Corrective Action Plans

Finding 564087 (2023-004)

None 2023

NC

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2023-004 Activities Allowed or Unallowed – Interprogram Activity Public and Indian Housing – CFDA Number 14.850 Other Matters, Questioned Costs Condition: The Authority has loaned monies from the Public and Indian Housing Program to the COCC. As of September 30, 2023 these loans totaled $349,352. ...

2023-004 Activities Allowed or Unallowed – Interprogram Activity Public and Indian Housing – CFDA Number 14.850 Other Matters, Questioned Costs Condition: The Authority has loaned monies from the Public and Indian Housing Program to the COCC. As of September 30, 2023 these loans totaled $349,352. Recommendation: The Authority should develop a plan based on budgeting and monitoring of COCC expenses to have the ability to reimburse funds to the Public and Indian Housing Program. Action Taken: To restore financial integrity and ensure proper use of COCC funds, the Authority will take the following actions: 1. COCC Optimization and Budget Reform: Develop and implement a proper, balanced COCC budget that reflects actual operating costs and allocates shared services appropriately. Establish budget accountability protocols, including monthly budget-to-actual reviews and variance reporting to the CFO, CEO, and Board. 2. Training and Capacity Building: Provide training for finance staff on COCC operations, HUD’s Asset Management model, and best practices for cost allocation and shared services. Engage external consultants to support financial modeling and long-term sustainability planning for RAD and LIHTC properties. 3. Shared Services Agreement: Formalize a Consulting and Shared Services Agreement to ensure that COCC services are appropriately billed and reimbursed by other programs. Monitor inter-program transactions to ensure compliance with HUD’s financial management requirements. 4. Salary Allocation and Cost Tracking: Conduct a salary allocation study to ensure that staff time is distributed adequately across programs. Implement time-tracking tools and cost allocation methodologies that align with HUD guidance and OMB Uniform Guidance. Effective Date: June 3, 2025 Contact Information Dr. Michael C. Threatt, Chief Executive Officer Sanford Housing Authority 317 Chatham Street Sanford, North Carolina 27330 (919) 776-7655

View Audit 358177 Questioned Costs: $1

Finding 563841 (2023-004)

Significant Deficiency 2023

Global Fund to End Modern Slavery

DC

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

2023-004 – Allowable Costs relating to Time and Effort and Internal Controls Management’s Corrective Action Plan: Management agrees with the Federal award finding identified in the audit. We acknowledge that a few timesheets and spreadsheets were missing from appropriate files during a two-month p...

2023-004 – Allowable Costs relating to Time and Effort and Internal Controls Management’s Corrective Action Plan: Management agrees with the Federal award finding identified in the audit. We acknowledge that a few timesheets and spreadsheets were missing from appropriate files during a two-month period of transition at the Fund, while maintaining that proper allocation process was followed up to the point of record keeping. The Fund understands the reasons for the missing timesheets and that these cases were unique and not indicative of the normal and prevalent internal control over the completion and approval of timesheets. The allocation of payroll for the months tested were based on the consistent and correct application of the payroll costs allocation methodology however in a limited number of cases the allocation spreadsheets weren’t properly saved. After announcement of dissolution, there was considerable staff turnover and rapid transition which created challenges and delays. We did maintain an effective control environment. This has been resolved. Management is saving allocation spreadsheets, and other required documentation as per policy on an ongoing basis.

View Audit 358064

Finding 563619 (2023-003)

Material Weakness 2023

Dallam Hartley Counties Hospital District

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Contact Information: Sharon Hunt, Interim Chief Financial Officer, Dallam Hartley Counties Hospital District Audit Finding Reference Number: 2023-003 Planned Corrective Action: DHCHD has contracted with another payroll provider. Human Resources staff will work with the payroll provider to ensure th...

Contact Information: Sharon Hunt, Interim Chief Financial Officer, Dallam Hartley Counties Hospital District Audit Finding Reference Number: 2023-003 Planned Corrective Action: DHCHD has contracted with another payroll provider. Human Resources staff will work with the payroll provider to ensure that appropriate documentation regarding pay amounts and other essential payroll and personnel data is maintained on each employee. Anticipated Completion Date: Completed as of October 1, 2024

View Audit 357940 Questioned Costs: $1

Finding 563611 (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) 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 357888 Questioned Costs: $1

Finding 562147 (2023-013)

Significant Deficiency 2023

Libson Regional School District

NH

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

2023-013 Document Policies and Procedures over Federal Awards (Significant Deficiency) Management’s Response: We do have policies and procedures for Federal Awards that need to be tweaked to assure the work is done as required. We will have this in place in the first part of 25-26. Name of Contact...

2023-013 Document Policies and Procedures over Federal Awards (Significant Deficiency) Management’s Response: We do have policies and procedures for Federal Awards that need to be tweaked to assure the work is done as required. We will have this in place in the first part of 25-26. Name of Contact Person and Completion Date: Toni Butterfield Anticipated Completion Date – 12/31/2025

View Audit 357779

Finding 561745 (2023-003)

Material Weakness 2023

Klawock Cooperative Association

AK

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles

Klawock Cooperative Association has switched its contract accountant. They will work closely with management to close out the books and records timely including the accuracy and completeness of the Schedule of Federal Awards and be better rained in identifying, recording and administering funds that...

Klawock Cooperative Association has switched its contract accountant. They will work closely with management to close out the books and records timely including the accuracy and completeness of the Schedule of Federal Awards and be better rained in identifying, recording and administering funds that are provided directly to its subrecipients.

View Audit 357376

Finding 561431 (2023-004)

Material Weakness 2023

Community Resource Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Cash Management

As noted in the finding, the significant staff turnover and financial constraints during the audit period caused some disruption in our ability to provide the necessary documentation for certain transactions. In light of this, we have developed and implemented a corrective action plan to ensure full...

As noted in the finding, the significant staff turnover and financial constraints during the audit period caused some disruption in our ability to provide the necessary documentation for certain transactions. In light of this, we have developed and implemented a corrective action plan to ensure full compliance with 2 CFR 200, grant agreements, and cost principles going forward. 1. Strengthening Documentation Procedures: o Community Resource Center, Inc. has committed to implementing a process in which all transactions will be supported by actual invoices and all reimbursement requests will be submitted with corresponding supporting documentation. This will include both the original invoices and any other necessary backup materials. o Community Resource Center, Inc. is working with a financial consultant (start date on November 1, 2024), to audit and refine the financial systems, with particular emphasis on improving the accuracy and transparency of our documentation processes. The financial consultant will also assist in ensuring that all future costs align with the requirements of the funding agency and the OMB guidelines. 2. Review and Update of Internal Controls: o In response to the finding, Community Resource Center, Inc. has begun revising internal controls to ensure that adequate checks and balances are in place, especially in times of staff turnover. This includes designing more robust systems for tracking and documenting all costs related to grants, ensuring that all documentation is easily accessible for audit and review purposes. o A dedicated team will be assigned to monitor compliance with the internal control processes, and we will conduct regular internal reviews to verify that supporting documentation for all transactions is complete, timely, and accurate. 3. Contingency Planning for Staff Turnover: o Recognizing the impact of turnover, Community Resource Center, Inc. is formalizing a contingency plan for future staff changes. This plan will include clear guidance on the retention and transfer of all financial records, as well as designating backup staff with sufficient training and authority to oversee and maintain compliance with all financial requirements. We will also implement cross-training for key financial personnel to ensure continuity and consistency in the event of unexpected departures. 4. Ongoing Staff Training: o Community Resource Center, Inc. is committed to providing ongoing training to staff responsible for financial reporting and compliance. This will ensure that all staff involved in grant transactions understand the requirements set forth in 2 CFR 200 and other applicable regulations. Community Resource Center, Inc. will also work with the financial consultant to identify and address any skill gaps within the team. 5. Monitoring and Audit of Corrective Actions: o Community Resource Center, Inc. will establish regular internal monitoring and audits of these corrective actions to ensure they are being followed effectively. This will include periodic spot-checks of transaction documentation to ensure completeness and accuracy, as well as regular reviews of our internal controls and procedures to ensure their ongoing effectiveness.

View Audit 357014 Questioned Costs: $1

Finding 561278 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of Renton

WA

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Prior RHA administrative staff were not getting the PHA’s Single Audit completed nor submitted by the deadline. RHA was 3 years behind when the new CEO took over on March 31, 2023. FY2020, FY2021 and FY2022 were not completed and submitted. By the time that these three were caught up, completed...

Prior RHA administrative staff were not getting the PHA’s Single Audit completed nor submitted by the deadline. RHA was 3 years behind when the new CEO took over on March 31, 2023. FY2020, FY2021 and FY2022 were not completed and submitted. By the time that these three were caught up, completed and submitted, that pushed FY2023 Audit to be late. The audit for FY2023 should be completed by the end of April 2025 and then we will be on task to start FY2024 in May and completed by the deadline of September 30, 2025. Then, RHA will stay on task and get these completed within its deadline timeline.

View Audit 356918

Finding 561273 (2023-003)

Material Weakness 2023

Knott County Fiscal Court

KY

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.306 § 200.318 § 200.329

Prepared by: Kevin Jacobs Date Prepared: 7-3-24 Person Responsible for Corrective Action Plan: Kevin Jacobs Jeff Dobson Anticipated Completion Date: 7-3-24 Official's Response: To be clear the documents had to be presented to FEMA to get reimbursement, this was done. The Fiscal Court will ende...

Prepared by: Kevin Jacobs Date Prepared: 7-3-24 Person Responsible for Corrective Action Plan: Kevin Jacobs Jeff Dobson Anticipated Completion Date: 7-3-24 Official's Response: To be clear the documents had to be presented to FEMA to get reimbursement, this was done. The Fiscal Court will endeavor to make sure the FEMA files are updated and complete after FEMA reimbursement.

View Audit 356900 Questioned Costs: $1

Finding 561180 (2023-002)

Material Weakness 2023

The Association of State Wetland Managers, Inc. Dba National Association of Wetland Managers

ME

Allowable Costs / Cost Principles

Statement of Condition: Internal control weakness - documentation of approval over allowable costs could not be located for select expenses, and ineffective control procedures over posting of approved indirect cost rate allocation. Criteria: National Association of Wetland Managers’ internal control...

Statement of Condition: Internal control weakness - documentation of approval over allowable costs could not be located for select expenses, and ineffective control procedures over posting of approved indirect cost rate allocation. Criteria: National Association of Wetland Managers’ internal control policies and procedures, indirect cost negotiation agreement, and the Uniform Guidance. Cause: Procedures are in place requiring supervisory approval of documentation before costs are coded to grants, but procedures were not performed on all invoices. Also, ineffective control procedures over posting of indirect payroll cost allocation as indicated by compliance finding. Corrective Action Plan: Contact person: Marla Stelk, Executive Director Corrective action to be taken: NAWM does not believe that corrective action is required for this finding. NAWM has strong procedures in place requiring supervisory approval of documentation before costs are coded to grants. In some circumstances, invoices are emailed to the Executive Director, who approves them by giving instructions regarding payment over email. Email approvals are maintained as record of this internal control. In our digital world with the ability to work remotely, there are times when the Executive Director and Accounting Manager are not physically located in the same office space. However, this does not diminish the strength of our internal controls for review and approval of allowable costs. However, as recommended above, NAWM has hired a professional financial consultant to review our indirect cost accounting procedures, make recommendations to improve our processes, and assist in implementation of these recommendations. Anticipated completion date: End of current fiscal year (December 31, 2025)

View Audit 356793

Finding 561179 (2023-001)

None 2023

The Association of State Wetland Managers, Inc. Dba National Association of Wetland Managers

ME

Allowable Costs / Cost Principles

Statement of Condition: Compliance over allowable cost, including application of the indirect cost rate supplied by the United States Department of the Interior. Approved provisional rate of 26.3% not used. Instead, allocation based upon prior month’s payroll. Criteria: The Uniform Guidance, indirec...

Statement of Condition: Compliance over allowable cost, including application of the indirect cost rate supplied by the United States Department of the Interior. Approved provisional rate of 26.3% not used. Instead, allocation based upon prior month’s payroll. Criteria: The Uniform Guidance, indirect cost negotiation agreement, and National Association of Wetland Managers’ internal control policies and procedures. Cause: Management’s misunderstanding of accounting application of the provisional rate method. Corrective Action Plan: Contact person: Marla Stelk, Executive Director Corrective action to be taken: As noted above, NAWM provides the negotiated Indirect cost rates to the Funding Agency at the time when the project budget is developed. Subsequent billing of the indirect cost is based on the time spent on the project. Within six (6) months after year end, a final indirect cost rate proposal is submitted based on actual costs. Billings and charges to contracts and grants are adjusted if the final rate varies from the provisional rate. If the final rate is greater than the provisional rate and there are no funds available to cover the additional indirect costs, NAWM may not recover all indirect costs. Conversely, if the final rate is less than the provisional rate, NAWM is required to pay back the difference to the funding agency. However, as recommended above, NAWM has hired a professional financial consultant to review our indirect cost accounting procedures, make recommendations to improve our processes, and assist in implementation of these recommendations. Anticipated completion date: End of current fiscal year (December 31, 2025)

View Audit 356793

Finding 561098 (2023-005)

Significant Deficiency 2023

Public Health Institute of Metropolitan Chicago

IL

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

Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, another instance was identified in which a timesheet was not complete and was missing hours worked. Corrective Action Taken or Planned: Management ...

Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, another instance was identified in which a timesheet was not complete and was missing hours worked. Corrective Action Taken or Planned: Management plans to reiterate the applicable policy and ensure timesheets are prepared, reviewed and contain the appropriate approvals. Anticipated Date of Completion: December 31, 2025 Name of Contact Person: Karen Reitan, President and Chief Executive Officer Management Response: Management concurs with the finding.

View Audit 356735

Finding 561088 (2023-003)

Material Weakness 2023

Aid for Aids of Nevada

NV

Allowable Costs / Cost Principles § 200.303

2023-003 Internal Controls System Over Allowable Costs. – U.S. Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS, Assistance Listing Number 14.241, Passed Through the City of Las Vegas, Nevada. Criteria: As defined in 2 CFR 200.303, auditee is required to main...

2023-003 Internal Controls System Over Allowable Costs. – U.S. Department of Housing and Urban Development, Housing Opportunities for Persons with AIDS, Assistance Listing Number 14.241, Passed Through the City of Las Vegas, Nevada. Criteria: As defined in 2 CFR 200.303, 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. Funds utilized under the Housing Opportunities for Persons with AIDS program are required to be expended on costs consistent with those outlined in 2 CRF 200 Subpart E – Cost Principles, and within the core service categories outlined in the grant agreement. Condition: Of the fourteen request for reimbursement (RFR) forms prepared and submitted to the grantor in order to receive reimbursement for expenditures during the year, seven were not reviewed and signed by the Executive Director. AFAN has designed a control such that a review of each RFR is performed to ensure expenditures are for allowable costs and allowable activities allowed for under the grant. However, this control was not performed consistently. Cause: The internal control system over the assessment of allowable costs was not operating effectively. A review of requests for reimbursement was either not performed or documentation was not maintained to support the appropriateness of expenses allocated to the grant. Context: Management failed to consistently perform an internal control to address the risk of improper expenses being reimbursed by the Organization’s grant. Effect: Not performing a review over the documents and allocations supporting requests for reimbursement for the grant increases the risk that inappropriate costs could be submitted for reimbursement which could be a violation of the terms of the federal grant agreement. Repeat Finding: No Recommendation: We recommend management design and implement a system of internal controls whereby a review of costs and the related supporting schedules being submitted for reimbursement are reviewed on a consistent basis and management ensures proper documentation of this review is maintained to support the performance of the control. Views of Responsible Officials and Planned Corrective Actions: Management will implement a control whereby the Executive Director will review and sign all requests for reimbursement prepared by the Finance Manager for submission. The Executive Director will ensure all backup is included and that all direct costs are approved and allowable prior to submission. Payroll related reimbursements will be reviewed to ensure the individuals included and allocation amongst grants are appropriate and the allocations agree to the final payroll records.

View Audit 356711

Finding 561086 (2023-001)

None 2023

Moses H Cone Memorial Hospital Operating Corporation, Inc.

NC

Questioned Costs Allowable Costs / Cost Principles

We have revised the calculation of the Paid Annual Leave award and verified that it uses the pay rates in effect at the time of the award for all employees. We confirmed that no other expenses for the COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“Provider Relief F...

We have revised the calculation of the Paid Annual Leave award and verified that it uses the pay rates in effect at the time of the award for all employees. We confirmed that no other expenses for the COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (“Provider Relief Fund”) reporting involved costs subject to similar point in time report parameters. The change to this cost item does not impact the full utilization of the Provider Relief Fund due to the presence of other expenses in the same category along with unreimbursed expenses and unused lost revenues remaining after the funds were exhausted. The discrepancy was due to imprecise instructions in the request for information. In the future, such ad hoc requests and the responsive reports will be verified by the Executive Director of Corporate Accounting before use.

View Audit 356706 Questioned Costs: $1

Finding 561002 (2023-004)

Material Weakness 2023

Cedarville Rancheria

CA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.318

Federal Awards Finding 2023-004: Noncompliance with Federal Award Program Requirements Finding/Condition We noted the following deficiencies: 1. The Rancheria was unable to provide supporting documentation for the allocation of expenditures reported for federal award programs. 2. The Rancheria wa...

Federal Awards Finding 2023-004: Noncompliance with Federal Award Program Requirements Finding/Condition We noted the following deficiencies: 1. The Rancheria was unable to provide supporting documentation for the allocation of expenditures reported for federal award programs. 2. The Rancheria was unable to provide actual time records for employees, supporting payroll expenditures claimed as expenditures for federal award programs. 3. The Rancheria was unable to provide documentation to show that it complied with the procurement standards required in 2 CFR 200.318. Additionally, the Rancheria does not have a procurement policy which complies with those standards. Planned Corrective Action The Rancheria will be updating and implementing policies and procedures to address these risks. Anticipated Completion Date December 31, 2024

View Audit 356634

Finding 560993 (2023-008)

Significant Deficiency 2023

Heading Home

NM

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. Management has reviewed the existing policies and procedures found in Section II Policy #201 of Heading Homes fiscal policies and procedures with appropriate staff and will enforce the ...

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. Management has reviewed the existing policies and procedures found in Section II Policy #201 of Heading Homes fiscal policies and procedures with appropriate staff and will enforce the policies and procedures to ensure all invoices and funds requests are properly reviewed and approved prior to processing. All invoices and requests for funds for fiscal year 2024 will be reviewed to ensure the payment request is reasonable and necessary. The invoice or funds request will be signed and dated by the preparer, as well as by the reviewer as evidence of approval for processing the payment. All invoices and funds requests will be maintained in the cloud server in a manner that allows them to be easily retrieved when needed. The disbursements in question were reviewed and found to be to vendors regularly used by Heading Home and Heading Home firmly believes that documentation of approval existed at one point in time. However, with the complete turnover in executive personnel during 2023, and the fact that the prior administration utilized an online system for document storage that the current administration has very little access to, we were unable to locate the approvals for these payments. Management anticipates the above corrective action plan to be fully implemented by June 30, 2024. Personnel responsible for ensuring implementation include Connie Chavez, Chief Executive Officer, Debbie Brickman, Chief Financial Officer, and Armando Sanchez, contract accountants team lead.

View Audit 356632

Finding 560843 (2023-004)

Significant Deficiency 2023

Beaufort Jasper Hampton Comprehensive Services, Inc.

SC

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

We concur with the auditor's findings. The Organization engaged a single contractor for services but did not maintain the necessary supporting documentation to demonstrate that the suspension and debarment verification procedures, as outlined in our procurement policy were conducted prior to securin...

We concur with the auditor's findings. The Organization engaged a single contractor for services but did not maintain the necessary supporting documentation to demonstrate that the suspension and debarment verification procedures, as outlined in our procurement policy were conducted prior to securing the services. We will update and revise our procurement policies to align with 2 CFR 200 standards. Lastly, we will develop templates for purchase justifications, bid evaluations, suspension/debarment checks, and cost/price analysis. We will ensure the use of this documentation is enforced across all departments.

View Audit 356598

Finding 560759 (2023-008)

Significant Deficiency 2023

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

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

U.S. Department of Housing and Urban Development Significant Deficiency in Internal Control over Compliance Community Development Block Grant – Assistance Listing No. 14.218 Condition: The Organization was unable to locate contract and/or contract extensions for federal funding awarded expended d...

U.S. Department of Housing and Urban Development Significant Deficiency in Internal Control over Compliance Community Development Block Grant – Assistance Listing No. 14.218 Condition: The Organization was unable to locate contract and/or contract extensions for federal funding awarded expended during the period. Recommendation: The Organization should review its internal controls and procedures to ensure all relevant documentation, such as contracts or agreements, is reviewed and retained for all federal funds awarded. Implementing a standardized process for document retention and training staff on proper record-keeping practices can help mitigate this issue in the future. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization has developed a contract database and review process for all new and existing contracts. This process includes appropriate naming conventions across all platforms to ensure accuracy in records. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2024.

View Audit 356548

Finding 560743 (2023-007)

Material Weakness 2023

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

Allowable Costs / Cost Principles Material Weakness Reporting

U.S. Department of Housing and Urban Development Material Weakness in Internal Control over Compliance Community Development Block Grant – Assistance Listing No. 14.218 Condition: During our testing, we noted that 21 out of 40 transactions tested exhibited a variance in the recalculation of wages...

U.S. Department of Housing and Urban Development Material Weakness in Internal Control over Compliance Community Development Block Grant – Assistance Listing No. 14.218 Condition: During our testing, we noted that 21 out of 40 transactions tested exhibited a variance in the recalculation of wages charged to the program. This variance was identified when comparing the wages charged to the program with the time and effort documented on the timesheet for the respective programs. Recommendation: We recommend the time and effort documentation be regularly reviewed by appropriate personnel to ensure accuracy and completeness of personnel cost documentation is appropriately reported to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization will implement a new process for wages charged to a program to ensure accuracy. This will also be monitored regularly and tracked through the accounting software in the grant spend management module. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2025.

View Audit 356548

Finding 560722 (2023-006)

Material Weakness 2023

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

Allowable Costs / Cost Principles Period of Performance Material Weakness § 200.403

U.S. Department of Health and Human Services U.S. Department of Housing and Urban Development Material Weakness in Internal Control over Compliance Community Service Block Grant – Assistance Listing No. 93.569 Community Development Block Grant – Assistance Listing No. 14.218 Condition: During ou...

U.S. Department of Health and Human Services U.S. Department of Housing and Urban Development Material Weakness in Internal Control over Compliance Community Service Block Grant – Assistance Listing No. 93.569 Community Development Block Grant – Assistance Listing No. 14.218 Condition: During our testing, we noted there were several salary expenditures charged to the grant based on the payroll period ending date, however the costs were incurred for the period 12/24/22 - 1/6/23, which the first eight days were prior to the start of the period of performance. There was also one transaction selected for testing where no supporting documentation was able to be located and one transaction that was incurred after the period of performance for the program. Recommendation: The Organization should work with the federal agency to provide additional documentation or justification for the expenses, or to adjust the budget or funding limits to ensure that all expenses are within the approved period of performance. It is important to address any period of performance findings as soon as possible to avoid potential penalties or repayment obligations. The Organization should also review its process of entering invoices and payroll related expenses into the accounting software to ensure the correct period is used for federal expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Organization expanded contract compliance to include financial contract compliance. The organization will also implement grant tracking and spend management modules in the accounting software to assist with monitoring expenses applied to contracts. A new process will also be implemented regarding payroll related expenses to ensure the correct period is used for federal expenditures. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2025.

View Audit 356548

Finding 560690 (2023-005)

Material Weakness 2023

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Material Weakness

U.S. Department of Agriculture U.S. Department of Health and Human Services U.S. Department of Housing and Urban Development Material Weakness in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative) – Assistan...

U.S. Department of Agriculture U.S. Department of Health and Human Services U.S. Department of Housing and Urban Development Material Weakness in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative) – Assistance Listing No. 10.569 and 10.565 Community Service Block Grant – Assistance Listing No. 93.569 Community Development Block Grant – Assistance Listing No. 14.218 Condition: During our testing, we noted there was a lack of supporting documentation and/or an approval for expenses charged to the federal programs. Recommendation: The Organization should review its internal controls and procedures to ensure all supporting documentation is retained for federally funded purchases. Also, management should implement an approval control for purchases incurred on the Organizations credit cards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization has developed a more robust contract compliance process. This process included internal audits which will include review of financial records. The organization has also developed a credit card policy which staff will be trained on before completion date. The organization also implemented a new credit card platform which allows for better tracking, approval and documentation of purchases. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2025.

View Audit 356548

Finding 560679 (2023-004)

Significant Deficiency 2023

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

Allowable Costs / Cost Principles Eligibility School Nutrition Programs

U.S. Department of Agriculture Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.569 and 10.565 Condition: CACLV does not have formal procedures in plac...

U.S. Department of Agriculture Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.569 and 10.565 Condition: CACLV does not have formal procedures in place to determine the Second Harvest Food Bank expenses incurred during the fiscal year that should be allocated to the TEFAP/CSFP administrative revenue received. CACLV has historically recognized revenue based on when cash is received which is not appropriate. Recommendation: We recommend the allocation of allowable costs and activities be completed at a minimum on a quarterly basis. Also, any direct expenses related to program activities should be recorded to the respective identifying program fund number within the accounting software. The amount of revenue recognized for the programs should be reflected of the expenses incurred up to the administrative funds received from the respective funders. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization will implement a standard allocation to be completed on a quarterly basis at the minimum. This process will be reviewed by management to ensure implementation. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 2025.

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Finding 560668 (2023-003)

Material Weakness 2023

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

Eligibility Subrecipient Monitoring Allowable Costs / Cost Principles

U.S. Department of Agriculture Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 2 out of the 21 agencies tested which distributed TEFAP commodities duri...

U.S. Department of Agriculture Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 2 out of the 21 agencies tested which distributed TEFAP commodities during fiscal year 2023. Recommendation: The Organization should prioritize the timely monitoring of participating agencies to allow for changes in food distributions if any ineligible participants are discovered. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization developed a schedule to complete monitoring and created a checklist to ensure that all documentation is in the appropriate folder. In addition, the organization began conducting internal audits to ensure the developed processes are being followed. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is May 2024.

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Finding 560651 (2023-010)

Material Weakness 2023

Shenandoah School Corporation

IN

Allowable Costs / Cost Principles § 200.303 § 200.403 § 200.430

FINDING 2023-010 Finding Subject: Education Stabilization Fund – Allowable Cost/Cost Principles Summary of Finding: To receive reimbursement for ESSER expenses paid, the School Corporation’s Treasurer completed a reimbursement request, and the Director of Curriculum reviewed it. The documentation at...

FINDING 2023-010 Finding Subject: Education Stabilization Fund – Allowable Cost/Cost Principles Summary of Finding: To receive reimbursement for ESSER expenses paid, the School Corporation’s Treasurer completed a reimbursement request, and the Director of Curriculum reviewed it. The documentation attached to the reimbursement request; however, did not include the following items: 􀁸 For one teacher, the School Corporation did not provide a Board approved contract or Salary Ordinance showing the approval of this teacher's position as a part-time tutor at $50 per hour. There was only an offer letter to the teacher from the Director of Curriculum. 􀁸 For the purchase of equipment in the amount of $318,922, the School Corporation did not provide a contract instead only a PO with a quote and a letter with the School Board’s approval to purchase. Additionally, there was no indication in the board minutes that this purchase had been put out to bid to the suppliers. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When the Business Manager and Director of Curriculum review the reimbursement form each month, an additional check for contracts of all employees paid will be added. All procurement documentation, including contracts, will be added to the archived documentation for purchase orders. Anticipated Completion Date: March 31, 2024

View Audit 356534

Finding 560646 (2023-009)

Material Weakness 2023

Shenandoah School Corporation

IN

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

FINDING 2023-009 Finding Subject: Child Nutrition Cluster – Non-Profit School Food Service Accounts Summary of Finding: Receipts for the grant were posted to the ledger by one individual without an oversight or review process in place to ensure the remitter, amount, fund, and receipt classification ...

FINDING 2023-009 Finding Subject: Child Nutrition Cluster – Non-Profit School Food Service Accounts Summary of Finding: Receipts for the grant were posted to the ledger by one individual without an oversight or review process in place to ensure the remitter, amount, fund, and receipt classification were accurate. Additionally, the same individual received the ACH notifications when monies from monthly meal reimbursements were credited to the School Corporation's bank account and performed the bank reconciliations. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Food Service Director and Business Manager hold a monthly financial meeting to review the food service finances. A report listing all receipts for the previous month to the food service fund will be reviewed at this meeting. This item will be added to the agenda. Anticipated Completion Date: March 31, 2024

View Audit 356534

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