Corrective Action Plans

Finding 571361 (2023-006)

Significant Deficiency 2023

Aids Arms, Inc. (dba Prism Health North Texas)

TX

Allowable Costs / Cost Principles § 200.405 § 200.412 § 200.414 § 200.430

2023-006 Management Response: Management respectfully disagrees with this Finding. • Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report th...

2023-006 Management Response: Management respectfully disagrees with this Finding. • Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). • Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. • Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. • Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. • Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. • Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.

View Audit 362309

Finding 571360 (2023-005)

Significant Deficiency 2023

Aids Arms, Inc. (dba Prism Health North Texas)

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.403

2023 – 005 - Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Recommendation: 1. Implement a Formal Expenditure Review and Approval Policy – Establish a policy requiring that all expenditures charged to grants be reviewed and approved by an appropriate...

2023 – 005 - Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Recommendation: 1. Implement a Formal Expenditure Review and Approval Policy – Establish a policy requiring that all expenditures charged to grants be reviewed and approved by an appropriate individual before being recorded in the system. 2. Require Documentation of Review and Approval – Ensure that invoices, payroll allocations, and other cost support documents include a signature, initials, or system-generated approval to confirm review. 3. Utilize System-Based Controls – If possible, configure the financial system to require electronic approval for all grant-related expenditures before costs are recorded. Management View: Management partially agrees with the finding. While we acknowledge that documentation of expenditure approval was not always retrievable, we believe the expenditures reviewed were all appropriate. Finding 2023-006 refers to the auditors’ assessment of expenditure review and approval processes that occurred in Calendar Year 2023. During Calendar Year 2023, Prism relied on email routing of expenditures for review and approval. As of this writing, Prism Health North Texas’ expenditure review and approval processes already meet or exceed the recommendations above. Action Taken: 1. Expenditure Review – All expenditures charged to grants are reviewed and approved by two qualified individuals. 2. Documentation of Review and Approval – a. Such review and approval for non-payroll expenditures occur in and are documented in the SAP Concur software before the costs are recorded in the accounting system (Abila). b. Such review and approval for payroll-related expenditures occur via and are documented via a combination of methods, also before they are recorded in Abila. i. Employees report their time, including how much time was devoted to grant activities, in the ExponentHR payroll system, and their supervisors approve both the time and the allocation in that system. ii. Programmatic measures that also support grant billing (“units”) are calculated from activity documented in the athenaOne electronic health record (EHR). iii. Payroll allocation is calculated by one person, based on the ExponentHR documentation and the units, then reviewed and imported into Abila by a second person. The unposted transactions are reviewed again before posting. 3. Utilize System-Based Controls – In place as above. Anticipated Completion Date: The recommendations are already in place. Responsible Contact Person(s): • Name: General Laffitte • Title: Vice President of Finance and Accounting • Phone: 214-623-6896 • Address: 3900 Junius St. Ste. 300, Dallas, Texas 75246 • Name: Jana Voege • Title: Chief Financial Officer Address: 3900 Junius St. Ste. 300, Dallas, Texas 75246 Corrective Action Plan Date: 4/28/2025 Cognizant or Oversight Agency for Audit Prism Health North Texas respectfully submits the following corrective action plan for the year ended FY2023. Name and address of independent public accounting firm: Armanino LLP 15950 Dallas Pkwy #600, Dallas, TX 75248 (972) 661 - 1843 Audit Period: The consolidated financial statements of AIDS Arms, Inc. were audited for the period of calendar year 2022 and 2023. The findings from the year ended December 31, 2023, schedule of findings and questioned costs are discussed below. The Findings are numbered consistently with the numbers assigned in the schedule.

View Audit 362309

Finding 571357 (2023-007)

Significant Deficiency 2023

Reach Community Development, Inc.

OR

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Finding No. 2023-007 CDBG Entitlement Grants Cluster Federal Assistance Listing Number #14.218 Uniform Guidance Compliance Requirement Code: A-Allowable Costs Criteria Owners must use CDBG funded portion of programs to fund minor rehabilitation services to approved recipients /address' in accordanc...

Finding No. 2023-007 CDBG Entitlement Grants Cluster Federal Assistance Listing Number #14.218 Uniform Guidance Compliance Requirement Code: A-Allowable Costs Criteria Owners must use CDBG funded portion of programs to fund minor rehabilitation services to approved recipients /address' in accordance with the Rehabilitation and Preservation Activities (570.202(b)(2) and/or (11)) during the grant period.. Condition The owner paid 1 vendor invoice of 79 tested, that was not incurred during the grant period and charged through to and was reimbursed by PHB under their CDBG Grant. Cause REACH's Community Builders Program Manager did not ensure that the invoices were for the appropriate grant period. Effect or Potential Effect CDBG funds may be spent inappropriately and REACH may be required to repay the grants and it may also result in a possible loss of future grants. Questioned Costs: $35. Context In connection with the procedures applied to compliance testing, there was 1 vendor invoice of 79 tested that was not for cost incurred during the grant period. Repeat Finding: No Recommendation REACH Community Builders Program Manager should follow procedures to ensure each vendor invoice is incurred during the grant period. Views of Responsible Officials Community Builders Program cell phone billing is part of the larger REACH billing system and this does create some challenges in approving billing as our IT department approves this billing. We are putting systems in place for the Community Builders Program Manager will work closer with the finance team to ensure all billing involves are for the correct time periods.

View Audit 362297 Questioned Costs: $1

Finding 571356 (2023-006)

Significant Deficiency 2023

Reach Community Development, Inc.

OR

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding No. 2023-006 CDBG Entitlement Grants Cluster Federal Assistance Listing Number #14.218 Uniform Guidance Compliance Requirement Code: A-Allowable Costs Criteria Owners must use CDBG funded portion of programs to fund minor rehabilitation services to approved recipients /address' in accordanc...

Finding No. 2023-006 CDBG Entitlement Grants Cluster Federal Assistance Listing Number #14.218 Uniform Guidance Compliance Requirement Code: A-Allowable Costs Criteria Owners must use CDBG funded portion of programs to fund minor rehabilitation services to approved recipients /address' in accordance with the Rehabilitation and Preservation Activities (570.202(b)(2) and/or (11)). Condition The owner paid 1 vendor invoice of 79 tested, that were not listed on the CDBG Address List as reported to Portland Housing Bureau (“PHB”) and charged through to and was reimbursed by PHB under their CDBG Grant. Cause REACH's Community Builders Program Manager did not ensure that the invoices were for an approved CDBG property. Effect or Potential Effect CDBG funds may be spent inappropriately and REACH may be required to repay the grants and it may also result in a possible loss of future grants. Questioned Costs: $40. Context In connection with the procedures applied to compliance testing, there was 1 vendor invoice of 79 tested that was not for an approved CDBG property. Repeat Finding: Yes – Finding 2022-007 Recommendation REACH Community Builders Program Manager should follow procedures to match each vendor invoice to the approved CDBG property listing prior to coding to CDBG and passing through for reimbursement from this grant. Views of Responsible Officials This instance was $40 that was in fact allocated incorrectly and the $40 spend was paid back to PHB in October 2024.

View Audit 362297 Questioned Costs: $1

Finding 571295 (2023-003)

None 2023

Town of Acushnet

MA

Allowable Costs / Cost Principles

Finding 2023-003 – 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 Programs Condition: During our test of cont...

Finding 2023-003 – 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 Programs Condition: During our test of controls over compliance it was noted that payroll for a Tutor was charged to the Education Stabilization ESSER II major program grant, however the expense should have been charged to the ESSER III major program instead. Criteria: Costs charged to the Education Stabilization ESSER II 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 payroll transactions posted to the Education Stabilization ESSER II major program it was noted that a Tutor charged to the Education Stabilization ESSER II major program grant should have been charged to Education Stabilization ESSER III based on the supporting documentation provided. Effect: Town of Acushnet 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: Could not be determined. Cause: The Town of Acushnet (School Department) implemented “best” practice of spending down older grant (ESSER II) awards prior to spending down newer awards. Due to timing, the grant budget was not amended prior to spend down of this related expense. Identification as a Repeat Finding: N/A Recommendation: We recommend the Town of Acushnet follow procedures to ensure that payroll expenditures charged to the grants are allowable costs as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles) Managements Response: We acknowledge the finding related to the payroll transaction for the Tutor charged to the Education Stabilization ESSER II major program grant. Upon review, we agree that based on the supporting documentation, the charges should have been posted to Education Stabilization ESSER III, rather than ESSER II. This was a result of a late adjustment made in order to utilize the remaining ESSER II funds before transitioning to the use of ESSER III funds. We understand the importance of correctly applying charges to the appropriate funding source and moving forward, we will ensure that our procedures are adjusted to avoid such misallocations and that all future charges are properly aligned with the designated funding source, in accordance with the established guidelines. Responsible for Corrective Plan: School Business Manager Estimated Completion Date: Fiscal Year 2024 Action Taken: The Schools have reviewed and updated our procedures to ensure that all future changes are properly aligned with the designated funding source in accordance with the established guidelines.

View Audit 362219

Finding 571264 (2023-002)

Significant Deficiency 2023

South Texas Development Council

TX

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.338 § 200.403

STDC acknowledges the auditor's finding regarding the inclusion of $12,153 in administrative costs in a supplemental reimbursement request submitted via Form B-13 to the Texas Department of State Health Services (DSHS) under the Ryan White HIV/AIDS Program – Part B. The costs in question lacked cont...

STDC acknowledges the auditor's finding regarding the inclusion of $12,153 in administrative costs in a supplemental reimbursement request submitted via Form B-13 to the Texas Department of State Health Services (DSHS) under the Ryan White HIV/AIDS Program – Part B. The costs in question lacked contemporaneous supporting documentation at the time of audit review. While STDC maintains that all costs submitted were incurred in good faith to support the Ryan White program, the lack of appropriate documentation constitutes a lapse in internal controls by the former Finance Director, Julia Gonzalez, over post-award claims processing. STDC has initiated an internal review and will consult with DSHS to determine the appropriate repayment action. Additional controls and protocols are being implemented to ensure that all future reimbursement requests—especially post-period—are fully documented, verified, and approved. Corrective Action Plan Finding Number: 2023-02 Planned Completion Date: July 31, 2025 Responsible Official: Director of Finance Corrective Actions to Be Implemented: 1. Policy and Procedure Development STDC shall develop a written policy governing post-award and supplemental reimbursement requests, with clear requirements for documentation and approval. The policy will define acceptable forms of documentation, including invoices, time records, internal allocation spreadsheets, and procurement records. 2. Document Verification Protocol Require pre-submission validation of all reimbursement entries by the Finance Director. 3. Supervisory Review and Sign-Off Supplemental claims must receive sign-off from both the Finance Director and the Executive Director prior to submission. Claims will include documentation verification and reconciliation to program records. 4. Training Ensure all finance department staff involved in grant accounting and reporting are trained on documentation requirements under 2 CFR Part 200, and internal review protocols for final and supplemental financial reports. 5. Communication with DSHS STDC will communicate with DSHS regarding the questioned costs and will take appropriate action based on agency guidance, including cost disallowance and repayment as required. 6. Quarterly Internal Reconciliation Establish recurring quarterly reviews of actual costs incurred versus amounts reimbursed to identify discrepancies and prevent accumulation of unsupported claims. Policy Title: Post-Award Reimbursement and Documentation Policy Effective Date: July 10, 2025, or upon adoption by the STDC Board of Directors Applies to: Finance Department, Grants Compliance, Department Heads Purpose To ensure that all reimbursement requests, including post-award and supplemental claims, are adequately documented, supported, and reviewed in compliance with 2 CFR §200 Subpart E. Policy Overview STDC shall not submit for reimbursement any cost for which contemporaneous and auditable documentation is not available. All supplemental reimbursement submissions must undergo a formal review and approval process to ensure the allowability, allocability, and documentation of all requested costs. Procedures 1. Required Documentation: Every cost line item included in a supplemental reimbursement must be supported by original documentation including: o General ledger detail o Paid invoice or payroll record o Allocation spreadsheet (if applicable) o Program approval or correspondence 2. Review Process: The Department Heads, or their designee, will verify that all documents meet federal allowability and documentation standards prior to submission to the Finance Department. A Supplemental Reimbursement Review Checklist must be completed and signed before submission of any supplemental requests. 3. Approval Authority: Final approval must be obtained from the Finance Director and Executive Director. 4. Retention Requirements: All reimbursement submissions and supporting documentation must be retained according to the STDC Local Record Retention Schedule. 5. Reporting Discrepancies: Any discrepancy, missing documentation, or unsupported cost identified must be reported to the Finance Director immediately for resolution before claim submission.

View Audit 362192 Questioned Costs: $1

Finding 571263 (2023-005)

Significant Deficiency 2023

South Texas Development Council

TX

Allowable Costs / Cost Principles § 200.302 § 200.403 § 200.405

STDC acknowledges the audit finding regarding the inclusion of sales tax on a utility invoice that was initially charged to multiple federal programs through the administrative cost pool. While the vendor issued credit for the sales tax in question, the original charge had already been distributed a...

STDC acknowledges the audit finding regarding the inclusion of sales tax on a utility invoice that was initially charged to multiple federal programs through the administrative cost pool. While the vendor issued credit for the sales tax in question, the original charge had already been distributed across multiple grants, and appropriate reallocations were not documented at the time of audit review. Documentation of the credit was made in the subsequent month’s billing cycle and applied to the listed programs. STDC takes seriously its obligation to ensure compliance with Uniform Guidance cost principles and recognizes the need to improve internal controls regarding invoice review and post-payment credit reconciliation. The Finance Department is taking immediate steps to make necessary reallocations to correct the grant charges and to implement control procedures that prevent future errors of this nature. Corrective Action Plan Finding Number: 2023-05 Planned Completion Date: July 31, 2025 Responsible Official: Director of Finance Corrective Actions to Be Implemented: 1. Immediate Reallocation of Sales Tax Credit The Finance Department will correct accounting entries to reallocate the $51.47 vendor credit back to the same federal grants charged. Journal entries will be completed and documented by July 31, 2025. 2. Invoice Review Protocol All vendor invoices will now be reviewed prior to payment for unallowable costs such as sales tax. Reviewers must initial a compliance checklist confirming allowability. 3. Credit Tracking and Reallocation Procedure Establish a formal mechanism for tracking vendor credits and documenting the reallocation of any prior charges to federal programs. Credits will be logged in STDC’s finance system (AccuFund) to the corresponding grants. 4. Staff Training Finance and grant staff will be trained on Uniform Guidance cost principles with specific attention to tax-exempt status and handling of credits. Training will be held annually and as part of onboarding. 5. Quarterly Reconciliation Review The Finance Department will implement quarterly reconciliation reviews to ensure that any sales tax mistakenly paid is credited back and accurately reallocated. Policy Insert: Sales Tax Review and Vendor Credit Reallocation Procedure Purpose: To ensure that all costs charged to federal awards are allowable and that any vendor credits (e.g., for sales tax) are correctly applied and documented in accordance with 2 CFR §200.403 and §200.405. Procedure: 1. Invoice Review Prior to Payment Accounting Technicians must review all invoices for unallowable items, including sales tax. Any invoice that includes sales tax must be returned to the program department for correction or payment adjusted accordingly by their vendors. 2. Vendor Credit and Grant Reallocation Upon receipt of a credit from a vendor, the credit must be reviewed for its original allocation(s) to federal grants. The credit amount must be allocated proportionally back to each grant that was charged. A reallocation journal entry must be documented and approved by the Finance Director. 3. Documentation and Recordkeeping Copies of invoices, credits, allocation entries, and internal review checklists must be retained with supporting documentation as required by STDC’s Local Record Retention Schedule. 4. Oversight The Finance Director will review the implementation of this policy on a quarterly for completeness and compliance.

View Audit 362192

Finding 571234 (2023-001)

Significant Deficiency 2023

Gulf Coast Transit District

TX

Allowable Costs / Cost Principles

Finding Number: 2023‐001 Federal Program Name: Federal Transit Cluster Assistance Listing Numbers: 20.507, 20.526 State Program Names: State Urbanized Area Formula Program; State Formula Grants for Rural Areas Contact Person: Ted Ross, Executive Director Updated Corrective Action Plan: The District ...

Finding Number: 2023‐001 Federal Program Name: Federal Transit Cluster Assistance Listing Numbers: 20.507, 20.526 State Program Names: State Urbanized Area Formula Program; State Formula Grants for Rural Areas Contact Person: Ted Ross, Executive Director Updated Corrective Action Plan: The District continues to strengthen its grant management framework through policy development and improved procedures. Actions to include: • Improved documentation of grant expense allocation • Updated purchasing procedures consistent with federal and state compliance expectations • Enhanced tracking of expenditures to specific programs and funding streams These measures have been incorporated into the district’s comprehensive Finance and Administration Policy, with staff training to be ongoing. Certification: The Gulf Coast Transit District affirms that all corrective actions noted above are actively corrected or are being addressed. Additional documentation or clarification will be provided to auditors upon request.

View Audit 362126

Finding 571227 (2023-002)

Material Weakness 2023

Pennsylvania Mountains Care Network

PA

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

Management agrees with the finding and has updated its internal lost revenue calculation, with cumulative amounts through Period 6 reporting. While management did attempt to update its lost revenue amounts with filing of its Period 4 reports, additional data entry errors were made. Four out of the s...

Management agrees with the finding and has updated its internal lost revenue calculation, with cumulative amounts through Period 6 reporting. While management did attempt to update its lost revenue amounts with filing of its Period 4 reports, additional data entry errors were made. Four out of the six entities that need to report on PRF funding have no further reporting periods; therefore, the Organization has no ability to make further corrections. As such, the internal records maintained by the Organization must serve as teh final reporting of the PRF funding.

View Audit 362109

Finding 571192 (2023-102)

Significant Deficiency 2023

Pancare of Florida, INC

FL

Subrecipient Monitoring Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303 § 200.328

Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in ...

Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal control and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.

View Audit 362092

Finding 571176 (2023-003)

Material Weakness 2023

City of Marietta

OH

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.329

Finding Number: 2023-003 Planned Corrective Action: City Auditor will stay in contact with Municipal Court Administrator and the Police Captain to ensure they submit Quarterly Reports on a timely basis. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess

View Audit 362089

Finding 571171 (2023-002)

Material Weakness 2023

City of Marietta

OH

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

Finding Number: 2023-002 Planned Corrective Action: City Auditor has confirmed the ARPA 3/31/24 and 3/31/25 Project and Expenditure Reports submitted agree to City Accounting records. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess

View Audit 362089

Finding 571140 (2023-001)

Material Weakness 2023

Puget Sound Regional Fire Authority

WA

Allowable Costs / Cost Principles Subrecipient Monitoring

Finding caption: The Authority did not have adequate internal controls for ensuring compliance with federal maintenance of effort requirements. Name, address, and telephone of Authority contact person: Rina Yu, Senior Accountant 20811 84th Avenue South, Suite 110 Kent WA 98032 253-856-4303 Correct...

Finding caption: The Authority did not have adequate internal controls for ensuring compliance with federal maintenance of effort requirements. Name, address, and telephone of Authority contact person: Rina Yu, Senior Accountant 20811 84th Avenue South, Suite 110 Kent WA 98032 253-856-4303 Corrective action the auditee plans to take in response to the finding: General Response: Puget Sound Fire respectfully disagrees with the Auditor's decision to elevate the two issues identified below to the level of a finding. Puget Sound Fire believes it substantially complied with the MOE and other grant requirements identified in issue 1 and worked closely with the granting agency, FEMA, to comply with all grant requirements. Based on the specific responses below, and Puget Sound Fire's good faith and reasonable efforts to cooperate and comply with the grant requirements, we respectfully request that the items be addressed in a management letter rather than a finding. Issue 1: Maintenance of Effort Puget Sound Fire respectfully disagrees with the Auditor's proposed finding. Puget Sound Fire did maintain and document the Maintenance of Effort attestation as described in the AFG grant's Notice of Funding Opportunity and followed best practices for tracking fiscal budget information as previously prescribed by SAO personnel. Puget Sound Fire's compliance is demonstrated in the 3-year budget history within the grant application/contract itself and Puget Sound Fi re provided SAO support Maintenance of Effort calculations for the years the grant was awarded. Puget Sound Fire Puget Sound Fire's governing board also approved budget increases year over year for the duration of the grant that exceeded the 80% average requirement. There is no 2 CFR Part 200 guidance on MOE other than what is included in the NOFO, and as an attestation, and the 3-year budget history was acceptable by FEMA, the grantor. Additionally, a finding is not warranted as following receipt of the same finding for the 2021 audit Puget Sound Fire adopted the SA O's feedback and has been following that guidance since then. Basing a finding for the current audit for actions that have been corrected pursuant to a prior audit is unreasonable. Puget Sound Fire complied with the MOE requirements following the 2021 finding and has no ability to go back to 2021 and change the past. Puget Sound Fire also notes that Puget Sound Fire's MOE efforts were reviewed, approved and monitored by FEMA, the grantor without issue. Puget Sound Fire has worked with and will continue to work with the grantor moving forward to implement best practices in calculating and maintaining MOE. AFG NOFO Statement - Maintenance of Effort A maintenance of effort is required under this program for all recipients, unless modified by a waiver, subject to waiver eligibility.An applicant seeking an award under this NOFO shall agree to maintain during the term of the grant, the applicant's aggregate expenditures relating to the activities allowable under this NOFO at not less than 80 percent of the average amount of such expenditures in the two fiscal years preceding the fiscal year in which the grant award is received. For more information on waiver eligibility, please see Appendix C-Award Administration Information, Section I. Economic Hardship Waivers of Cost Share and Maintenance of Effort Requirements for the FP&S Grant Program for more information. Anticipated date to complete the corrective action: Puget Sound Fire thanks the Washington State Auditor's Office for its thorough review of fiscal years 2021 through 2023. We are committed to implementing the recommended corrective actions, enhancing our internal controls, and addressing all identified deficiencies. Corrective actions for the three issues identified by the SAO have been initiated and will be fully implemented by January 1, 2026. Issue 1: Maintenance of Effort (MOE) Puget Sound Fire currently maintains and documents the MOE attestation in accordance with applicable Federal Notices of Funding Opportunities. To further improve compliance, we will work directly with our grantors to ensure MOE calculations align with best practices and updated guidance. This action will be completed by January 1, 2026.

View Audit 362049

Finding 571126 (2023-002)

Material Weakness 2023

City of Sammamish

WA

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

Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls and did not comply with federal wage rate requirements. Name, address, and telephone of City contact person: Vicky Carlsen, Director of Finance 801 228th Avenue SE Sammamish, WA 98075 (425) 295-...

Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls and did not comply with federal wage rate requirements. Name, address, and telephone of City contact person: Vicky Carlsen, Director of Finance 801 228th Avenue SE Sammamish, WA 98075 (425) 295-0590 Corrective action the auditee plans to take in response to the finding: The City has implemented process changes that requires project managers to forward appropriate wage documentation to Finance along with invoices for payment. Finance is able to verify the wage document prior to issuing payment for invoices. Anticipated date to complete the corrective action: Already implemented

View Audit 362012

Finding 570976 (2023-003)

Material Weakness 2023

Yazoo County School District

MS

Allowable Costs / Cost Principles Reporting

We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability and safeguarding of assets.

View Audit 361901

Finding 570975 (2023-002)

Significant Deficiency 2023

Yazoo County School District

MS

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, including compliance with state and federal purchasing requirements.

View Audit 361901

Finding 570919 (2023-005)

None 2023

YWCA New Hampshire

NH

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430

Description of Finding: Payroll charges for grants were based on a percentage of time reported by employees. The percentage was based on management’s decision and set when budgeting and not based on actual hours worked. There was not sufficient documentation to provide the basis for an appropriate a...

Description of Finding: Payroll charges for grants were based on a percentage of time reported by employees. The percentage was based on management’s decision and set when budgeting and not based on actual hours worked. There was not sufficient documentation to provide the basis for an appropriate allocation of payroll charges to the federal program. Planned Corrective Action: To ensure accurate payroll allocation to federal programs, YWCA New Hampshire will implement the following: 1. Time and Effort Reporting: Implement a time and effort reporting system by August 31, 2025, requiring employees to track actual hours worked on grant-funded activities weekly. 2. Policy Update: Revise the Payroll Allocation Policy to mandate that payroll charges to grants be based on actual hours worked, supported by time and effort reports. 3. Training: Train all grant-funded employees and supervisors on the time and effort reporting system by September 15, 2025. 4. Certification Process: Require employees and supervisors to certify time and effort reports monthly, with certifications retained for audit purposes. 36 5. Monitoring: The Finance Manager will review time and effort reports quarterly to ensure accurate allocation, with findings reported to the Executive Director. Responsible Party: Finance Manager, overseen by Caroline Catlender, Executive Director Anticipated Completion Date: September 30, 2025

View Audit 361880 Questioned Costs: $1

Finding 570915 (2023-002)

Significant Deficiency 2023

YWCA New Hampshire

NH

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

Description of Finding: Payroll documentation was found to be inadequate, as there were missing approved pay rates, lack of supporting documentation for stipends and differentials paid, and timecards submitted which were not approved, mathematically incorrect, and/or which did not agree to the payro...

Description of Finding: Payroll documentation was found to be inadequate, as there were missing approved pay rates, lack of supporting documentation for stipends and differentials paid, and timecards submitted which were not approved, mathematically incorrect, and/or which did not agree to the payroll paid. Planned Corrective Action: To strengthen internal controls over payroll, YWCA New Hampshire will implement the following: 1. Payroll Policy Revision: Update the Payroll Policy to require documented approval of pay rates, stipends, and differentials, with all documentation retained in employee files. 34 2. Timecard Approval Process: Implement an electronic timekeeping system by July 31, 2025, requiring supervisor approval of timecards before payroll processing. The system will flag mathematical errors and discrepancies. 3. Training: Provide training for supervisors and payroll staff on the new timekeeping system and documentation requirements by August 15, 2025. 4. Reconciliation Process: The Payroll Coordinator will perform a monthly reconciliation of timecards against payroll records, with discrepancies investigated and resolved before finalizing payroll. 5. Audit Checks: The CFO will conduct quarterly audits of payroll records to ensure compliance with the updated policy, with results reported to the Executive Director. Responsible Party: Payroll Coordinator and Finance Manager, overseen by Caroline Catlender, Executive Director Anticipated Completion Date: August 15, 2025

View Audit 361880 Questioned Costs: $1

Finding 570914 (2023-001)

Significant Deficiency 2023

YWCA New Hampshire

NH

Questioned Costs Allowable Costs / Cost Principles § 200.403

Description of Finding: A disbursement made to a vendor was not supported with adequate documentation to support the payment that was made. Planned Corrective Action: To address the lack of adequate documentation for vendor disbursements, YWCA New Hampshire will implement the following measures: 1. ...

Description of Finding: A disbursement made to a vendor was not supported with adequate documentation to support the payment that was made. Planned Corrective Action: To address the lack of adequate documentation for vendor disbursements, YWCA New Hampshire will implement the following measures: 1. Policy Update: Revise the Financial Management Policy to mandate that all disbursements require supporting documentation, including invoices, purchase orders, and approval signatures, before processing. 2. Training: Conduct mandatory training for all staff involved in procurement and payment processes on proper documentation requirements by June 30, 2025. 3. Internal Review Process: Establish a pre-payment review checklist to be completed by the Finance Manager to ensure all required documentation is present. 4. Document Retention: Implement a digital filing system, through Bill.com, to store and organize all disbursement-related documents, ensuring easy retrieval for audits. 5. Monitoring: The CFO will conduct monthly reviews of a sample of disbursements to verify compliance, with findings reported to the Executive Director. Responsible Party: Finance Manager, overseen by Caroline Catlender, Executive Director Anticipated Completion Date: July 31, 2025

View Audit 361880 Questioned Costs: $1

Finding 570870 (2023-001)

Significant Deficiency 2023

Human Services Alliance of Greater Prince William

VA

Allowable Costs / Cost Principles

The Alliance documented the ARPA designated hours per employee and made adjustments where needed to allocate money away f rom ARPA funds when those were not reported. This process will be documented and all data and calculations supporting the allocations will be retained.

View Audit 361801

Finding 570789 (2023-003)

Material Weakness 2023

Social & Environmental Entrepreneurs, Inc.

CA

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

Views of responsible officials and planned corrective actions: Management acknowledges the oversight in not utilizing timecards for salaried employees whose compensation is charged to federal contracts. To strengthen internal controls and ensure compliance with applicable federal regulations, manage...

Views of responsible officials and planned corrective actions: Management acknowledges the oversight in not utilizing timecards for salaried employees whose compensation is charged to federal contracts. To strengthen internal controls and ensure compliance with applicable federal regulations, management is committed to implementing corrective measures. As part of this effort, management will update existing policies and procedures, and will identify and provide targeted training for accounting personnel responsible for allocating salary charges to federal contracts.

View Audit 361731 Questioned Costs: $1

Finding 570656 (2023-003)

Material Weakness 2023

Tuerk House, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.308 § 200.309 § 200.334 § 200.403

The Organization acknowledges this repeat finding and will take steps to address the deficiencies noted. Since the prior year's audit, management will implement updated procedures to strengthen internal controls around documentation of allowable costs charged to federal awards. These measures includ...

The Organization acknowledges this repeat finding and will take steps to address the deficiencies noted. Since the prior year's audit, management will implement updated procedures to strengthen internal controls around documentation of allowable costs charged to federal awards. These measures include the development of a formal time and effort reporting system, which requires all grant-funded employees to submit periodic certifications that reflect actual hours worked and funding source allocation. Supervisors are now required to review and approve these certifications to ensure alignment with actual program activities. Additionally, the Organization will reinforce its invoice documentation and review process. All expenditures charged to the Block Grant and Opioid STR programs must now be supported by detailed invoices and documentation that clearly demonstrate allocability, allowability, and consistency with the approved grant budget and period of performance. These requirements are monitored through monthly reviews by the finance department. The Organization has also adopted a document retention policy aligned with 2 CFR §200.334, and relevant staff have received training on documentation and compliance requirements for federal awards. These corrective actions are being actively monitored by the Director of Finance to ensure full implementation and ongoing compliance. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025

View Audit 361679 Questioned Costs: $1

Finding 569962 (2023-001)

Material Weakness 2023

International Institute of Wisconsin, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles Reporting

AUDIT FINDINGS Currently, IIW is concluding an outside objective review of grants/contracts, since August 2022, to confirm the audit findings for 2022 and combined with the 2023 regular audit IIW should be able to determine the exact amounts, any payback through adjustments made by the state for sub...

AUDIT FINDINGS Currently, IIW is concluding an outside objective review of grants/contracts, since August 2022, to confirm the audit findings for 2022 and combined with the 2023 regular audit IIW should be able to determine the exact amounts, any payback through adjustments made by the state for subsequent payments after errors were made, and the nature of the over allocation of FTE’s. The reason for the need to combine the 2022 with 2023 audits is that the state and federal fiscal year beginning and ending overlap IIW’s fiscal year period. IIW does not dispute findings from the 2022 & 2023 audits. Corrective Actions: • Participating in close financial monitoring with granting agencies • IIW Audit Manual created and ratified by IIW Board • Improved Segregation of Financial Roles • Implemented new financial system to facilitate improvements in GAAP • Implemented new chart of accounts to facilitate improved reporting, reconciliation, and billing • Improved reconciliation for both bank and programs • Improved financial controls for banking and investment management • Began reimbursement of identified funds that are required to be paid back to granting agencies Sincerely yours, Paul F. Trebian, Ed.D., MBA/TM, MA, BS President & CEO International Institute of Wisconsin ptrebian@iiwisconsin.org 414-403-9735 Cell CST

View Audit 361224 Questioned Costs: $1

Finding 569950 (2023-005)

Material Weakness 2023

Idaho Immunization Coalition, Inc.

ID

Questioned Costs Allowable Costs / Cost Principles Cash Management

THE ORGANIZATION WILL IMPLEMENT A PROCESS TO ENHANCE INTERNAL CONTROLS ASSOCIATED WITH THE REVIEW OF REVENUES AND EXPENDITURES TIMELY TO ENSURE ACCURATE AND COMPLETE REPORTING OF THE FINANCIAL STATEMENTS. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. THE ORGANIZATION WIL...

THE ORGANIZATION WILL IMPLEMENT A PROCESS TO ENHANCE INTERNAL CONTROLS ASSOCIATED WITH THE REVIEW OF REVENUES AND EXPENDITURES TIMELY TO ENSURE ACCURATE AND COMPLETE REPORTING OF THE FINANCIAL STATEMENTS. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT EXPENDITURES SUBMITTED FOR REIMBURSEMENT OF FEDERAL AWARD PROGRAMS. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION WILL TERMINATE THE CURRENT AGREEMENT WITH THE CPA AND MOVE TO ANOTHER CPA FIRM TO MEET THE NEEDS OF THE ORGANIZATION IN A PROFESSIONAL, QUALIFIED AND TIMELY MANNER. MOVE TO ANOTHER CPA FIRM BY NO LATER THAN SEPTEMBER 1, 2025. THE ORGANIZATION THROUGH ITS BOARD OF DIRECTORS WILL CREATE A “FINANCIAL POLICY COMMITTEE” WHICH WILL BE RESPONSIBLE TO WORK WITH THE EXECUTIVE DIRECTOR, THE NEW CPA TO OUTLINE AND CREATE NEW POLICIES, PROCEDURES AND PROCESSES, ALONG WITH OVERSIGHT OF THE FINANCIAL WELL-BEING OF THE ORGANIZATION AND REPORT TO THE BOARD OF DIRECTORS. IMMEDIATELY, THE PROCESS WILL BEGIN TO RECRUIT THE COMMITTEE MEMBERS ON JUNE 25, 2025.

View Audit 361194 Questioned Costs: $1

Finding 569949 (2023-004)

Material Weakness 2023

Idaho Immunization Coalition, Inc.

ID

Questioned Costs Allowable Costs / Cost Principles § 200.210 § 200.331

THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD...

THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD OF DIRECTORS WILL CREATE A “FINANCIAL POLICY COMMITTEE” WHICH WILL BE RESPONSIBLE TO WORK WITH THE EXECUTIVE DIRECTOR, THE NEW CPA TO OUTLINE AND CREATE NEW POLICIES, PROCEDURES AND PROCESSES, ALONG WITH OVERSIGHT OF THE FINANCIAL WELL-BEING OF THE ORGANIZATION AND REPORT TO THE BOARD OF DIRECTORS. IMMEDIATELY, THE PROCESS WILL BEGIN TO RECRUIT THE COMMITTEE ON JUNE 25, 2025.

View Audit 361194 Questioned Costs: $1

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