Corrective Action Plans

Finding 1218287 (2023-009)

Material Weakness 2023

Lead Academy

AL

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.430

Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, and the use of a third-party payroll provider, supporting documentation necessary to verify and document vendor payments and payroll transactions was not available, resulting in the inabili...

Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, and the use of a third-party payroll provider, supporting documentation necessary to verify and document vendor payments and payroll transactions was not available, resulting in the inability to obtain sufficient, appropriate audit evidence related to these amounts. Corrective Action: The school (LEAD Academy) contracted with New Schools for Alabama (NSFA) during 2023 to handle all their finance and accounting needs. By the end of 2023, the school also transitioned all payroll services to New Schools for Alabama. Prior to 2024, a third-party vendor was handling/processing payroll for LEAD Academy. Additionally, procedures were not in place to maintain monthly payroll data (timesheets, leave balances, documentation of annual salaries) prior to 2024. All financial records are now maintained digitally, with the original documents residing at the school. Additionally, NSFA worked with existing staff regarding proper documentation and filing of financial records and helped establish a new filing system. In 2024, payroll processing for the school was transitioned to NSFA, utilizing the state approved accounting/payroll software. Monthly procedures are now in place for the submission, approval and documentation of all payroll transactions. Expected Completion Date: September 30, 2024

View Audit 404529

Finding 1218280 (2023-008)

Material Weakness 2023

Lead Academy

AL

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, supporting documentation necessary to verify and document vendor payment was not available, resulting in the inability to obtain sufficient, appropriate audit evidence related to these amou...

Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, supporting documentation necessary to verify and document vendor payment was not available, resulting in the inability to obtain sufficient, appropriate audit evidence related to these amounts. During the testing of ESSER funds, there were 2 instances where the purchase order could not be located and one invoice that could not be located. Corrective Action: The school (LEAD Academy) contracted with New Schools for Alabama (NSFA) during 2023 to handle all their finance and accounting needs. By the end of 2023, the school also transitioned all payroll services to New Schools for Alabama. NSFA helped establish a purchase order procedure and worked with the school to make sure a purchase order or signed contract is in place prior to the purchase of goods and services. Additionally, approval on all invoices is required before NSFA processes them for payment, in order to verify that all goods and services have been received. Prior to 2024, proper procedures were not in place to maintain vendor files and accounts payable documentation. All financial records are now maintained digitally, with the original documents residing at the school. Additionally, NSFA worked with existing staff regarding proper documentation and filing of financial records and helped establish a new filing system. NSFA requires the school to indicate the source of funding for purchases, in order to know how to code the expenditure. We utilize monthly budget to actual reports to verify that expenditures are in line with the approved budget, ensuring that the correct coding has been used. We also ensure that only allowable expenditures are charged to federal funds, based on approved federal Egap applications and budgets.

View Audit 404529

Finding 1218279 (2023-007)

Material Weakness 2023

Lead Academy

AL

Allowable Costs / Cost Principles § 200.303 § 200.430

Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, and the use of a third-party payroll provider, supporting documentation necessary to verify and document payroll transactions was not available, resulting in the inability to obtain suffici...

Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, and the use of a third-party payroll provider, supporting documentation necessary to verify and document payroll transactions was not available, resulting in the inability to obtain sufficient, appropriate audit evidence related to these amounts. Corrective Action: The school (LEAD Academy) contracted with New Schools for Alabama (NSFA) during 2023 to handle all their finance and accounting needs. By the end of 2023, the school also transitioned all payroll services to New Schools for Alabama. Prior to 2024, a third-party vendor was handling/processing payroll for LEAD Academy. The upload file produced by the vendor was not accurately formatted, resulting in incorrect entries to some general ledger accounts, which required extensive corrections by NSFA to the FY 2023 financials. Many of these corrections involved federal ESSER funding, and the school was not able to identify specific individuals paid with ESSER funds or provide backup documentation. Additionally, procedures were not in place to maintain monthly payroll data (timesheets, leave balances, documentation of annual salaries) prior to 2024. All financial records are now maintained digitally, with the original documents residing at the school. Additionally, NSFA worked with existing staff regarding proper documentation and filing of financial records and helped establish a new filing system. In 2024, payroll processing for the school was transitioned to NSFA, utilizing the state approved accounting/payroll software. Monthly procedures are now in place for the submission, approval and documentation of all payroll transactions. Expected Completion Date: September 30, 2024

View Audit 404529

Finding 1218253 (2023-001)

Material Weakness 2023

HAWAII STATE RURAL HEALTH ASSOCIATION

HI

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.512

May 31, 2026 Hawaii State Rural Health Association Single Audit Report: Corrective Action Plan For the Year Ended December 31, 2023 Finding 2023-001 Management Response Management acknowledges the audit finding regarding the late submission of the audit, the data collection form, and the reporting p...

May 31, 2026 Hawaii State Rural Health Association Single Audit Report: Corrective Action Plan For the Year Ended December 31, 2023 Finding 2023-001 Management Response Management acknowledges the audit finding regarding the late submission of the audit, the data collection form, and the reporting package to the Federal Audit Clearinghouse. Corrective Action Plan After completion of the 2023 audit, we will be in a position to hire an auditor to perform the 2024 and 2025 audits at the same time, to get us back on a timely basis with the Uniform Guidance reporting requirements. Responsible Person: Summer K. Mochida-Meek, Executive Director Timeline: Corrective actions will be completed by September 30, 2026, for the year ended December 31, 2025. Summer K. Mochida-Meek Executive Director

View Audit 404503

Finding 1217889 (2023-001)

Material Weakness 2023

ARANSAS COUNTY NAVIGATION DISTRICT

TX

Allowable Costs / Cost Principles Cash Management Reporting

Management acknowledges the need to expand the current capacities of the finance team and is in the process of recruiting additional experienced and qualified personnel. To assist with immediate reporting and compliance needs, the District continues to utilize external consultants to provide assista...

Management acknowledges the need to expand the current capacities of the finance team and is in the process of recruiting additional experienced and qualified personnel. To assist with immediate reporting and compliance needs, the District continues to utilize external consultants to provide assistance with grant programs and related accounting procedures.

View Audit 403976

Finding 1217744 (2023-002)

Material Weakness 2023

Head Start of Lane County

OR

Allowable Costs / Cost Principles § 200.400 § 200.405

As of the 2024-2025 fiscal year, the agency has created a sustainable cost allocation process that will be in place moving forward. New policies were created, including a system for analysis of allocations throughout the year. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Curr...

As of the 2024-2025 fiscal year, the agency has created a sustainable cost allocation process that will be in place moving forward. New policies were created, including a system for analysis of allocations throughout the year. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Currently in place as of 7/1/2024

View Audit 403870

Finding 1217654 (2023-008)

Material Weakness 2023

LAUREL ADVOCACY & REFERRAL SERVICES, INC.

MD

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management

LARS will develop and adopt a written cost allocation policy that governs the distribution of shared costs across funding sources. The policy will include the following: • An enumeration of permissible allocation bases, which may include client counts by program, usage logs, program participation da...

LARS will develop and adopt a written cost allocation policy that governs the distribution of shared costs across funding sources. The policy will include the following: • An enumeration of permissible allocation bases, which may include client counts by program, usage logs, program participation data, square footage, or other equitable measures that reflect the relative benefit received by each program • A prohibition on allocating costs based on funding availability, grant end dates, or spend-down considerations • A requirement that all shared cost allocations be supported by contemporaneous documentation identifying the allocation base used, the calculation applied, and the period covered • A requirement for supervisory review and approval of all shared cost allocations prior to recording in the accounting system • Consistent application of the chosen allocation methodology across all periods and funding sources

View Audit 403810

Finding 1217396 (2023-007)

Material Weakness 2023

The Wellness Plan Medical Centers

MI

Allowable Costs / Cost Principles Cash Management § 200.303 § 200.430

Condition: Due to a lack of effectively designed and implemented controls to ensure compliance with allowable cost principles, management requested reimbursement based upon employment contract agreements rather than actual payroll costs incurred for the individuals working under the grant. Planned C...

Condition: Due to a lack of effectively designed and implemented controls to ensure compliance with allowable cost principles, management requested reimbursement based upon employment contract agreements rather than actual payroll costs incurred for the individuals working under the grant. Planned Corrective Action: The organization will implement internal controls to ensure expenditure is allowed in accordance with 2 CFR 200 Subpart E. Costs must be necessary, reasonable, and allocable. Contact person responsible for corrective action: Charles Berry (CFO) Anticipated Completion Date: 06/30/2026

View Audit 403582

Finding 1216947 (2023-003)

Material Weakness 2023

Leather and Hide Council of America

DC

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Views of Responsible Officials and Planned Corrective Actions: LHCA's methodology for qualifying laboratory and affiliated organization expenses as industry in-kind contribution was developed in direct consultation with FAS program officials in June 2023. As documented in LHCA's written summary of t...

Views of Responsible Officials and Planned Corrective Actions: LHCA's methodology for qualifying laboratory and affiliated organization expenses as industry in-kind contribution was developed in direct consultation with FAS program officials in June 2023. As documented in LHCA's written summary of that meeting, transmitted to senior FAS program and operations officials including the FMD program officer and acknowledged without objection, FAS validated the eligibility of research, marketing, policy, and technical expenses funded through industry funds, focused on target markets, and connected to UES activities. LHCA was acting on direct FAS guidance, not making unsupported determinations, and that documentation is available for the auditor's review. The revenue figures that appeared in LHCA's contribution documentation served as an allocation methodology, a proportional basis for determining what share of multi-purpose expenses relates to export promotion, not as the contribution itself. The actual contribution claimed consisted of underlying expenses allocated using that methodology. LHCA acknowledges that this methodology was not clearly labeled in the documentation provided to auditors, and will revise its documentation format to clearly distinguish the allocation calculation from the contribution amount claimed, ensuring the two are not conflated in future reviews. LHCA will formalize its contribution tracking procedures with a written policy document that defines eligible activities consistent with FAS guidance, specifies the allocation methodology and its basis, and requires that all claimed contribution be supported by verifiable expense documentation consistent with the hierarchy established in FMD §1484.33(f) and the cost principles in 2 CFR Part 200 Subpart E. A documented review and approval process will be implemented to ensure contribution amounts are accurate, allowable, and properly supported prior to submission.

View Audit 403243

Finding 1216733 (2023-001)

Material Weakness 2023

STEPS to Recovery Homes

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles

Management of the Organization will restructure all classes in the functional classing system, as well as utilize the project function, and consistently apply expenditures such that system reports accurately reflect income and expenditures by program / grant.

View Audit 403177

Finding 1216662 (2023-009)

Material Weakness 2023

College of the Marshall Islands

MH

Allowable Costs / Cost Principles § 200.303 § 200.403

Activities Allowed or Unallowed/ Allowable Costs/Cost Principles The College acknowledges the finding and recognizes earlier corrective measures were not sufficient to fully address the concern. To improve monitoring of allowable expenditures and compliance with federal cost principles, the College ...

Activities Allowed or Unallowed/ Allowable Costs/Cost Principles The College acknowledges the finding and recognizes earlier corrective measures were not sufficient to fully address the concern. To improve monitoring of allowable expenditures and compliance with federal cost principles, the College will incorporate routine budget-to-expenditure reviews into its recurring grant management meetings. Additional oversight and review responsibilities will also be assigned to the Grants Office to strengthen compliance monitoring, improve accountability, and ensure expenditures are properly evaluated and documented prior to approval.

View Audit 403112

Finding 1216657 (2023-005)

Material Weakness 2023

College of the Marshall Islands

MH

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403

Activities Allowed or Unallowed & Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and agrees that certain payroll and non-payroll expenditures charged to federal programs were not adequately supported with sufficient documentation to clearly demonstrate allow...

Activities Allowed or Unallowed & Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and agrees that certain payroll and non-payroll expenditures charged to federal programs were not adequately supported with sufficient documentation to clearly demonstrate allowability, proper allocation, and alignment with objectives. The deficiencies resulted from weaknesses in internal control procedures, incomplete supporting documentation, and prior filing and record retention practices. To address this, the College has upgraded and institutionalized a cloud-based filing system to ensure complete, accessible, and properly organized documentation for all grant-funded positions and expenditures. Internal controls have been strengthened to require signed employment and overload contracts, proper funding source verification, and supervisory review before any grant-related payroll costs are charged. With the upgraded systems and the support of newly hired skilled staff, the College is now better equipped to maintain compliance and oversight. Staff will continue to be trained twice a year on federal allowability and cost principles to prevent recurrence of similar issues in future audits.

View Audit 403112

Finding 1216199 (2023-002)

Material Weakness 2023

LIFE Academy

AL

Allowable Costs / Cost Principles

Life Academy will work to complete the audit for the fiscal year no later than nine months after the end of the audit period.

View Audit 402683

Finding 1215750 (2023-005)

Material Weakness 2023

Harvest Hope Food Bank

SC

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

2023-005 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake...

2023-005 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635

View Audit 402412

Finding 1215735 (2023-002)

Material Weakness 2023

Harvest Hope Food Bank

SC

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

2023-002 CDBG Activities Allowed and Allowable Costs Significant Deficiency Corrective Action: We now have staff that can review invoices properly prior to payment. Invoices paid will have a final signoff prior to payment. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-6...

2023-002 CDBG Activities Allowed and Allowable Costs Significant Deficiency Corrective Action: We now have staff that can review invoices properly prior to payment. Invoices paid will have a final signoff prior to payment. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635

View Audit 402412

Finding 1215384 (2023-002)

Material Weakness 2023

New Space Nexus

NM

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

Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, ...

Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, procurement, cash management, subrecipient monitoring, reporting, record retention, and internal controls. The Financial Analyst will be responsible for maintaining and updating these policies, with oversight from the Executive Director, and policies will be reviewed at least annually and updated as needed. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst, by March 31st, 2024

View Audit 401939

Finding 1214959 (2023-004)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF LITTLE ROCK, ARKANSAS

CA

Allowable Costs / Cost Principles HUD Housing Programs Special Tests & Provisions

Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.01...

Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.019 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements regarding Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2023.

View Audit 401728

Finding 1214888 (2023-006)

Material Weakness 2023

Escambia County Board of Education

AL

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Equipment & Real Property Management § 200.313

Develop and implement a comprehensive capital asset and inventory management system. Ensure all federally funded equipment includes required documentation: Funding source (FAIN); Acquisition date and cost; Location, use, and condition. Conduct a full inventory of all federally funded equipment. Esta...

Develop and implement a comprehensive capital asset and inventory management system. Ensure all federally funded equipment includes required documentation: Funding source (FAIN); Acquisition date and cost; Location, use, and condition. Conduct a full inventory of all federally funded equipment. Establish procedures to ensure proper classificaiton of expenditures as capital outlay. Provide training on Unidorm Guidance (2 CFR 200) requirements to all relevant staff. Inventory and system implementation: Within 90 days. Full compliance: By end of fiscal year.

View Audit 401645

Finding 1214739 (2023-006)

Material Weakness 2023

Detroit Central City Cmh, Inc.

MI

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

For 11 of 22 tenant files selected for testing, the Organization was unable to provide both the signed sublease agreement and the master lease agreement. One file lacked both documents. Although the Compliance Supplement does not require these documents for determining rent reasonableness under the ...

For 11 of 22 tenant files selected for testing, the Organization was unable to provide both the signed sublease agreement and the master lease agreement. One file lacked both documents. Although the Compliance Supplement does not require these documents for determining rent reasonableness under the Continuum of Care Program, the Organization’s internal policies require them. Management acknowledges the condition noted. While the Compliance Supplement does not require examination of lease agreements for this program and no instances of noncompliance were identified, we agree that maintaining complete tenant files—including signed sublease agreements and master lease agreements—is an important internal control to support documentation of rent reasonableness and compliance with our own policies. The missing documents resulted from inconsistent file maintenance during the audit period. The Organization has taken steps to strengthen its documentation and retention procedures to ensure all required lease documents are properly maintained and readily accessible going forward.

View Audit 401484

Finding 1214605 (2023-002)

Material Weakness 2023

Wellstar Health System, Inc. and Affiliates

GA

Allowable Costs / Cost Principles § 200.303

Finding No: 2023 002 Federal Agency: U.S. Department of Homeland Security Federal Emergency Management Agency Assistance Listing Number: 97.036 Program: COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) Award Year: July 1, 2022 to June 30, 2023 Compliance Requirements:...

Finding No: 2023 002 Federal Agency: U.S. Department of Homeland Security Federal Emergency Management Agency Assistance Listing Number: 97.036 Program: COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) Award Year: July 1, 2022 to June 30, 2023 Compliance Requirements: Activities allowed or unallowed and Allowable costs/cost principles Criteria In accordance with the Federal Emergency Management Agency (FEMA) Public Assistance Program and Policy Guide, Version 2.1, Chapter 2, costs are not eligible for reimbursement if the applicant received funding from another source (e.g., patient revenue or insurance) for the same work funded by FEMA. FEMA refers to this as a duplication of benefits. On February 15, 2023, FEMA issued a memorandum titled Hypothetical Reasonable Applicant Methods, which outlines the basic elements for estimating duplication of benefits within net patient service revenue. Subsequent to FEMA both obligating and paying project worksheet #548183A, the Department of Homeland Security (DHS) engaged the RAND Corporation’s Homeland Security Research Division (RAND), through the Homeland Security Operational Analysis Center (HSOAC), to assist with the administration of disaster grants to health care providers related to COVID 19. Additionally, 2 CFR 200.303 requires non federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Conditions Found On March 3, 2023, FEMA obligated and paid project worksheet #548183A for $2,719,181 related to Remdesivir drug costs and reimbursements which were included in the total expenditures for this program of $16,310,090 for the year ended June 30, 2023. Most insurance providers, including the federal government, pay hospitals a single flat fee for an entire patient stay (known as a ‘bundled payment’) rather than paying for every individual item used. As a result, when the System receives a payment for an inpatient stay, it isn’t possible to determine exactly how much of that payment was for a specific drug like Remdesivir. However, FEMA program requirements require the hospital to offset claimed costs by payments from other sources. Since there is not a payer level breakdown of the payment for Remdesivir, management applied a cost based allocation methodology to estimate the portion of bundled inpatient reimbursement attributable to Remdesivir. In June 2023, HSOAC issued an Applicant Review Memo indicating that they had evaluated project #548183A and determined the methodology utilized by management to calculate the estimated payments received from other sources related to Remdesivir drug costs and reimbursements to be unreasonable. The System could not provide the additional information requested by RAND to support actual payments received from other sources related to Remdesivir costs within project #548183A since that information does not exist under prevailing inpatient reimbursement structures. Therefore, at the request of the System, FEMA de obligated $2,719,181. Cause The System used a methodology to calculate the estimated payments received from other sources that was not in accordance with FEMA’s regulations. Further, the System was unable to provide requested documentation related to actual payments received from other sources to RAND because that information specific to the Remdesivir drug costs does not exist under prevailing inpatient reimbursement structures. Effect The funds obligated for project worksheet #548183A were subsequently de obligated at the request of the System and the System returned these funds to FEMA. Questioned Cost $2,719,181 Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year Not a repeat finding. Recommendation We recommend that the System strengthen controls over the management review process to prevent unallowable costs and inaccurate amounts from being charged to Federal programs as well as ensure all relevant documentation is maintained in accordance with Federal requirements. View of Responsible Official For project worksheet 548183A, Wellstar Health System, Inc was not provided with methodology or approach to FEMAs request for patient level financials, including all costs incurred directly with each patient. Wellstar Health System, Inc. believed the request for information from FEMA was in conflict with FEMA’s "COVID-19 Patient Care Revenue Duplication of Benefits Recipient and Subrecipient Guide", published in October 2022, as well as overly burdensome and unreasonable. Wellstar Health System, Inc. subsequently requested FEMA to de obligate project worksheet 548183A and repaid all funds. Corrective Action Plan Wellstar Health System has trained responsible internal team members on approach and methodology of FEMA published guidelines. Wellstar Health System, Inc. will also engage external, experienced consultants as needed for future FEMA claims. Anticipated Completion Date: Wellstar Health System, Inc has already implemented the corrective action. Name of Contact Person for Corrective Action: Beth Loudermilk, VP Financial Planning & Analysis

View Audit 401278

Finding 1214496 (2023-003)

Material Weakness 2023

Tucson Audubon Society

AZ

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.414

Upon receiving results of the FY21 audit (completed in FY24), TAS’ Director of Finance was informed that the inclusion of the Biological Expertise line item on federal billing records (approximately 7.5% additional uplift) was not allowable as it was being calculated. TAS is allowed a 10% de minimis...

Upon receiving results of the FY21 audit (completed in FY24), TAS’ Director of Finance was informed that the inclusion of the Biological Expertise line item on federal billing records (approximately 7.5% additional uplift) was not allowable as it was being calculated. TAS is allowed a 10% de minimis rate on noted FY22 Federal awards, some of which also included a Biological Expertise line item that is budgeted as an hourly rate. TAS had been calculating uplift amounts owed by simply adding the Biological Expertise (7.5%) to the de minimis rate (10%) for a total uplift of 17.5%. This was done at the direction and approval of our federal partners. However, due to Biological Expertise being entered in the federal and approved budgets as an hourly line item and not a percentage TAS was considered out of compliance by using this method of calculation. After the presentation of this finding in mid-2024, TAS adjusted federal billing for administrative expenses to the de minimis rate (10%) as a percentage, unless otherwise noted in the agreement. Anticipated completion date: In effect.

View Audit 401199

Finding 1214226 (2023-003)

Material Weakness 2023

Family Involvement Center, Inc.

AZ

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303 § 200.430

Recommendation: We recommend that management implement a requirement for employees to complete level of effort forms attesting to actual time spent working on the federal program on a regular basis, but no less than annually, during the fiscal period. These forms should be reviewed by a supervisor k...

Recommendation: We recommend that management implement a requirement for employees to complete level of effort forms attesting to actual time spent working on the federal program on a regular basis, but no less than annually, during the fiscal period. These forms should be reviewed by a supervisor knowledgeable of the employee’s activities and grant requirements and retained thereafter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management established a standardized quarterly process for updating Level of Effort (LOE) forms. All completed forms are retained and archived within the organization’s SharePoint environment to support proper documentation and audit readiness. Name(s) of the contact person(s) responsible for corrective action: Deidre Calcoate, Executive Director Planned completion date for corrective action plan: 01/09/2025

View Audit 400935

Finding 1214225 (2023-002)

Material Weakness 2023

Family Involvement Center, Inc.

AZ

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303 § 200.430

Recommendation: We recommend that management implement a requirement for employees to complete level of effort forms attesting to actual time spent working on the federal program on a regular basis, but no less than annually, during the fiscal period. These forms should be reviewed by a supervisor k...

Recommendation: We recommend that management implement a requirement for employees to complete level of effort forms attesting to actual time spent working on the federal program on a regular basis, but no less than annually, during the fiscal period. These forms should be reviewed by a supervisor knowledgeable of the employee’s activities and grant requirements and retained thereafter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management established a standardized quarterly process for updating Level of Effort (LOE) forms. All completed forms are retained and archived within the organization’s SharePoint environment to support proper documentation and audit readiness. Name(s) of the contact person(s) responsible for corrective action: Deidre Calcoate, Executive Director Planned completion date for corrective action plan: 01/09/2026

View Audit 400935

Finding 1213862 (2023-005)

Material Weakness 2023

Knoxville Knox County Community Action Committee

TN

Allowable Costs / Cost Principles

U.S. Department of Health & Human Services Allowable Costs/Cost Principles Recommendation: We recommend that CAC Discontinue the use of unrestricted gift cards for CSBG funded participant assistance. Implement policies requiring that any gift cards or vouchers be restricted at the vendor level to al...

U.S. Department of Health & Human Services Allowable Costs/Cost Principles Recommendation: We recommend that CAC Discontinue the use of unrestricted gift cards for CSBG funded participant assistance. Implement policies requiring that any gift cards or vouchers be restricted at the vendor level to allowable CSBG purposes or replaced with alternative assistance mechanisms that provide adequate safeguards. Consult state CSBG administering agency guidance prior to implementing participant assistance methods to ensure costs are allowable and properly controlled. Explanation of disagreement with audit finding: CAC does not disagree with the audit finding. Action taken in response to finding: Management acknowledges the finding regarding the provision of direct assistance using Relief Assistance (RAP) gift cards under the CSBG program. In its role as a designated essential service provider, CAC used CSBG funds to provide direct assistance to eligible individuals and families in need. RAP cards were used for allowable purchases such as food, household items, clothing, and personal necessities. Management explored options to implement vendor-based restrictions on card usage; however, no vendors were identified with the capability to apply such restrictions. As an alternative, CAC implemented participant acknowledgment forms outlining allowable uses and restrictions. Due to COVID-related conditions at the time, post-distribution verification procedures were not feasible. Upon further evaluation of Uniform Guidance requirements and program-specific restrictions, management determined that this approach did not provide sufficient control to ensure allowability. Based on this determination, CAC has discontinued the use of unrestricted gift cards for CSBG-funded participant assistance and will not utilize federal funds for direct assistance cards unless they can be appropriately restricted and controlled in accordance with program requirements. Planned completion date for corrective action plan: The prohibition against using CSBG funds for unrestricted gift cards is currently in effect.

View Audit 400695

Finding 1213727 (2023-020)

Material Weakness 2023

Stillwater County

MT

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Corrective Action: Utilize project management detail record keeping for any public assistance grants to assure that the expenditures qualify for cost principles as outlined in 2 CFR part 200 subpart E.

View Audit 400644

Corrective Action Plans

Filters