regulation requires the County to determine that contractors, individuals, businesses receiving Federal funds have not been suspended or debarred from receiving Federal funds. After the assessment Fremont County has identified an area of improvement including internal controls. Staff members have implemented and utilize the Federal Debarred Website, www.SAM.gov, to be in compliance with the Federal Award requirement moving forward with the grant administrator. Staff members will also be encouraged to take annual Federal Award courses provided by Colorado Government Finance Officers Association or other similar entities. Fremont County will continue to enhance and streamline training for new and existing personnel, in the finance department, and implement new preventive controls. Fremont County believes these steps will resolve the procurement, suspension and debarment for all Federal Awards.

View Audit 363846

Finding 572560 (2023-006)

Significant Deficiency 2023

Cherokee Boys Club, Inc.

NC

Allowable Costs / Cost Principles

Finding 2023-006: Significant Deficiency - Allowable Costs/Cost Principles Condition: Documentation of the review and approval of certain expenditures was unable to be located. Corrective Action: The Club agrees with this finding and has established procedures to ensure that all required signature...

Finding 2023-006: Significant Deficiency - Allowable Costs/Cost Principles Condition: Documentation of the review and approval of certain expenditures was unable to be located. Corrective Action: The Club agrees with this finding and has established procedures to ensure that all required signatures are obtained before posting intercompany expenses for transportation. The Assistant Finance Director receives the monthly invoices from the Bus Department and forwards them to the Cherokee Central Schools Finance Director for approval before completing the monthly posting. Person Responsible For Corrective Action: Barry McMillan, Assistant Finance Director Anticipated Completion Date: June 30, 2024

View Audit 363709

Finding 572526 (2023-008)

Material Weakness 2023

Churches United for the Homeless

MN

Questioned Costs Allowable Costs / Cost Principles Cash Management

2023‐008 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working to establish better financial reporting to ensure that costs a...

2023‐008 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working to establish better financial reporting to ensure that costs are appropriately allocated to grants for reimbursement and to establish adequate supporting documentation for all expenditures reimbursed with federal, state, or grant funding. Planned implementation date of corrective action – Calendar year 2025.

View Audit 363689 Questioned Costs: $1

Finding 572523 (2023-007)

Significant Deficiency 2023

Churches United for the Homeless

MN

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

2023‐007 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working within the invoice approval system to build in safeguards to p...

2023‐007 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working within the invoice approval system to build in safeguards to prevent invoices from being routed without CEO approval. Planned implementation date of corrective action – Calendar year 2025.

View Audit 363689

Finding 572520 (2023-006)

Material Weakness 2023

Churches United for the Homeless

MN

Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties

2023‐006 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – The financial management team is reviewing the requirements for federal expenditures...

2023‐006 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – The financial management team is reviewing the requirements for federal expenditures under Uniform Guidance for better understanding of the requirements and to establish appropriate policies and procedures for handling of federal funding. Planned implementation date of corrective action – Calendar year 2025.

View Audit 363689

Finding 572502 (2023-001)

Significant Deficiency 2023

Alianza Americas

IL

Allowable Costs / Cost Principles

Finding 2023-001 Adherence and Application of Fiscal and Accounting Policies and Procedures – Repeat Finding ...

Finding 2023-001 Adherence and Application of Fiscal and Accounting Policies and Procedures – Repeat Finding Federal Agency: U.S. Department of Health and Human Services Program Name: Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security Assistance Listing #: 93.318 Questioned Costs: None Corrective Action: We agree with the auditor’s comments and the recommended actions. The Organization recognizes the importance of consistent adherence to its established Financial Management Policies and Procedures, specifically related to the required approval of expenditures by upper management. To address this finding and prevent recurrence, Alianza Americas will implement the following corrective actions: ● Policy Reinforcement: Revise and redistribute the organization’s Financial Management Policies and Procedures manual to all staff involved in the review, processing, or approval of financial transactions. ● Training: Conduct mandatory refresher training for all staff involved in the review, processing, or approval of financial transactions by July 31, 2025. ● Controls and Compliance Checks: Developed and implemented a financial transaction spreadsheet to ensure that all required approvals are obtained before processing. Finance staff have been instructed to reject any incomplete or non-compliant documentation. ● Monitoring and Oversight: Monthly internal audits will be conducted by the Associate Director of Operations to verify compliance and address any discrepancies proactively. These measures will ensure that expenditures are reviewed and approved in accordance with policy, and that proper documentation is maintained for all financial transactions. Contact Person: Dulce Guzmán, Executive Director Anticipated Completion Date: July 31, 2025

View Audit 363642

Finding 572501 (2023-001)

Significant Deficiency 2023

Greater Lawrence Technical School

MA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Audit Finding Reference: 2023-001 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melis...

Audit Finding Reference: 2023-001 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melissa Martel, Director of Finance Completion Date: December 12, 2023

View Audit 363636

Finding 572328 (2023-061)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.208 § 200.332 § 200.339 § 200.414 § 200.415

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will provide training to personnel on the requirements and regulations related to subrecipient monitoring. Recommendation to management will be implemented, internal controls and compliance measures that allow for the identification, reporting, and monitoring of ...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will provide training to personnel on the requirements and regulations related to subrecipient monitoring. Recommendation to management will be implemented, internal controls and compliance measures that allow for the identification, reporting, and monitoring of subrecipient activities Prevention Activities/TANF. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572249 (2023-037)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Questioned Costs Allowable Costs / Cost Principles Eligibility

VIEWS OF RESPONSIBLE OFFICIALS Establish a peer or supervisory review process for a percentage of eligibility determinations prior to final approval and implement a common error log to identify areas requiring further training or adjustment of procedures. IMPLEMENTATION DATE During Fiscal Year 2025-...

VIEWS OF RESPONSIBLE OFFICIALS Establish a peer or supervisory review process for a percentage of eligibility determinations prior to final approval and implement a common error log to identify areas requiring further training or adjustment of procedures. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Sidnia Vélez, Child Care Program Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)

View Audit 363366 Questioned Costs: $1

Finding 572243 (2023-034)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.302 § 200.305 § 200.334 § 200.335 § 200.336

VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026....

VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)

View Audit 363366

Finding 572241 (2023-033)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.302 § 200.305 § 200.328 § 200.329 § 200.334

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572237 (2023-032)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.302 § 200.303 § 200.305 § 200.328 § 200.329

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572236 (2023-031)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.300 § 200.306 § 200.309 § 200.403

VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Estab...

VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Establish an indirect cost policy to standardize the evaluation and approval for subrecipient. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572233 (2023-030)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302 § 200.405

VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPL...

VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Doris Jiménez, Finance Director Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)

View Audit 363366 Questioned Costs: $1

Finding 572217 (2023-003)

Significant Deficiency 2023

Galveston County Health District

TX

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

Planned Corrective Action: We will develop internal reports to align with UDS reporting requirements. We will also create a reconciliation log to track changes and justifications. We will assign an individual to oversee data integrity and submission. Name of Contact Person: Ruth Cable, CFO, Lane Bak...

Planned Corrective Action: We will develop internal reports to align with UDS reporting requirements. We will also create a reconciliation log to track changes and justifications. We will assign an individual to oversee data integrity and submission. Name of Contact Person: Ruth Cable, CFO, Lane Baker, COO, and Tomiko Fisher, COO Anticipated completion date: October 31, 2025

View Audit 363352

Finding 572086 (2023-001)

Significant Deficiency 2023

North Mississippi Education Consortium, Inc.

MS

Questioned Costs Allowable Costs / Cost Principles § 200.403 § 200.430

Issue: Summary Condition: The Auditee submitted reimbursement requests to the Mississippi Department of Education (MOE) that were not fully supported: Standard monthly amounts requested for Digital Learning Instructor (DU) labor exceeded actual contract costs, resulting in overstatements. 1 of 60 it...

Issue: Summary Condition: The Auditee submitted reimbursement requests to the Mississippi Department of Education (MOE) that were not fully supported: Standard monthly amounts requested for Digital Learning Instructor (DU) labor exceeded actual contract costs, resulting in overstatements. 1 of 60 items sampled lacked support for $11,700 in charges. Cause: The Consortium requested funds before receiving invoices or verifying actual expenses. There was no reconciliation process in place to verify that reimbursement requests matched actual expenditures. Effect: Federal funds were received in excess of allowable costs and not returned to the grantor. These excess reimbursements represent questioned costs which the grantor could request funds to be refunded. Criteria: In accordance with 2 CFR 200.403 and 200.430, costs must be necessary, reasonable, and allocable, and adequately documented to be allowable under federal awards. Questioned Costs: Total known questioned costs are $49,082, which includes: $37,382 related to Digital Learning Instructor (DLI) contract labor, including $34,445 in excess labor charges and $2,937 in related indirect costs. These charges were identified through a 100% review of all DU contract labor activity for fiscal year 2023. $11,700 from a single reimbursement request that partially lacked supporting documentation. This item was identified during testing of a sample of 60 items totaling $6,545,759.87. Response: The Consortium acknowledges the finding and agrees with the audit's assessment. The practice of requesting reimbursement based on estimated monthly amounts without timely reconciliation to actual expenses was not in alignment with federal cost principles under 2CFR 200.403 and 200.430. We recognize that this oversight led to the disbursement of excess federal funds, and we are committed to promptly resolving this issue and implementing strong internal controls to prevent recurrence. Corrective Action Plan: Reconciliation Process Implementation: We have implemented a formal reconciliation process to ensure reimbursement requests are in line with actual cost. This includes reviewing all invoices and matching them to amounts requested. Return of Excess Funds: We are identifying and preparing to return any excess federal funds that were distributed as a result of these overstatements, as part of our reconciliation review. Corrective Action Timeline: The reconciliation process was initiated in June 2025. The return of fund to Mississippi Department of Education will begin with sending the audit report to MDE and getting directions on how to return overstated funds. Responsible Individuals: Mark Brown, business manager, is leading the implementation of the corrective action measures, in collaboration with Projects Coordinator, Susan Scott.

View Audit 363217 Questioned Costs: $1

Finding 572058 (2023-004)

Significant Deficiency 2023

Waikiki Health

HI

Allowable Costs / Cost Principles § 200.303

Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develo...

Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develop written policies requiring cash disbursements to follow a clear, tiered approval process based on the amount. For example: • Up to a set threshold: Department manager approval • Above threshold: Department manager plus finance director/CFO approval • High-value disbursements: Additional executive or board-level approval. Requiring supporting documents (invoices, contracts, purchase orders) for every disbursement. Approvers must verify accuracy and completeness before authorizing payment. If there are any questions regarding this plan, please e-mail Yumiko Molden at ymolden@waikikihealth.org. Sincerely, Yumiko Molden CFO

View Audit 363175

Finding 572033 (2023-003)

Material Weakness 2023

Catherine McAuley Center, Inc.

IA

Allowable Costs / Cost Principles § 200.302 § 200.305 § 200.502 § 200.510

Finding 2023-003 - Material Weakness in Internal Control over Compliance and Material Noncompliance (Qualified Opinion) - Inadequate Tracking of Expenditures and Retention of Documentation: Activities Allowed or Unallowed: Allowable Costs/Cost Principles and Reporting (A/B/L) for Assistance Listing ...

Finding 2023-003 - Material Weakness in Internal Control over Compliance and Material Noncompliance (Qualified Opinion) - Inadequate Tracking of Expenditures and Retention of Documentation: Activities Allowed or Unallowed: Allowable Costs/Cost Principles and Reporting (A/B/L) for Assistance Listing Number 19.510 and 93.567 Criteria: The Code of Federal Regulations (CFR) Section 200.510(b) states in part, “The auditee must also prepare a schedule of federal expenditures for the period covered by the auditee’s consolidated financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Also, in accordance with CFR Section 200.302(b) - Financial Management, the auditees financial management system must provide 1) identification of all federal awards received and expended; 2) accurate, current, and complete disclosure of the financial results of each federal award or program; 3) records that identify adequately the source and application of funds for federally‐funded activities; 4) effective control over, and accountability for, all funds, property, and other assets; 5) comparison of expenditures with budget amounts for each Federal award; 6) written procedures to implement the requirements of section 200.305 and; 7) written procedures for determining the allowability of costs in accordance with Subpart E and the terms and conditions of the Federal award. Recipients of federal awards must submit accurate, complete and timely financial and performance reports. The Organization should have internal controls designed to ensure compliance with those provisions. The Organization should retain sufficient documentation such as invoice and allocation support for expenditures to retain documentation for audit purposes. Condition: During detail testing of expenditures, it was noted that the Organization did not maintain adequate documentation to support how certain costs were allocated to the federal program. Several transactions lacked sufficient detail, such as invoice or expense reimbursement form. Several expenditures selected for testing did not obtain sufficient approval by an individual at the Organization. It was noted that quarterly reports provided to the federal program were not reviewed by an individual at the Organization prior to submission to ensure accurate report of expenditures. Cause: The Organization does not have an adequate system in place to ensure quarterly reports have sufficient supporting documentation, proper approval/review, and accurate reporting prior to submission. Responsibilities for expenditure tracking were not clearly assigned, and there was no formal review process in place. The Organization is not following their Document Retention Policy. Effect: The effect of this condition increases the possibility that quarterly financial reports are misstated or inaccurate and increase the risk of noncompliance with federal requirements. The effect of this condition also increases the risk that expenditures are unallowable per the grant, federal regulations, or cost principles due to the insufficient support of proper approval retained. Questioned costs: None Repeat Finding: Yes - 2022-004 Recommendation: Policies and procedures should be in place to ensure quarterly financial reports are properly supported, accurately reported, and adequately approved and reviewed. A formal review process should be established to ensure compliance. The Organization should following the Document Retention Policy that was put in place and required by law. Management Response: There is no disagreement with the audit finding. Management has taken steps to address these deficiencies in fiscal year 2025 including but not limited to: the implementation of a new accounting system that includes document retention and review/sign off logs, the engagement of a third-party CPA firm to provide client advisory and accounting services and the review and updating of accounting policies and procedures for best practices. Responsible Person for Corrective Action Plan: Marc Hall, Director of Operations Implementation Date for Corrective Action Plan: Fiscal year 2025

View Audit 363139

Corrective Action Plans

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