Corrective Action Plans

Finding 559992 (2023-002)

Significant Deficiency 2023

Central Arizona Irrigation & Drainage District

AZ

Allowable Costs / Cost Principles Reporting Procurement, Suspension & Debarment § 200.508 § 200.510

COVID-1 9 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21 .027 Recommendation: We recommend the District design controls to ensure an adequate review process over the invoices recorded and presented on the schedule of expenditures of federal awards to determine complian...

COVID-1 9 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21 .027 Recommendation: We recommend the District design controls to ensure an adequate review process over the invoices recorded and presented on the schedule of expenditures of federal awards to determine compliance with the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District’s policies will be updated and approved if needed to conform to federal guidance. Name(s) of the contact person(s) responsible for corrective action: Ron McEachern, General Manager or Delia Stoor, Accounting Manger Planned completion date for corrective action plan: September 30, 2024

View Audit 355902

Finding 559904 (2023-003)

Material Weakness 2023

Organized Parents Make A Difference, Inc.

CT

Allowable Costs / Cost Principles

The Organization implemented procedures to ensure invoices and payroll are approved including the use of bill.com and a cash report approval of all payments. Payroll is prepared by the CFO and is reviewed by the Executive Director. It is then entered into Quickbooks by our outsourced accountants.

View Audit 355829

Finding 559858 (2023-002)

Material Weakness 2023

Washington County

OR

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.208 § 200.328

Finding Number: 2023-002 Planned Corrective Action: The Chief Financial Administrator will ensure all ARPA expenditures are included on the Project and Expenditure Reports. Anticipated Completion Date: March 31, 2025 Responsible Contact Person: Ben Cowdery, Chief Financial Administrator

View Audit 355799

Finding 559783 (2023-003)

Significant Deficiency 2023

Portland Community Reinvestment Initiatives, Inc.

OR

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.502 § 200.510

While PCRI does have systems in place to adequately track federal expenditures, the preparation of the schedule of federal expenditures was delayed in large part due to the deficiencies outlined in Finding 2023-001, which led to delays in accurately compiling the information required for the schedul...

While PCRI does have systems in place to adequately track federal expenditures, the preparation of the schedule of federal expenditures was delayed in large part due to the deficiencies outlined in Finding 2023-001, which led to delays in accurately compiling the information required for the schedule of federal expenditures, and that the transition of relevant accounting processes to the outsourced accounting firm will resolve this deficiency going forward. The timeline for full transition of relevant accounting processes to the outsourced accounting firm which started in January of 2025 is approximately seven months due to the complexities of PCRI’s operations. PCRI anticipates this transition being complete in July of 2025.

View Audit 355753

Finding 559264 (2023-001)

Significant Deficiency 2023

Oklahoma City Innovation District, Inc.

OK

Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.305

Identifying Number: 2023-001; Lack of Written Policies and Procedures Recommendation: The Organization should develop and implement comprehensive written policies and procedures in accordance with the requirements of the Uniform Guidance. Action Taken: In response to the finding, management will t...

Identifying Number: 2023-001; Lack of Written Policies and Procedures Recommendation: The Organization should develop and implement comprehensive written policies and procedures in accordance with the requirements of the Uniform Guidance. Action Taken: In response to the finding, management will take action to develop and implement the necessary written policies and procedures. Comprehensive training will be provided to all relevant staff to ensure compliance with federal requirements. Anticipated completion date: June 30, 2025 Name of contact person and title: Jeffrey Seymour, President / CEO

View Audit 355490

Finding 559163 (2023-003)

Significant Deficiency 2023

Ozarks Regional YMCA

MO

Allowable Costs / Cost Principles Cash Management § 200.302

Management agrees with the finding and has developed and implemented the appropriate policies and procedures effective September 2024.

View Audit 355391

Finding 559143 (2023-002)

Significant Deficiency 2023

The Enola Group, Inc.

NC

Reporting Allowable Costs / Cost Principles

Name of Contact Person: Terri Brown, Director of Finance Corrective Action: Due to the extreme turnover within the Finance Director position in FY 22-23, there were more than normal accounting errors that were corrected by journal entries in the FY22 audit. The Executive Director addressed the turno...

Name of Contact Person: Terri Brown, Director of Finance Corrective Action: Due to the extreme turnover within the Finance Director position in FY 22-23, there were more than normal accounting errors that were corrected by journal entries in the FY22 audit. The Executive Director addressed the turnover by hiring a Finance Director with extensive non-profit finance and operation experience. In addition, training was provided on the accounting software. The Finance Director role has been occupied by one individual for multiple years. A Bookkeeping position was also created and filled which now allows for more separation of duties. A system of checks and balances have been established between the Bookkeeper, Administrative Assistant, Finance Director and Executive Director. This system includes the enhancement of protocols such as cash receipts, disbursements process and journal vouchers, monthly one on one in depth review of financials with Program Directors and Finance Director, and monthly Finance Director and Executive Director meetings. In addition, the Executive Director, Finance Director and Bookkeeper are now using the secured server to file digital copies of most financial documents. The Finance Director has monthly finance meetings with each Program Director to review their monthly actuals against budget. In addition, the accounting system is now remote which allows for access based on role for the Bookkeeper and Executive Director. The organization has created a third position, Accounts Receivable Coordinator to process all AR related duties. Proposed Completion Date: Immediately.

View Audit 355382

Finding 556167 (2023-001)

Significant Deficiency 2023

North Central Fire Protection District

CA

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

As soon as this recommendation was verbally made to staff in 2024, staff implemented a procedure to have all journal entries reviewed and approved by a member of management. Staff has reviewed all 2022-23 journal entries to ensure the appropriate initials/signatures reflect review and approval by a ...

As soon as this recommendation was verbally made to staff in 2024, staff implemented a procedure to have all journal entries reviewed and approved by a member of management. Staff has reviewed all 2022-23 journal entries to ensure the appropriate initials/signatures reflect review and approval by a member of management.

View Audit 354842

Finding 556098 (2023-007)

Significant Deficiency 2023

Black Community Provider Network, INC

IL

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.318 § 200.331 § 200.403 § 200.405

Plan: Contracts are reviewed and updated annually by the compliance officer. Anticipated Date of Completion: 4/28/2025 Name of Contact Persons: Michael Holmes Management Response: Due to the repeated extensions of certain government grants and contracts, there were delays in securing contract re...

Plan: Contracts are reviewed and updated annually by the compliance officer. Anticipated Date of Completion: 4/28/2025 Name of Contact Persons: Michael Holmes Management Response: Due to the repeated extensions of certain government grants and contracts, there were delays in securing contract renewals with updated budget allocations. This issue has now been addressed with the completion and submission of revised budgets and grants.

View Audit 354800 Questioned Costs: $1

Finding 556097 (2023-006)

Significant Deficiency 2023

Black Community Provider Network, INC

IL

Questioned Costs Allowable Costs / Cost Principles § 200.403 § 200.404 § 200.405 § 200.414

Plan: BCPN confirms that indirect costs are calculated in accordance with government guidelines outlined in 2 CFR Part 200. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: Due to adopting to use a calendar year instead of a fiscal year, BCPN's ...

Plan: BCPN confirms that indirect costs are calculated in accordance with government guidelines outlined in 2 CFR Part 200. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: Due to adopting to use a calendar year instead of a fiscal year, BCPN's indirect costs for FY24 will be reflected in the financial statements for the period ending June 30, 2024, rather than December 31, 2023. We confirm that the indirect costs are being billed and spent in compliance with the guidelines outlined in the government contract and there is no need for funds to be returned.

View Audit 354800 Questioned Costs: $1

Finding 556096 (2023-005)

Significant Deficiency 2023

Black Community Provider Network, INC

IL

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

Plan: The cost allocation policy has been implemented and submitted to outsourced auditing firms for review and approval by funders as of 2024. This policy is now actively in use. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: BCPN successfull...

Plan: The cost allocation policy has been implemented and submitted to outsourced auditing firms for review and approval by funders as of 2024. This policy is now actively in use. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: BCPN successfully implemented a new allocation policy for the year 2024.

View Audit 354800

Finding 556084 (2023-003)

Material Weakness 2023

Dover Interfaith Mission for Housing, Inc.

DE

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Fraud was identified by board members of the Dover Interfaith Mission for Housing (DIMH) in November 2023 with respect to the Emergency Housing and Health programs, and an internal investigation ensued. Prior to this finding, a committee of the board reviewed the Executive Director’s (ED) financial ...

Fraud was identified by board members of the Dover Interfaith Mission for Housing (DIMH) in November 2023 with respect to the Emergency Housing and Health programs, and an internal investigation ensued. Prior to this finding, a committee of the board reviewed the Executive Director’s (ED) financial reporting and were confident in her documentation, which was also approved by the City of Dover manager of the Emergency Housing and Health programs. Briefly, the ED had invented invoices from motels and landlords along with applications from individuals and families who did not exist. In both programs, DIMH provided funds to cover motel stays and landlord payments and was reimbursed by the City of Dover. In practice, the ED simply took DIMH funds, deposited them into a personal account, and provided invented documents to the City that resulted in reimbursement to DIMH. This clever ruse had eluded both board and city personnel monitoring the expenditures and reimbursements. Once there was suspicion of fraud, board members not involved in prior program oversight actively reviewed files with the City’s program manager to ascertain its extent. A meeting was held between the board chair and the city’s program manager to review all files in order to determine the approximate extent of the fraud, which was clearly limited to these two grant programs. In early January 2024, DIMH board members arranged to meet with the Dover Police Department to provide an overview of the fraud. This led to police contact with local FBI and HUD inspector general offices along with the US attorney for Delaware, with the same board members providing all files and in-person descriptions of the scam. On February 28, 2025, the former ED met with federal officials to determine whether to endeavor to resolve the matter or to engage in litigation. She was given March 14, 2025 as a deadline for her decision. At that date, she agreed to work towards a settlement of resolution of the case and not to go to court. The details of this agreement are pending as of March 14, 2025. In early 2024, the DIMH board engaged a new external accounting firm and created a new control environment with significant internal controls and separation of duties developed in collaboration with the contracted CPA firm.

View Audit 354781 Questioned Costs: $1

Finding 556083 (2023-002)

Material Weakness 2023

Dover Interfaith Mission for Housing, Inc.

DE

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Fraud was identified by board members of the Dover Interfaith Mission for Housing (DIMH) in November 2023 with respect to the Emergency Housing and Health programs, and an internal investigation ensued. Prior to this finding, a committee of the board reviewed the Executive Director’s (ED) financial ...

Fraud was identified by board members of the Dover Interfaith Mission for Housing (DIMH) in November 2023 with respect to the Emergency Housing and Health programs, and an internal investigation ensued. Prior to this finding, a committee of the board reviewed the Executive Director’s (ED) financial reporting and were confident in her documentation, which was also approved by the City of Dover manager of the Emergency Housing and Health programs. Briefly, the ED had invented invoices from motels and landlords along with applications from individuals and families who did not exist. In both programs, DIMH provided funds to cover motel stays and landlord payments and was reimbursed by the City of Dover. In practice, the ED simply took DIMH funds, deposited them into a personal account, and provided invented documents to the City that resulted in reimbursement to DIMH. This clever ruse had eluded both board and city personnel monitoring the expenditures and reimbursements. Once there was suspicion of fraud, board members not involved in prior program oversight actively reviewed files with the City’s program manager to ascertain its extent. A meeting was held between the board chair and the city’s program manager to review all files in order to determine the approximate extent of the fraud, which was clearly limited to these two grant programs. In early January 2024, DIMH board members arranged to meet with the Dover Police Department to provide an overview of the fraud. This led to police contact with local FBI and HUD inspector general offices along with the US attorney for Delaware, with the same board members providing all files and in-person descriptions of the scam. On February 28, 2025, the former ED met with federal officials to determine whether to endeavor to resolve the matter or to engage in litigation. She was given March 14, 2025 as a deadline for her decision. At that date, she agreed to work towards a settlement of resolution of the case and not to go to court. The details of this agreement are pending as of March 14, 2025. In early 2024, the DIMH board engaged a new external accounting firm and created a new control environment with significant internal controls and separation of duties developed in collaboration with the contracted CPA firm.

View Audit 354781 Questioned Costs: $1

Finding 556042 (2023-003)

Significant Deficiency 2023

Joseph's House and Shelter, Inc.

NY

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

Finding 2023-003--General Oversight--Significant Deficiency Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restr...

Finding 2023-003--General Oversight--Significant Deficiency Recommendation: We recommend that the Organization create policies and procedures to ensure proper oversight of the financial reporting function. In addition, we would recommend the Organization to consider the costs and benefits of restructuring the finance department. This could include allocating additional resources to hire additional employees, reallocation of responsibilities within the organization and less reliance on the contracted accounting services. View of Responsible Officials and Planned Corrective Actions: The Executive Director has worked to reduce the reliance on outside contracted accounting services. Beginning in Q1 2022, agency leadership took necessary action to begin restructuring the Finance Department following a change in staffing with the contracted accounting service. In Q2 2022, the agency promoted a long-tenured staff member to the newly-created Director of Grants and Finance position, which separated and removed all finance duties from the Director of Administration. To support the Director of Grants and Finance, a full-time Grants and Finance Specialist staff position was created in Q3 of 2022 To further strengthen financial oversight and ensure timely access to grant funds, the organization implemented a structured monthly grant billing schedule. This process ensures that vouchering is completed on time, reducing delays in reimbursements and mitigating cash flow disruptions. As a result, grant reimbursements have been received more consistently, alleviating financial strain and improving overall fiscal stability. Joseph’s House has created a 21-page Accounting Policies and Procedures Manual to ensure proper oversight of all fiscal functions. Changes are currently in process and will be sent for review by the Board’s Finance Committee followed by a final review and approval of the full Board of Directors. The organization has scaled back reliance on the contracted accounting service and has ensured that all claims, with the implementation of personnel time-tracking systems, are submitted through our Finance Department. We continue to use a contracted accounting service for higher-level accounting duties and for on-going advisement that supplements, instead of replaces, the work of internal staff. We are confident these changes have improved the agency’s ability to provide adequate management oversight in the financial reporting process. This was completed in Q2 of 2023.

View Audit 354774

Finding 556009 (2023-004)

Material Weakness 2023

Dekalb County Board of Education

GA

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

2023-004 Allowable Costs Program Name: Child Nutrition Cluster Assistance Listing Number: 10.553 and 10.555 Pass-Through Agency: Georgia Department of Education Criteria: In accordance with the terms of the Child Nutrition Grant and 2 CFR 200, Cost Principles for States, Local Governments, and India...

2023-004 Allowable Costs Program Name: Child Nutrition Cluster Assistance Listing Number: 10.553 and 10.555 Pass-Through Agency: Georgia Department of Education Criteria: In accordance with the terms of the Child Nutrition Grant and 2 CFR 200, Cost Principles for States, Local Governments, and Indian Tribes, specific documentation must be maintained to support salaries and wages charged to the federal program. Where employees are expected to work solely on a single Federal award or cost objective, charges for their salaries and wages will be supported by periodic certifications that the employees worked solely on that program for the period covered by the certification. These certifications will be prepared at least semi-annually and will be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Where employees work on multiple activities or cost objectives, a distribution of their salaries or wages will be supported by personnel activity reports or equivalent documentation. Corrective Action Plan: We concur with this finding. The District is developing corrective actions to strengthen Child Nutrition Cluster Department internal controls, policies, and procedures and ensure adherence through improved monitoring. Through collaboration, the Finance Division and the School Nutrition Department will review payroll detail reports and ensure periodic certifications for all employees are completed timely. Estimated Completion Date: Fiscal Year 2025 Contact Person: Dr. Connie Walker, School Nutrition Executive Director Telephone: 678-676-1200 E-mail: Connie_R_Walker@dekalbschoolsga.org

View Audit 354728 Questioned Costs: $1

Finding 555923 (2023-002)

Material Weakness 2023

Cheyenne and Arapaho Tribes Department of Housing

OK

Procurement, Suspension & Debarment Allowable Costs / Cost Principles HUD Housing Programs

2023-002 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsi...

2023-002 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Mr. Damon Dunbar, Executive Director Timeframe: As of December 31, 2025

View Audit 354589

Finding 555818 (2023-002)

Material Weakness 2023

Open Cities Health Center, Inc. and Affiliate

MN

Questioned Costs Allowable Costs / Cost Principles

Finding 2023-002: Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: A walkthrough of fourteen individuals was performed to review perso...

Finding 2023-002: Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: A walkthrough of fourteen individuals was performed to review personnel files and payroll related to salary for the Organization. Of the fourteen files reviewed, two had no approved current pay rate documented, and the salary or hourly rate paid was not the rate contained in the file. Also, there was no timesheet provided to support the time charged to the federal grant for eleven of the fourteen individuals tested. Action Planned in Response to the Finding: All payroll activities are managed through ADP. The Human Resources team will familiarize themselves with time and effort reporting requirements and implement a standardized checklist for each personnel file. This checklist will serve as an internal control to ensure that each file is complete, reflects current pay rates, and accurately documents time allocated to grant activities. Additionally, the Finance team will take the following steps to strengthen compliance and accuracy in grant reporting: 1. Assign personnel whose responsibilities are 100% fully dedicated to specific grant activities. 2. Maintain a detailed allocation table tracking employee time and effort by individual grant. Official Responsible for Ensuring the CAP: Marilyn Powers-Campbell Planned Completion Date: December 2024

View Audit 354532 Questioned Costs: $1

Finding 555756 (2023-002)

Material Weakness 2023

Renaissance Social Services, Inc.

IL

Allowable Costs / Cost Principles Reporting

We have executed strategic process improvements and personnel adjustments within the Finance function specifically designed to facilitate more efficient and timely completion of month-end, quarter-end, and year-end close procedures. These improvements include standardized workflows, clearly defined ...

We have executed strategic process improvements and personnel adjustments within the Finance function specifically designed to facilitate more efficient and timely completion of month-end, quarter-end, and year-end close procedures. These improvements include standardized workflows, clearly defined responsibilities, and process automation. Additionally, the finance team has committed to ensuring adequate time allocation for all audit activities. We have established a proactive planning framework that incorporates appropriate buffer periods to guarantee completion well in advance of regulatory deadlines. Furthermore, we commit to conducting all fieldwork within the initially scheduled timeframes to prevent timeline extensions.

View Audit 354409

Finding 555755 (2023-001)

Material Weakness 2023

Renaissance Social Services, Inc.

IL

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

The Finance Team has developed and deployed a comprehensive month-end close process that includes: • A detailed procedural checklist with clearly defined responsibilities • Specific deadlines for each critical task in the close sequence • Formal approval requirements at key control points • A target...

The Finance Team has developed and deployed a comprehensive month-end close process that includes: • A detailed procedural checklist with clearly defined responsibilities • Specific deadlines for each critical task in the close sequence • Formal approval requirements at key control points • A targeted completion timeline of 30 days post month-end To support this enhanced process, we have strategically increased resources within the finance function, including additional staff allocation to high-priority areas. Furthermore, we are conducting a thorough assessment of automation opportunities throughout our accounting workflow to improve efficiency, reduce manual processing, and accelerate the completion of key accounting tasks.

View Audit 354409

Finding 555627 (2023-008)

Material Weakness 2023

Sullivan County Community College

NY

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

The Vice President of Administrative Services will seek to add staff to the finance department to support grant initiatives. During FY 24‐25 a grant policy will be developed and effort be made to communicate each grant initiative as it becomes available, to the Executive Council. This process and st...

The Vice President of Administrative Services will seek to add staff to the finance department to support grant initiatives. During FY 24‐25 a grant policy will be developed and effort be made to communicate each grant initiative as it becomes available, to the Executive Council. This process and staffing update will help the college provide more detail, accuracy and controls over grants. This will be accomplished by 8/31/24.

View Audit 354200

Finding 555618 (2023-001)

Material Weakness 2023

Okanogan County

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles

The County did experience issues with the reporting portal for these funds. When we requested assistance, we received generic responses and little assistance from the Treasury. It wasn’t until November 2024 that we were finally able to gain the assistance we needed to gain full access to the Treas...

The County did experience issues with the reporting portal for these funds. When we requested assistance, we received generic responses and little assistance from the Treasury. It wasn’t until November 2024 that we were finally able to gain the assistance we needed to gain full access to the Treasury portal as well as some guidance on the reports. On January 1, 2025, the Treasury provided guidance that is helpful to us in understanding the reporting requirements. Now that we have the access and guidance we need, all reports will be submitted accurately and on time.

View Audit 354181

Finding 555501 (2023-007)

Material Weakness 2023

Sacramento Housing and Revelopment Agency

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Emergency Solutions Grants Program – Assistance Listing No. 14.231 Recommendation: We recommend that the Agency reviews the controls in place to ensure that subrecipient payments are paid timely and within program requirements. Explanation of disagreement with audit finding: There is no disagreeme...

Emergency Solutions Grants Program – Assistance Listing No. 14.231 Recommendation: We recommend that the Agency reviews the controls in place to ensure that subrecipient payments are paid timely and within program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recurrence of the issue, we began implementing a corrective action plan. Specifically, we are enhancing our internal controls and began developing a comprehensive technical procedure manual that will serve as a detailed guide that provides a clear reference for finance and accounting staff to ensure consistency, compliance and efficiency in financial operations. Additionally, as SHRA is filling vacancies due to significant turnover across the entire Finance Department, specific training is provided to new employees in the following areas: • Building HOME • Capital Fund • CDBG • Continuum of Care • Developing a Cost Allocation Plan • Financial Management Part I and Part II (for CPD programs) • HCV Two Year Tool • IDIS • Mainstream Vouchers • Overview of Asset Management • PHA Financial Management Name(s) of the contact person(s) responsible for corrective action: Irene De Jong, DIRECTOR OF FINANCE Planned completion date for corrective action plan: December 31, 2025

View Audit 354004

Finding 555497 (2023-004)

Significant Deficiency 2023

Sacramento Housing and Revelopment Agency

CA

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

Recommendation: We recommend that the Agency reviews the controls in place to ensure that payroll transactions are charged to the correct program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recu...

Recommendation: We recommend that the Agency reviews the controls in place to ensure that payroll transactions are charged to the correct program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recurrence of the issue, we began implementing a corrective action plan. The Agency hired a Payroll Analyst in January 2025, who will be tasked with reviewing payroll transactions and reports on a monthly/quarterly basis and ensuring that payroll charges are reflected in the correct program. Name(s) of the contact person(s) responsible for corrective action: Irene De Jong, DIRECTOR OF FINANCE Planned completion date for corrective action plan: December 31, 2025

View Audit 354004 Questioned Costs: $1

Finding 555319 (2023-002)

Material Weakness 2023

Grant A Gift Autism Foundation

NV

Allowable Costs / Cost Principles § 200.303

Grant a Gift Autism Foundation Corrective Action Plan Year Ended December 31, 2023 2023-002 U.S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing Number 21.027, Passed through the State of Nevada’s Department of Health and Human Services – In...

Grant a Gift Autism Foundation Corrective Action Plan Year Ended December 31, 2023 2023-002 U.S. Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing Number 21.027, Passed through the State of Nevada’s Department of Health and Human Services – Internal Control Systems over Compliance, Allowable Costs Criteria: As defined in 2 CFR 200.303, the auditee is required to maintain a system of internal control over compliance designed to provide reasonable assurance that federal award transactions executed are in compliance with the terms and conditions of the federal award. Condition: During our audit, we were informed that the Organization did not maintain evidence of the review of the allocation of time spent on federal grants by employees. Cause: The internal control system over the assessment of the allocation of allowable payroll costs was not operating effectively. Context: Evidence of the internal controls over the review and allocation of payroll costs was not maintained. Effect: Lack of evidence of review of employee time spent working on federal grants for payroll costs reimbursed under the grants increases the risk that unallowable costs could be submitted for reimbursement. Recommendations: We recommend that management design and implement a system of internal controls whereby employees utilize a grant time tracking sheet reflecting the amount of employee time spent working towards each grant the Organization expends, that this sheet is reviewed by each employee’s supervisor, and that proper documentation is maintained. Views of Responsible Officials: Management will ensure evidence of supervisor approval is obtained and maintained by January 2024 Responsible official: Eric Hill Title: Director of Finance & HR

View Audit 353949

Finding 555252 (2023-005)

Significant Deficiency 2023

Community Health Service, Inc.

MN

Special Tests & Provisions Allowable Costs / Cost Principles Significant Deficiency

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submi...

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. *Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: *A regular internal review and audit process will be revisited to ensure that backup, storage, and retention practices are being followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. *Any discrepancies or issues identified during audits will be addressed promptly, and corrective actions will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: *Training sessions will be conducted for all relevant staff on the updated backup, storage, and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. *Refresher training will be provided quarterly to ensure ongoing compliance and awareness.

View Audit 353876

Corrective Action Plans

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