Corrective Action Plans

Finding 513380 (2023-002)

Material Weakness 2023

NJ

Allowable Costs / Cost Principles Student Financial Aid Eligibility

The University concurs with this finding but cannot respond why the student was awarded outside the of procedure and methodology set up for awarding HEERF Funds. The decisions were made by individuals no longer with the University and no documentation was found to determine why the student was award...

The University concurs with this finding but cannot respond why the student was awarded outside the of procedure and methodology set up for awarding HEERF Funds. The decisions were made by individuals no longer with the University and no documentation was found to determine why the student was awarded outside the policy in place. The Controller’s Office and Financial Aid Office are working together to make sure that in future funds like the HEERF will have documentation attached to secure that we follow procedure and policy and document any exceptions.

View Audit 331221

Finding 513371 (2023-006)

Material Weakness 2023

Catholic Charities of the Diocese of Camden

NJ

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

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Homeland Security Passed through Cumberland Co...

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Homeland Security Passed through Cumberland County: Grant No. 39 5962 00 Grant No. ARPA R 5962 00 Emergency Food and Shelter National Board Program AL# 97.024 11/2021 12/2023 11/2021 12/2023 Passed through Salem County Board of Social Services Grant No. ARPA R 6028 00 11/2021 12/2023 Passed through Atlantic County Grant No. 39 5948 00 Grant No. ARPA R 5948 00 Passed through Cape May County Grant No. ARPA R 5960 00 Grant No. 39 5960 00 11/2021 12/2023 11/2021 12/2023 11/2021 12/2023 11/2021 4/2023 2023-006 -Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria Emergency Food and Shelter National Board Program (EFSP) funds may be used for food and related expenses (such as transporting food/food preparation and serving equipment); mass shelter; other shelter (such as hotels and motels); and rent/mortgage and/or utility assistance limited to one month. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. ,roj"':::;: Charities USt\, www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I "I'd: 856-342-4100 I Fax: 856-342-4180 Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: a W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. a Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I Tel: 856-342-4100 I Fax: 856-342-4180 Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above.

View Audit 331207

Finding 513361 (2023-005)

Material Weakness 2023

Catholic Charities of the Diocese of Camden

NJ

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

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Health and Human Services Temporary Assistance ...

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Health and Human Services Temporary Assistance for Needy Families (TANF) - AL #93.558 Passed through Camden County Health Department: Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through Cumberland County Office on the Aging and Disabled Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through Salem County Board of Social Services Grant No. None Available 1/2022 12/2022 Grant No. None Available Passed through Gloucester County 1/2023 12/2023 Grant No. None Available 1/2022 12/2022 Grant No. None Available 1/2023 12/2023 Passed through New Jersey Department of Human Services Division of Family Development Grant No. SF22009 10/2021 9/2022 Grant No. SF23009 10/2022 9/2023 2023-005 - Activities Allowed and Allowable Costs and Eligibility (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria TANF funds monthly cash assistance payments to low-income families with children. The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102-590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. ,,o,s::::;: C:h.1riries USA. www.catholiccharitiessouthjersey.org 1845 Haddon Avcll1le, Camden, NJ 08103 I Td: 856-342-4100 I Fax: 856-342-4180 Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. • Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. www.catholiccharitiessouthjersey.org 1845 Haddon Avenue, Camden, NJ 08103 I Td: 856-342-4100 I Fu.: 856-3424180 Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org stions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone ii address above.

View Audit 331207

Finding 513357 (2023-004)

Material Weakness 2023

Catholic Charities of the Diocese of Camden

NJ

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

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Veterans Affairs Direct Award: Grant No. 12 NJ...

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Veterans Affairs Direct Award: Grant No. 12 NJ 053 55 Grant No. 12 NJ 053 22 VA Homeless Providers Grant and Per Diem Program AL# 64.033 9/2021 9/2023 10/2021 3/2023 Grant No. 12 NJ 053 HL 9/2021 9/2023 Grant No. 12 NJ 053 LT 8/2022 9/2026 Grant No. 12 NJ 053 23 9/2021 9/2023 2023-004 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria The Homeless Veterans Comprehensive Service Programs Act of 1992 (Public Law 102 590) established the VA Homeless Providers Grant and Per Diem Program to fund the costs of creating or improving transitional supportive housing facilities or services centers, and grants to support case managers to assist Veterans in attaining or retaining permanent housing. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive' assistance payments along with controls over review of documentation in participant files and processing of these payments. View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: Theim.proper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in Febr·uary 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB. Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETO Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above.

View Audit 331207

Finding 513354 (2023-003)

Material Weakness 2023

Catholic Charities of the Diocese of Camden

NJ

Questioned Costs Internal Control / Segregation of Duties Eligibility

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Housing and Urban Development Emergency Solutio...

Diocese of Camden Single Audit Corrective Action Plan For the Fiscal Year Ended June 30, 2023 Re-submitted: November 25, 2024 Wipfli LLP 1502 London Road, Suite 200 Duluth, MN 55812 Attn: Michelle Swoboda, CPA FEDERAL AWARD FINDING U.S. Department of Housing and Urban Development Emergency Solutions Grant Program AL# 14.231 Passed through State of New Jersey Department of Community Affairs: Grant No. 2019 02156 036106 8/2020 3/2023 Grant No. 2022 02156 0337 00 7/2021 7/2023 Grant No. 2022 02156 0339 00 4/2022 7/2023 Grant No. 2022 02156 0338 00 4/2022 9/2023 Grant No. 2022 02156 0052 08 12/2019 9/2023 Grant No. 2020 02156 0042 08 12/2019 9/2023 Grant No. 2020 02156 0042 04 12/2019 9/2023 Grant No. 2019 02156 0361OS 12/2018 9/2023 2023-003 - Activities Allowed and Allowable Costs (Significant Deficiency) Statement of Condition Supportive service expenditures were processed and paid for ineligible participants. Criteria ESG funds may be used for five program components: street outreach, emergency shelter, homelessness prevention, rapid re-housing assistance, and HMIS; as well as administrative activities. The five program components and the eligible activities that may be funded under each are set forth in 24 CFR 576.101 through 576.107. Cause Due to lack of supervisory oversight, several employees falsified participant documents whereby ineligible individuals with personal relationships to these employees receive assistance payments. Effect Management became aware of the improprieties and hired an independent forensic investigator. The forensic investigator identified improper disbursements to ineligible participants along with other disbursements that required further research, inconclusive, insufficient, unverified, and LLC discrepancy disbursements. Management also notified the State of New Jersey Department of Community Affairs Office of Auditing. Recommendation Management should strengthen controls over documentation required for participants to receive assistance payments along with controls over review of documentation in participant files and processing of these payments. www.catholiccharitiessouthjersey.org 1845 Haddon A\-enue, Camden, NJ 08103 I Tel: 856•342-4100 I Fu: 856---3424180 Serving si.,;: counties of Southern Nev,1Jersey: Atlantic, Camden, Cape May; Cumbedand, Gloucester & Salem View of Responsible Officials Management agrees with the recommendation and has begun implementing additional procedures to ensure that applicant files are complete and that case files and support are being reviewed by supervisory personnel. Corrective Action: The improper activity was identified in October 2023 and the following actions were subsequently taken: • Two caseworks and a supervisor were terminated. • The agency's Executive Director retired. • The agency's Controller was temporarily elevated to Interim Administrator, overseeing day-to-day operations and reviewing all agency disbursements. • The central accounting department revised the check processing procedures to ensure that the following documentation accompanied housing related check requests: o W-9 signed by the vendor o A signed Promissory Agreement from the client, landlord and caseworker if the agency is paying Rent/Sec Dep. o Proof of Ownership for the property (Deed, Tax bill, NJ Parcels website) documentation. The Proof of Ownership documentation must match the W-9. Management has taken steps to ensure that the rental properties for which assistance will be rendered are in fact owned by the landlord stated on the lease. o Copy of an executed rental lease. o Rent Ledger, or a letter from the Landlord on their letterhead detailing client past and overdue charges/payments. Should include dates, amounts, etc... o Proof of Hardship - case management notes detailing hardship are sufficient for the Accounting Dept, although not necessarily sufficient for the requirement of the grant. • Policy changes with regard to check distribution have been modified. All checks are mailed directly to the vendor/payee from the central accounting department. • Two supervisors replaced the one terminated supervisor in order to ease the amount of supervision duties tasked to one person. • A new Executive Director for the Organization was hired in February 2024. • Created and filled the position of Grants Compliance Specialist. This position is responsible to: o Review, revise and create, where needed, policies/procedures to ensure that 0MB Uniform Administrative Requirements are being considered and followed in the administering of all grant funding. o Responsible for regularly reviewing client files on a judgmental basis in order to ensure adherence to the agency's policies and procedures. Mandated the universal use of ETD Case Management Solution as the soul repository of client information, case notes with a link to electronic client documentation files on the agency network. This provides electronic access to client case files as well as an electronic audit trail. Projected Completion Date As mentioned, the actions note above have been implemented. Management and the Grant Compliance Specialist continue to review, modify and communicate policies/procedures with all case management staff. Contact Person Robert Waite, Controller 856-342-4186; robert.waite@camdendiocese.org If you have questions or concerns regarding this Plan, please reach out to Robert Waite, Controller using the phone number or email address above. Robert T Waite, Controller

View Audit 331207 Questioned Costs: $1

Finding 513339 (2023-002)

Material Weakness 2023

School Administrative Unit No. 16

NH

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

The SAU Grant's Coordinator will be responsible for ensuring the annual grant certification form for salary employees is completed and maintained.

View Audit 331205

Finding 513261 (2023-003)

Significant Deficiency 2023

School Administrative Unit No. 16

NH

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

SAU16 has policy DAF in all the school districts, expect the SAU. We will ask the joint board to adopt policy DAF.

View Audit 331205

Finding 513084 (2023-003)

Material Weakness 2023

Allen County

IN

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

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and...

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and submitted each report without a review or oversight process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-003, the Chief of Staff to the Board of Commissioners will have the Controller to the Board of Commissioners review the P&E Reports and the Recovery Plan Performance Report prior to being electronically submitted to the Department of Treasury via its State and Local Fiscal Recovery Funds portal. If errors are discovered by the Controller, the Chief of Staff will correct the electronic entry prior to submission. Anticipated Completion Date: This CAP will be completed by October 31, 2024, the deadline for submitting the third quarter 2024 P&E Report.

View Audit 331014

Finding 513082 (2023-001)

Material Weakness 2023

Allen County

IN

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.300 § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The...

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purpose of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. The Health Issues and Challenges grant is a reimbursable grant, whereby the County received reimbursement on a percase basis at a stated rate for Case Management and Environmental Investigation activities performed. The Department of Health received federal receipts related to the grant in the amount of $130,479 during 2023. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. Receipts of the program were adequately identified through the use of an account number within the County Health Fund (285) in the Allen County's ledger (ledger) which was unique to the Health Issues and Challenges grant receipts. However, the ledger did not adequately identify the expenditures of the grant program within the County Health Fund. Through inquiry with the Department of Health employees and review of unitprepared support of grant expenditures, we determined expenditures were made with grant funds during the audit period, however, we were unable to distinguish between the expenditures of the Health Issues and Challenges grant and all other activities of the Department of Health in the County Health Fund. Due to the lack of separate identification of expenditures in the financial records, we were not able to establish a population from which to audit the Health Issues and Challenges grant for compliance with the following compliance requirements of the program: 􀁸 Activities Allowed or Unallowed 􀁸 Allowable Costs/Cost Principles 􀁸 Period of Performance 􀁸 Procurement and Suspension and Debarment As such, the full award amount of $130,479, as reported on the Schedule of Expenditures of Federal Awards, was determined to be questioned costs. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Recommendation: We recommend that management of the Health Department establish a system of internal controls to ensure that grant award funds are adequately accounted for and tracked in such a manner as to determine the activity, receipts and disbursement, associated with the grant. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: When we were informed of the outcomes of the SBOA audit and the subsequent needs for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP. We feel this finding/issue could be easily remedied by following our normal procedure for grants, whereby we develop a new fund, craft a Fund Ordinance for approval by the Allen County Commissioners to establish said new fund, and then subsequently track all expenditures and reimbursements in the separate fund vs. utilizing a line item for deposits in the main Health Fund as was done with this grant (which lacked the ability to denote exact salary expenditures and such next to each payment as it was all done within the larger fund for all staff and expenses. We were not aware of this need. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a separate fund will be created through development and approval of a local fund ordinance. All expenditures allowed by said grant and all reimbursements received by the grant funder will be tracked solely and only within the separate grant fund that is tied to the signed contract from the funder. If there are staff payments for salaries or benefits being reimbursed by a grant, we will ensure that: (1) the hours/minutes per staff member per pay period for all work associated with these grant duties are tracked appropriately so as to ensure we are invoicing the grant funder for the exact and accurate work hours (regardless of whether or not the grant contract specifies this be tracked or reimbursed per minute/hour, as most do not require this); and (2) these amounts will be noted alongside the expenditures in the grant fund for clarity upon invoicing or auditing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024. This is the standard practice for most grants we have accepted, and therefore, we will not vary from this practice in the future even if given permission to do so.

View Audit 331014 Questioned Costs: $1

Finding 513062 (2023-003)

Significant Deficiency 2023

Southside Community Health Services, INC

MN

Allowable Costs / Cost Principles § 200.400

Finding 2023-003 Condition: The organization did not properly maintain documentation to support the pay rate authorization. Corrective Action Plan: Management will conduct internal audits to randomly select pay statements and verify there are pay rate authorization documents to support the pay r...

Finding 2023-003 Condition: The organization did not properly maintain documentation to support the pay rate authorization. Corrective Action Plan: Management will conduct internal audits to randomly select pay statements and verify there are pay rate authorization documents to support the pay rate in the pay statements. Person responsible: Finance Director and Human Resources Manager Completion date: Starting 4th quarter of 2024 and through 2025 until management is satisfied the problem is resolved.

View Audit 330957

Finding 513007 (2023-001)

Significant Deficiency 2023

City of Lebanon

NH

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

Audit Finding Reference: 2023-001 Management’s Response and Planned Corrective Action: The City will review and update its existing policies to ensure they include the necessary language and provisions required by 2 CFR 200. This effort aims to align the City's policies with federal re...

Audit Finding Reference: 2023-001 Management’s Response and Planned Corrective Action: The City will review and update its existing policies to ensure they include the necessary language and provisions required by 2 CFR 200. This effort aims to align the City's policies with federal regulations, ensuring compliance with grant management standards, cost principles, and audit requirements outlined in the Uniform Guidance. Name of Contact Person and Completion Date: Name 1: Shaun Mulholland, City Manager Name 2: Vicki Lee, Finance Director Anticipated Completion Date – 1/31/2025

View Audit 330904

Finding 512958 (2023-001)

Material Weakness 2023

Housing Authority of Randolph County

WV

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

2023-001 – ALN 14.871 – Housing Voucher Cluster – Activities Allowed and Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Ex...

2023-001 – ALN 14.871 – Housing Voucher Cluster – Activities Allowed and Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024 2023-002 – Significant Deficiency in Internal Controls over Financial Reporting Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024

View Audit 330764 Questioned Costs: $1

Finding 512683 (2023-001)

Material Weakness 2023

Evergreen Recovery Centers

WA

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

Corrective Action Plan for the Material Weakness identified as part of the Single Audit Reports For the Year Ended December 31, 2023 Finding Number 2023-001 Contact Person(s): Patrick Evans, CEO Material Weakness: The Organization received and utilized the federal award to pay for general contractor...

Corrective Action Plan for the Material Weakness identified as part of the Single Audit Reports For the Year Ended December 31, 2023 Finding Number 2023-001 Contact Person(s): Patrick Evans, CEO Material Weakness: The Organization received and utilized the federal award to pay for general contractor services for a construction project that was ongoing at the time of the award. The Organization had entered the procurement of general contractor service prior to receiving the federal award and in accordance with its existing procurement policy,which included a competitive procurement process with a price analysis. However, there was not a procurement policy in place that specifically covered the criteria required under the Uniform Guidance. As a result, the Organization did not have a procurement policy and process in place that resulted in compliance with the Uniform Guidance including the maintenance of records to detail the history of the procurement in accordance with 2 CFR 200.318(i). Corrective action planned: ERC will update the existing procurement policy to be in accordance with the Uniform Guidance. Once the policy is completed, procedures will be developed to ensure compliance with the policy and training provided for personnel responsible for federal procurements. Anticipated completion date: 3/31/2025

View Audit 330479

Finding 512676 (2023-004)

Material Weakness 2023

City of Wausau

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal...

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal control or procedure manuals include all of the required compliance requirements. We also recommend that the City ensure multiple individuals are trained on the administration of the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz Planned completion date for corrective action plan: 10/14/2024

View Audit 330477

Finding 512674 (2023-002)

Significant Deficiency 2023

City of Wausau

WI

Allowable Costs / Cost Principles Reporting Significant Deficiency

Reporting and Environmental Reviews – CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the repo...

Reporting and Environmental Reviews – CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the reporting process. We also recommend the City document these procedures and internal controls as required by Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Community Development Manager and/or Community Development Specialist will prepare all Draw Requests and complete CDBG reports, including, but not limited to, the Annual Action Plan, CAPER, 5-Year Consolidated Plan, Labor Standards Report, and Minority/Women-Owned Business Reports. All Draw Requests will be reviewed by the Finance Director or Assistant Director, while other reports will be reviewed by the Development Director prior to submission to ensure accuracy and compliance. This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz, Randy Fifrick Planned completion date for corrective action plan: 9/30/2024

View Audit 330477

Finding 512560 (2023-004)

Significant Deficiency 2023

Benton County School District

MS

Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Accounts payable testing and internal controls A. Name of contact person responsible for corrective action: Name: Dr. Regina Biggers Title: Superintendent B. Corrective action planned: The District will implement policies and procedures to establish an internal control system that will req...

Accounts payable testing and internal controls A. Name of contact person responsible for corrective action: Name: Dr. Regina Biggers Title: Superintendent B. Corrective action planned: The District will implement policies and procedures to establish an internal control system that will require accountability with regard to accounts payable and purchasing. That will also ensure proper safeguarding of assets and accurate accounting records. C. Anticipated completion date: Immediately

View Audit 330390

Finding 512511 (2023-007)

Material Weakness 2023

County of Delta

MI

Allowable Costs / Cost Principles Cash Management Procurement, Suspension & Debarment § 200.303

Material Weakness and Noncompliance – Written Policies Required by the Uniform Guidance Statement of Condition/Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards. 2 CFR 200.303(a) establishe...

Material Weakness and Noncompliance – Written Policies Required by the Uniform Guidance Statement of Condition/Criteria: Delta County does not have written policies and procedures to implement the requirements of 2 CFR section 200 for the administration of federal awards. 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal controls over the federal awards that Provide assurance that the entity is managing the federal awards in compliance with federal statutes, regulations, and the conditions of the federal award. Planned Corrective Action: County management will develop written policies and procedures for grants. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

View Audit 330302

Finding 512510 (2023-006)

Material Weakness 2023

County of Delta

MI

Reporting Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

Material Weakness and Noncompliance – Preparation of Schedule of Expenditures of Federal Awards (SEFA) Statement of Condition/Criteria: The Code of Federal Regulations requires a nonfederal entity to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s ...

Material Weakness and Noncompliance – Preparation of Schedule of Expenditures of Federal Awards (SEFA) Statement of Condition/Criteria: The Code of Federal Regulations requires a nonfederal entity to prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with CFR Section 200.502(a) and must reconcile amounts reported in the SEFA to the amounts reported in the auditee’s financial statements. Planned Corrective Action: County management will develop a closing process to ensure all federal expenditures are identified, recorded, and reconciled on the SEFA. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

View Audit 330302

Finding 512473 (2023-003)

Significant Deficiency 2023

Women's Coalition of St. Croix

VI

Allowable Costs / Cost Principles Reporting

2023-003: Reporting Response: Transitions in Women’s Coalition of St. Croix (WCSC) financial personnel during and after year-end resulted delays to the audit process for the audit period ending September 30, 2023. To address this problem, WCSC hired a fiscal consultan...

2023-003: Reporting Response: Transitions in Women’s Coalition of St. Croix (WCSC) financial personnel during and after year-end resulted delays to the audit process for the audit period ending September 30, 2023. To address this problem, WCSC hired a fiscal consultant in August 2022 to oversee the fiscal office, prepare and complete all grant reports, and to coordinate all fiscal audits. WCSC also hired a full-time bookkeeper in October 2022 to conduct day-to-day financial transactions and to assist with audit and grant reporting. WCSC has already engaged its Auditors to conduct the FY2024 audit, which will be completed by April 30th, 2025 Estimated Completion Date: April 30th, 2025. Contact: Carolyn Forno, Fiscal Officer

View Audit 330248

Finding 512466 (2023-003)

Significant Deficiency 2023

Treepeople, Inc.

CA

Questioned Costs Period of Performance Internal Control / Segregation of Duties

In 2023, TreePeople engaged an independent consulting firm to reconcile all accounts and perform month-end and year-end close activities. Also in 2023, TreePeople implemented new policies and procedures to support timely reporting – including new month-end and year-end close procedures. In 2024, ...

In 2023, TreePeople engaged an independent consulting firm to reconcile all accounts and perform month-end and year-end close activities. Also in 2023, TreePeople implemented new policies and procedures to support timely reporting – including new month-end and year-end close procedures. In 2024, TreePeople hired a new CFO and a new controller, bringing extensive non-profit finance and government grant management experience to the organization. The new CFO promptly implemented additional controls addressing month-end close activities and additional reviews and approvals of journal entries by the CFO and controller. The Accounts Receivable team, which previously reported to the programs team, will be reporting to the CFO starting December 1, 2024, to ensure timeliness and accuracy in charging of expenses, billing and revenue recognition for TreePeople’s government grants. Moving the Accounts Receivable team under the CFO's supervision will consolidate oversight and help strengthen our internal control process and assist in streamlining accounting and financial operations. To ensure expenses are coded to the proper federal program and spent within the allowable period of performance, the organization will leverage new accounting software to strengthen reconciliations and proper recording of revenue and expenses to the proper federal program in the proper period. All training and new processes will be updated and implemented by March 31, 2025.

View Audit 330228 Questioned Costs: $1

Finding 512386 (2023-008)

Material Weakness 2023

Custer County

MT

Questioned Costs Allowable Costs / Cost Principles Cash Management

NONCOMPLIANCE WITH ALLOWABLE COSTS/COST PRINCIPLES; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No’s 113004 AND 112605, YEAR ENDED JUNE 30, 2023 Name of contact person: County Commissioners Corrective Action: The Board of Commissioners along with the Department ...

NONCOMPLIANCE WITH ALLOWABLE COSTS/COST PRINCIPLES; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No’s 113004 AND 112605, YEAR ENDED JUNE 30, 2023 Name of contact person: County Commissioners Corrective Action: The Board of Commissioners along with the Department Head will work with the Budget Manager to adjust the structure of the budget to separate expenditures by cost category. Furthermore a procedure will be developed to review the grant reimbursement report prior to submittal. Proposed Completion Date: Immediately

View Audit 330130 Questioned Costs: $1

Finding 512254 (2023-001)

Material Weakness 2023

Center on Halsted

IL

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

Corrective Actions Taken or Planned: ▪ Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in all financial processes including grant reconciliatio...

Corrective Actions Taken or Planned: ▪ Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in all financial processes including grant reconciliation. This updated contractual agreement & relationship occurred on March 1, 2024. ▪ Taken: Documentation has already begun to be gathered for allowable expenses and approval of certain expenses per grant, via written email documentation. This is currently being operationalized and will be fully implemented by our Senior Accountant Jeong Shin and our Senior Director of Finance Reginald Walker. Anticipated completion date: August 15th, 2024. ▪ Planned: Ensure adequate documentation for approval and alignment of expenses to specific grants. This is currently being operationalized and will be fully implemented by our Senior Accountant Jeong Shin and our Senior Director of Finance Reginald Walker. Anticipated completion date: August 15th, 2024. ▪ Planned: Verification of allowable expenses with grant management and finance leadership with monthly check-ins with program directors. This will be facilitated by our Director of Grants Brenna Quinn, our Senior Accountant Jeong Shin, and led by our Senior Director of Finance Reginald Walker. Anticipated completion date: September 1st, 2024. ▪ Planned: New Senior Director of Finance Reginald Walker has been hired and a priority of their job function is to create stronger internal controls with sufficient checks and balances. Anticipated completion date: September 1st, 2024.

View Audit 330028 Questioned Costs: $1

Finding 512237 (2023-002)

Significant Deficiency 2023

Metropolitan School District of Warren County

IN

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding 2023-002 – Child Nutrition Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Matthew Parkinson, CFO Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corre...

Finding 2023-002 – Child Nutrition Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Matthew Parkinson, CFO Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Business Office and Payroll staff will review a Labor Distribution Report to verify that the staff is only paying appropriate personnel from the Food Service Fund. Anticipated Completion Date: 6/30/24

View Audit 330027 Questioned Costs: $1

Finding 512236 (2023-004)

Significant Deficiency 2023

City of Clarksville

TX

Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs

City of Clarksville, TX accounting department and Mayor will develop a process in which the audit will be completed in a timely manner to submit it to the FAC by hiring an auditor earlier in the year and submitting it to the Clearing house within 30 days of the audit report or nine months after the ...

City of Clarksville, TX accounting department and Mayor will develop a process in which the audit will be completed in a timely manner to submit it to the FAC by hiring an auditor earlier in the year and submitting it to the Clearing house within 30 days of the audit report or nine months after the Organization’s year end

View Audit 330016

Finding 512166 (2023-005)

None 2023

Detroit Health Care for the Homeless Dba Advantage Health Centers

MI

Allowable Costs / Cost Principles Reporting Special Tests & Provisions

Due to administrative issues, the Organization was unable to submit the reporrs in a timely manner. We will ensure that all the reports are timely submitted as per the grant requirements.

View Audit 329922

Corrective Action Plans

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