Corrective Action Plans

Finding 520056 (2023-001)

Significant Deficiency 2023

NM

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Department of Transportation Safer New Mexico Now, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 to December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings...

Department of Transportation Safer New Mexico Now, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 to December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT There were no findings or matters required to be reported in accordance with Governmental Auditing Standards. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY Department of Transportation 2023-01 ALLOWABILITY – INTERNAL CONTROLS OVER PAYROLL DISBURSEMENTS, FINANCIAL CLOSE, AND REPORTING (REPEATED - PREVIOUSLY 2022-02) Federal Program Title(s): ALN 20.600 – State and Community Highway Safety ALN 20.608 – Minimum Penalties for Repeat Offenders for Driving While Intoxicated ALN 20.616 – National Priority Safety Program Recommendation: CLA recommends management continue to assess the current procedures for payroll allocations to ensure that expenditures are not claimed in error.. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action Planned/Taken in response to finding: The individual directly responsible for the errors is no longer with the Organization and the duties related to payroll have been assigned to someone more familiar with the responsibility that the role entails. The Organization has retained the services of a skilled accounting team to conduct a thorough review and assessment of all payroll related policies and procedures. As a result, processes have been updated and duties have been segregated related to this process. The Organization has implemented new procedures to verify and confirm payroll allocations, added in additional layers of review, and reinforced accountability to ensure accurate reporting and allocation moving forward. Name(s) of the contact person(s) responsible for corrective action: Lisa Kelloff, CEO Planned completion date for corrective action plan: Safer has currently implemented the above noted responses to the finding during 2024. If the Department of Transportation or other Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Lisa Kelloff, CEO at 505-856-6143.

View Audit 339565 Questioned Costs: $1

Finding 520036 (2023-003)

Significant Deficiency 2023

Unique People Services - Aids Programs, Inc..

NY

Allowable Costs / Cost Principles § 200.430

Unique – AIDS has read the proposed recommendations and has agreed to comply although our funding sources has never had any issues with the allocation methods being used since inception. Unfortunately, we are not able to modify the budget estimates for the past fiscal year. Rest assured that going ...

Unique – AIDS has read the proposed recommendations and has agreed to comply although our funding sources has never had any issues with the allocation methods being used since inception. Unfortunately, we are not able to modify the budget estimates for the past fiscal year. Rest assured that going forward, Unique People Services will strive to maintain its books as recommended with the time study for the very few employees that have been allocated to the two programs being impacted by the audit field work. Please note that it has never been our intentions not to comply with the regulations, but since the issues were never raised or brought to light in prior years, we felt that it was not necessary to alter the process. However, going forward, we are committed to fully comply with 2 CFR 200.430 charges to Federal awards for salaries and wages in order to accurately reflect the work performed by our employees and anticipate to have this completed by February 28, 2025. The Chief Financial Officer, Ive Pierre, is monitoring this process

View Audit 339528

Finding 520031 (2023-002)

Material Weakness 2023

Feeding San Diego

CA

Questioned Costs Allowable Costs / Cost Principles Reporting

Identification of federal programs 21.027 - Child Care and Development Block Grant (ARPA) Condition The Organization was unable to provide support for backpacks or food pantry boxes provided for certain sites throughout the year. Views of Responsible Officials: Management agrees with the finding...

Identification of federal programs 21.027 - Child Care and Development Block Grant (ARPA) Condition The Organization was unable to provide support for backpacks or food pantry boxes provided for certain sites throughout the year. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339495 Questioned Costs: $1

Finding 520029 (2023-005)

Significant Deficiency 2023

Feeding San Diego

CA

Allowable Costs / Cost Principles Cash Management Reporting

Identification of federal programs 10.558 - Child and Adult Care Food Program (CACFP) Condition The Organization does not retain documentation of review of supper meals and snacks uploaded for reimbursement. Views of Responsible Officials: Management agrees with the finding and observation. Con...

Identification of federal programs 10.558 - Child and Adult Care Food Program (CACFP) Condition The Organization does not retain documentation of review of supper meals and snacks uploaded for reimbursement. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339495

Finding 520028 (2023-004)

Significant Deficiency 2023

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting

Identification of federal programs 21.027/10.558 - American Rescue Plan Act (ARPA) and Child and Adult Care Food Program (CACFP) Condition The Organization did not have adequate internal controls surrounding reception of food boxes, backpacks, supper meals, or snacks provided as some selections d...

Identification of federal programs 21.027/10.558 - American Rescue Plan Act (ARPA) and Child and Adult Care Food Program (CACFP) Condition The Organization did not have adequate internal controls surrounding reception of food boxes, backpacks, supper meals, or snacks provided as some selections did not have supervisory review of support. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339495

Finding 520027 (2023-003)

Significant Deficiency 2023

Feeding San Diego

CA

Allowable Costs / Cost Principles Reporting

Identification of federal programs 10.558 – Child and Adult Care Food Program (CACFP) Condition The Organization was unable to provide documentation to support the number of supper meals or snacks distributed at certain sites throughout the year. Views of Responsible Officials: Management agrees...

Identification of federal programs 10.558 – Child and Adult Care Food Program (CACFP) Condition The Organization was unable to provide documentation to support the number of supper meals or snacks distributed at certain sites throughout the year. Views of Responsible Officials: Management agrees with the finding and observation. Contact Person: Fendy Wogu, Finance Controller Proposed Completion Date: October 31, 2024

View Audit 339495

Finding 519859 (2023-002)

Material Weakness 2023

City of Tulare

CA

Allowable Costs / Cost Principles § 200.302 § 200.328

We concur with the finding and understand the importance of establishing appropriate internal controls. Staff was aware of this condition prior to the beginning of the audit process and, therefore, acquired a consultant to prepare the Project and Expenditure Reports for review prior to submission.

View Audit 339152

Finding 519858 (2023-010)

Significant Deficiency 2023

Milwaukee Public Schools

WI

Allowable Costs / Cost Principles

Corrective Action Planned: The Milwaukee Public School District, specifically the Department of Financial Planning and Budget Services, oversees important Medicaid compliance tasks like billing, quarterly reports, the finalization of the IEP Ratio, and annual reports. To avoid any future findings, t...

Corrective Action Planned: The Milwaukee Public School District, specifically the Department of Financial Planning and Budget Services, oversees important Medicaid compliance tasks like billing, quarterly reports, the finalization of the IEP Ratio, and annual reports. To avoid any future findings, the office is taking the following actions: First, the Department is working on better training and understanding of Medicaid compliance tasks. They've hired additional staff members to help review their procedures for Medicaid activities. This review will ensure that all necessary tasks and deadlines are clearly documented with instructions for completing each task. These materials will be updated annually and shared with District staff and third-party vendors, such as MJ Cares and PCG, to keep everyone informed on the required tasks and how to finish them correctly. Additionally, the Director of Financial Planning and Budget Services is focused on retaining knowledge and ensuring accountability for successful results. Staff members are being cross-trained within their department and are also collaborating with others, including the Office of Finance and the Office of Specialized Services. Department leaders will hold quarterly meetings with staff to make sure all Medicaid activities are carried out properly. the specific actions to be taken to eliminate or mitigate the recurrence of the finding. Name(s) of Contact Person(s) Responsible for Corrective Action: Budget Director Anticipated Completion Date: June 2025

View Audit 339133

Finding 519843 (2023-004)

Material Weakness 2023

Productive Alternatives, Inc.

MN

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

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: The organization should ensure proper documentation is retained to support the approval of allowable costs by someone knowledgeable of the grant and its guidelines. The Organization should re...

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: The organization should ensure proper documentation is retained to support the approval of allowable costs by someone knowledgeable of the grant and its guidelines. The Organization should reconcile the budgeted payroll allocation charged to the grant after-the-fact to actual work performed to ensure the allocation accurately reflected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will ensure moving forward that proper support is retained for allowable costs charged to the grant and budgeted amounts are reconciled to after-the fact actual amounts. Name(s) of the contact person(s) responsible for corrective action: Denise DeMartelaere, Co-Director of Finance Planned completion date for corrective action plan: 12/31/2025

View Audit 339087 Questioned Costs: $1

Finding 519714 (2023-002)

Significant Deficiency 2023

Advent House Ministries, Inc.

MI

Allowable Costs / Cost Principles Reporting Significant Deficiency

January 7, 2025 Advent House Ministries, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period: The finding from the December 31, 2023 schedule of findings and ...

January 7, 2025 Advent House Ministries, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period: The finding from the December 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Findings - Financial Statement Audit Finding 2023-001 - Significant Deficiency Recommendation: Advent House Ministries, Inc. should consider obtaining the necessary skills, knowledge, or experience to prepare and/or review the footnotes related to the financial statements of the Organization. Action Taken: We concur with the recommendation, the Organization has contracted with an accountant in 2024 with the skills, knowledge, and experience to address the above recommendation. Finding - Federal audit Finding 2023-002 - Significant Deficiency Recommendation: Advent House Ministries, Inc. currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Action to be Taken: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package. Sincerely yours, Susan Cancro, Executive Director

View Audit 338820

Finding 519623 (2023-001)

Material Weakness 2023

Longview School District No. 122

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Longview School District No. 122 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of F...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Longview School District No. 122 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District 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: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Joan Parsons, Lead Accountant 2715 Lilac St Longview, WA 98632 (360)575-7177 Corrective action the auditee plans to take in response to the finding: The District has now enhanced its process surrounding collection and verification of certified payroll reports to include sending a weekly inquiry to the point of contact for the prime contractor for each federally-funded construction project. The inquiry requests the prime contractor to: • disclose if the prime contractor performed any work on the project that would be subject to Davis-Bacon prevailing wage requirements and if so, supply the certified payroll reports • identify any subcontractors who performed work on the project that would be subject to Davis-Bacon prevailing wage requirements, and if so, supply the certified payroll reports This communication is sent via email, read receipt requested, and the prime contractor’s response (or lack thereof) is documented and followed up on as necessary. Anticipated date to complete the corrective action: This process was implemented June 2024.

View Audit 338730

Finding 519519 (2023-002)

Significant Deficiency 2023

Living Indepdence for Everyone, Inc. (life)

MS

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

Compliance Requirement – Living Independence for Everyone, Inc. (LIFE) is subject to 2 CFR section 200.303 and 45 CFR section 75.303. Both require that non-federal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance tha...

Compliance Requirement – Living Independence for Everyone, Inc. (LIFE) is subject to 2 CFR section 200.303 and 45 CFR section 75.303. Both require that non-federal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Recommendation – The Organization should continue working with the assistance of ACL to correct the significant deficiencies noted by the ACL review team in order to improve internal control over compliance and meet the requirements and expectations of 2 CFR section 200.303 and 45 CFR section 75.303. Corrective Action Plan – The Organization agrees with the finding and has made substantial progress in addressing the significant deficiencies identified in their internal control over compliance. The Organization is committed to continuing to work diligently and in full cooperation with ACL to implement the corrective actions included in their compliance review report. Contact Person – Roger Bullock, Executive Director

View Audit 338528

Finding 519518 (2023-001)

None 2023

Living Indepdence for Everyone, Inc. (life)

MS

Questioned Costs Allowable Costs / Cost Principles

Compliance Requirement – Living Independence for Everyone, Inc. (LIFE) is subject to 45 CFR sections 75.403-405 which require all expenses charged to a federal award to be allowable, reasonable and allocable. Recommendation – The Organization should adopt and implement formalized policies to provide...

Compliance Requirement – Living Independence for Everyone, Inc. (LIFE) is subject to 45 CFR sections 75.403-405 which require all expenses charged to a federal award to be allowable, reasonable and allocable. Recommendation – The Organization should adopt and implement formalized policies to provide guidance on assessing staff performance and delivery of bonus payments. Also, the Organization should maintain sufficient documentation of the methodology followed in determining the amount of any bonus payments and the approval of such payments. Corrective Action Plan – The Organization agrees with the finding and is in the process of adopting updated policies and having them approved by ACL. These updated policies will provide clear guidance on the staff performance review process and the methodology for determining any bonus amounts to be paid. Contact Person – Roger Bullock, Executive Director

View Audit 338528 Questioned Costs: $1

Finding 519488 (2023-009)

Significant Deficiency 2023

Kipp Delta, Inc. D/b/a Kipp Delta Public Schools

AR

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

Views of responsible officials and planned corrective actions: Management agrees with this finding and will ensure copies of all employee contracts are maintained. See 2023-004 for management’s detailed action plan, timeline, and the responsible parties for all Education Stabilization Fund findings.

View Audit 338456 Questioned Costs: $1

Finding 519486 (2023-007)

Significant Deficiency 2023

Kipp Delta, Inc. D/b/a Kipp Delta Public Schools

AR

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

Views of responsible officials and planned corrective actions: Management agrees with this find and will review time certifications in comparison to salaries and wages recorded to the program. See 2023-004 for management’s detailed action plan, timeline, and the responsible parties for all Education...

Views of responsible officials and planned corrective actions: Management agrees with this find and will review time certifications in comparison to salaries and wages recorded to the program. See 2023-004 for management’s detailed action plan, timeline, and the responsible parties for all Education Stabilization Fund findings.

View Audit 338456 Questioned Costs: $1

Finding 519483 (2023-004)

Material Weakness 2023

Kipp Delta, Inc. D/b/a Kipp Delta Public Schools

AR

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place to maintain adequate supporting documentation for all transactions. Action Plan: Establish clear guidelines and training on allowable costs for federally funded program...

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place to maintain adequate supporting documentation for all transactions. Action Plan: Establish clear guidelines and training on allowable costs for federally funded programs. Implement a compliance checklist for all federally funded expenditures to ensure alignment with Education Stabilization Fund requirements. Conduct internal audits every quarter to monitor compliance and document findings. Timeline: Immediate implementation; quarterly compliance reviews. Responsible Parties: Finance Director, APSRC, and Directors.

View Audit 338456 Questioned Costs: $1

Finding 519481 (2023-001)

Material Weakness 2023

Mental Health Resource of Texas, Inc.

TX

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

I. VIA HOPE 2023 MANAGEMENT CORRECTIVE ACTION PLAN: ► BACKGROUND: CONTINUATION, ADDRESS MULTI-YEAR FRAUD: STRENGTHEN INTERNAL CONTROLS: Management and staff continue to work with the insurance carrier and local law enforcement agencies to restore funds and strengthen its internal controls. ► Update:...

I. VIA HOPE 2023 MANAGEMENT CORRECTIVE ACTION PLAN: ► BACKGROUND: CONTINUATION, ADDRESS MULTI-YEAR FRAUD: STRENGTHEN INTERNAL CONTROLS: Management and staff continue to work with the insurance carrier and local law enforcement agencies to restore funds and strengthen its internal controls. ► Update: History and Board Actions: In FY 2021, Via Hope experienced a significant loss of revenue due to the ending of contracts from its two primary funding streams – the Health and Human Services Commission and the Hogg Foundation for Mental Health. This loss of revenue resulted in the Board recommending and approving the reduction of staff and the departure of the CEO. In FY 2022, the Board recommended and approved the termination of its Accounts Manager and the former Board Chairman stepped in to voluntarily manage the finances until the organization could make other arrangements. The former chairman stepped down from his role and an election of officers was held to install a new Chair. By January 2022, with new revenue coming into the organization, the Board selected a new CEO and in December 2022, a new accounts manager was hired. Once the new accounts manager began reconciling the accounts, a pattern of questionable expenditures became evident with PayPal and other accounts. The CEO and staff informed the Board of what appeared to have happened and recognizing its fiduciary responsibility, the Board approved the engagement of a forensic audit by an external audit firm, The Wesley Peachtree Group (WPG) of Atlanta, Georgia. The forensic audit resulted in findings that fraudulent activity in the amount of $233,000 was likely to have occurred. As a result, the CEO was instructed to file an insurance claim with Frost Insurance. To process the claim, Frost required the involvement of law enforcement which was approved by the Board. Formal investigations were launched and remain ongoing with the Austin Police Department and the Travis County District Attorney's office. Recently, law enforcement met with the Board and provided an update on the investigation. Subsequently, the CEO was requested to follow up with the insurance carrier and state regulatory agencies to ensure the prompt receipt of its insurance claim from PayPal and other potential sources. II. FINDINGS AND RECOMMENDATIONS: Finding 2023-001 - Internal Control Deficiencies (Material Weakness) a) Time and Effort, Payroll and Human Resource Forms and Contracts - In response to the finding, Management will require monthly Time and Effort reports for each employee, develop new human resource forms, and update staff contracts at the beginning of the fiscal year. b) Drawdowns and Written Approvals - With the addition of the new Finance staff member in January 2025, management will initiate a written approval process. All payroll adjustments, drawdowns, credit card purchases, and payments will require invoices, receipts, and written approvals before payment is made. The Accounting Manager will also work with the CEO to ensure that staff provide receipts promptly and that journal entries are recorded on a monthly basis. c) Receipts, Written Approvals, PP&E Schedule - Receipts and written approvals were addressed in Response (C). While the organization maintains an equipment log, we will establish a formal Property, Plant, and Equipment Schedule (PP&E), particularly noting equipment purchased with federal funds. d) Paypal, Frost, Forte - Management continues to work with law enforcement to obtain misappropriated funds from PayPal, and other potential accounts. As indicated, investigators met with the CEO, staff, Frost Bank, and the Board to obtain information regarding these accounts. It is our understanding that they may meet with prior Via Hope executives as well. We will update the auditors when more information is provided. e) Segregation of Duties - Management has begun the process of interviewing qualified staff to segregate duties in the Finance office. This will ensure that one individual will no longer be responsible for handling funds, payments, reconciliations, and General Ledger (GL) postings. The individual will be in place by January 2025.

View Audit 338449 Questioned Costs: $1

Finding 519404 (2023-002)

Significant Deficiency 2023

Crawford County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403 § 200.415

FA 2023-002 Strengthen Budgetary Controls over Expenditures Internal Control Impact: Significant Deficiency Compliance Impact: Activities Allowed or Unallowed Allowable Costs/Cost Principle Prior Year Finding: None Description: A review of expenditures charged to the Elementary and Secondary ...

FA 2023-002 Strengthen Budgetary Controls over Expenditures Internal Control Impact: Significant Deficiency Compliance Impact: Activities Allowed or Unallowed Allowable Costs/Cost Principle Prior Year Finding: None Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund program revealed instances in which expenditures has not been properly approved by the pass- through entity. Corrective Action Plans: the School District will work with all entities to confirm that all existing controls are adhered to by developing and implementing an improved monitoring process. This process will ensure that all expenditures comply with all applicable policies and regulations. Estimated Completion Date: June 30, 2024 Contact Person: Daisy M. Prather, Finance Director Telephone: (478) 836-3131 extension 106 Email: daisy.prather@crawfordschools.org

View Audit 338350 Questioned Costs: $1

Finding 519402 (2023-001)

Material Weakness 2023

Crawford County Board of Education

GA

Subrecipient Monitoring Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.302 § 200.303

FA 2023-001 Improve Controls over Financial Reporting Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Prior Year Finding: None Description: The accounting procedures of the School District were insufficient to provide adequate internal controls over multipl...

FA 2023-001 Improve Controls over Financial Reporting Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Prior Year Finding: None Description: The accounting procedures of the School District were insufficient to provide adequate internal controls over multiple control categories. Corrective Action Plans: Management will review, design, and implement procedures to strengthen the internal controls over the accounting functions to ensure transactions are properly processed and reported. Estimated Completion Date: June 30, 2024 Contact Person: Daisy M. Prather, Finance Director Telephone: (478) 836-3131 extension 106 Email: daisy.prather@crawfordschools.org

View Audit 338350

Finding 519400 (2023-007)

Material Weakness 2023

Town of Seabrook

NH

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Audit Finding Reference: 2023-007 Management’s Response and Planned Corrective Action: Implement a record keeping process for all rates and weighted rates for payroll. Name of Contact Person and Completion Date: Name: William Manzi

View Audit 338332 Questioned Costs: $1

Finding 519310 (2023-001)

Material Weakness 2023

Startupnv, Inc.

NV

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management

StartUpNV, Inc. Corrective Action Plan Year Ended December 31, 2023 2023-001 System of Internal Controls and Resulting Disclaimer of Opinion Criteria: The Internal Revenue Service (IRS) has defined a charitable organization as “organized and operated exclusively for religious, charitable, scient...

StartUpNV, Inc. Corrective Action Plan Year Ended December 31, 2023 2023-001 System of Internal Controls and Resulting Disclaimer of Opinion Criteria: The Internal Revenue Service (IRS) has defined a charitable organization as “organized and operated exclusively for religious, charitable, scientific, testing for public safety, literary, educational, or other specified purposes.” As a result of an entity being recognized as an exempt charitable organization, the nonprofit is entitled to favorable treatment(s) reserved for such entities (e.g., reduced taxation). Condition: The Organization was unable to produce sufficient appropriate audit evidence to support its assertion that revenues and expenditures related to StartUpNV, Inc. exclusive activities. Cause: The system of internal controls implemented by the Organization was not well-defined and did not contain appropriate segregation of duties amongst non-interested parties. Effect: The Organization was unable to provide sufficient appropriate audit evidence to support issuance and receipt of an unmodified audit opinion. This led to delays in the overall audit process resulting in late filing of the Data Collection Form to the Federal Audit Clearinghouse (FAC). Recommendation: We recommend management design and implement a system of internal controls whereby clear delineation between StartUpNV, Inc. activities and those of interested parties is supported. Further, we recommend that this system of internal controls be well documented and consistently applied. Risk assessment as it relates to general exempt organization compliance, as well as specific compliance related to federal award receipts, should be consistently performed by appropriate, competent personnel. With these systems in place, StartUpNV, Inc. will be better positioned to support regulatory expectations and requirements. Responsible official: Maggie Saling Title: Chief of Operations Email: maggie@startupnv.org Phone number: 805.302.1862 StartUpNV will create a policy document that shows procedures for internal control of expenditures that includes independent oversight. StartUpNV plans to contract with an outside party to perform an independent review and approval of expenditures prior to grant reimbursement requests and establish formal, documented procedures governing this process. Due to the recent resignation of the board treasurer, the incoming treasurer will assume oversight responsibility for this independent reviewer and budgetary and expenditure controls. The current Executive Director plans to announce his retirement from the non-profit organization – and announce a Board of Directors search process for his replacement. The appointment of a new Executive Director will address the requirements for the segregation of duties and independence. The Chief of Operations will provide guidance and support to the new Executive Director, ensuring a smooth transition of responsibilities through her planned retirement by the end of the year. The search and hiring process for a new Executive Director is anticipated to be completed within a timeline of 6 months.

View Audit 338154

Finding 519295 (2023-003)

Material Weakness 2023

Jacobson Memorial Hospital Care Center and Subsidiary

ND

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Federal Agency Name: Department af Health and Human Services Program Name: Cavid-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Hospital's calculation of lost revenue claimed under the federal program as an allowable...

Federal Agency Name: Department af Health and Human Services Program Name: Cavid-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The Hospital's calculation of lost revenue claimed under the federal program as an allowable cost contained no formal review or approval by a separate individual outside of the preparer. In addition, there was no evidence retained that the Hospital's special report submitted to t he Department of Health and Human Services for Period 4 was reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Scott Brooks, CEO and Stephanie La Brie, CFO Corrective Action Plan: Internal controls will be updated to include that all reports and supporting documents will be reviewed by the CEO if the CFO compiles for accuracy and vice versa. The reviewer will sign off by email or by physical signature that they have reviewed and agree with the support. Anticipated Completion Date: 6/30/2024

View Audit 338062

Finding 519151 (2023-004)

Significant Deficiency 2023

Southwest Center for Hiv/aids, INC

AZ

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties § 200.430

Item: 2023-004 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Spec...

Item: 2023-004 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR § 200.430 – Compensation – charges to federal programs for salaries and wages should be supported by a system of internal controls which provides reasonable assurance the amounts charged are accurate, allowable and properly allocated. Condition: Incorrect allocation of employee hours were charged to the federal program. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2024 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. Billings are reviewed by supervisors, including a review of the underlying supporting documentation, prior to submission of the billing. Additional training and record retention practices will be added and/or enhanced to ensure there is evidence of supervisory review of the underlying supporting documentation. Such review and record retention processes will include documentation of noted discrepancies and rationale for such discrepancies if not corrected.

View Audit 337692

Finding 519150 (2023-003)

Material Weakness 2023

Southwest Center for Hiv/aids, INC

AZ

Allowable Costs / Cost Principles Material Weakness Reporting § 200.405

Item: 2023-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Spec...

Item: 2023-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR § 200.405 – Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2024 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.

View Audit 337692

Finding 519149 (2023-002)

Material Weakness 2023

Southwest Center for Hiv/aids, INC

AZ

Allowable Costs / Cost Principles Material Weakness Reporting § 200.405

Item: 2023-002 Assistance Listing Number: 93.914 Programs: HIV Prevention Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Maricopa County Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In acco...

Item: 2023-002 Assistance Listing Number: 93.914 Programs: HIV Prevention Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Maricopa County Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR § 200.405 – Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2024 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.

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