Corrective Action Plans

Finding 499876 (2024-001)

Significant Deficiency 2024

IA

HUD Housing Programs Allowable Costs / Cost Principles Reporting

Finding 2024-001 – Tenant Files Condition: Kanesville’s tenant move out files omitted required elements in accordance with the HUD handbook and PRAC contract. This finding occurred when M3 was managing the property. Kanesville hired a new management agent that is familiar with HUD standards. Correct...

Finding 2024-001 – Tenant Files Condition: Kanesville’s tenant move out files omitted required elements in accordance with the HUD handbook and PRAC contract. This finding occurred when M3 was managing the property. Kanesville hired a new management agent that is familiar with HUD standards. Corrective Action Plan: Management agent is currently documenting tenant move out files in compliance with the HUD handbook and PRAC contract. Status: Completed.

View Audit 322740

Finding 499458 (2024-007)

Material Weakness 2024

Outpatient Medical Center, Inc.

LA

Questioned Costs Allowable Costs / Cost Principles Material Weakness

2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. ...

2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. Internal auditing has already been implemented to ensure compliance with reporting requirements. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Richard Bruce, Chief Operating Officer

View Audit 322303

Finding 499450 (2024-005)

Material Weakness 2024

Outpatient Medical Center, Inc.

LA

Allowable Costs / Cost Principles Questioned Costs § 200.403

2024-005 Period of Performance Corrective action planned: The Fiscal Supervisor and/or the Director of Fiscal Operations will review expenditures before payment to ensure that GAAP and the accrual basis of accounting are being followed. Month-end closing procedures will include a review of all pre...

2024-005 Period of Performance Corrective action planned: The Fiscal Supervisor and/or the Director of Fiscal Operations will review expenditures before payment to ensure that GAAP and the accrual basis of accounting are being followed. Month-end closing procedures will include a review of all prepaid expenses to assure that a separate schedule is maintained and reconciled to the general ledger. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Cathy Liles, Director of Fiscal Operations

View Audit 322303 Questioned Costs: $1

Finding 499446 (2024-004)

Material Weakness 2024

Outpatient Medical Center, Inc.

LA

Allowable Costs / Cost Principles Questioned Costs

2024-004 Allowable Costs/Cost Principles Corrective action planned: The Fiscal Supervisor and/or the Director of Fiscal Operations will review expenditures before payment and will ensure that goods and/or services have been received before expenditure is posted into the accounting records. OMC c...

2024-004 Allowable Costs/Cost Principles Corrective action planned: The Fiscal Supervisor and/or the Director of Fiscal Operations will review expenditures before payment and will ensure that goods and/or services have been received before expenditure is posted into the accounting records. OMC clerical and other staff will be trained on expenditure coding, based on the current year’s budget. Financial reports for each grant cost center will be reviewed each month and reconciled to the cash disbursements shown in the Payment Management System. Anticipated completion date: 11-30-24 Contact person responsible for corrective action: Cathy Liles, Director of Fiscal Operations

View Audit 322303 Questioned Costs: $1

Finding 499442 (2024-001)

Significant Deficiency 2024

Shenandoah Haven, Inc.

TN

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Findings Reference Number: 2024-001 Federal Agency: Department of Housing and Urban Development Federal Program:Supportive Housing for Persons with Disabilities CFDA Number: 14.181 Management's response: Management concurs with the finding. Corrective Action Plan: Management will re -evaluate contro...

Findings Reference Number: 2024-001 Federal Agency: Department of Housing and Urban Development Federal Program:Supportive Housing for Persons with Disabilities CFDA Number: 14.181 Management's response: Management concurs with the finding. Corrective Action Plan: Management will re -evaluate controls around cost identification and authorization in efforts to minimize potential error going forward. Implementation Date: Immediately.

View Audit 322299

Finding 499412 (2024-001)

Significant Deficiency 2024

Stoddard CO Public Water District #4

MO

Internal Control / Segregation of Duties Questioned Costs Procurement, Suspension & Debarment

1. Finding 2024-001 a. We concur with the finding and recommendation. b. Management realizes the duties are reevaluated regularly and with the size of the District it is not feasible to add additional employees. They believe that they have adequate safeguards against material misstatements; however...

1. Finding 2024-001 a. We concur with the finding and recommendation. b. Management realizes the duties are reevaluated regularly and with the size of the District it is not feasible to add additional employees. They believe that they have adequate safeguards against material misstatements; however, they will continue to strive to improve this deficiency. c. The Board of Directors is responsible for evaluating safeguards against material misstatements to the financial statements. d. This is an ongoing process, therefore, there is no anticipated completion date.

View Audit 322270

Finding 498228 (2024-001)

Material Weakness 2024

Denmark Technical College

SC

Student Financial Aid Allowable Costs / Cost Principles

Return of Title IV Funds Corrective Action Plan: The College Financial Aid Office and Business Office will implement new internal controls and procedures to ensure all student Title IV calculations are calculated correctly, reviewed in a timely manner, and ensure funds are returned promptly. Dea...

Return of Title IV Funds Corrective Action Plan: The College Financial Aid Office and Business Office will implement new internal controls and procedures to ensure all student Title IV calculations are calculated correctly, reviewed in a timely manner, and ensure funds are returned promptly. Deadlines have been created to submit student withdrawals timely to the Financial Aid Department. A monthly reconciliation between the Registrar and Financial Aid Office will ensure withdrawals and correct withdrawal dates are reported to the Financial Aid Office in a timely manner. The Business Office will review the Financial Aid Office's calculation of funds for accuracy to ensure the correct amount is returned to the Department of Education. Anticipated Completion Date: Fiscal year 2025. Name of Contact Person Responsible for the Corrective Action Plan: Rashad Rogers

View Audit 320975

Finding 497638 (2024-004)

Material Weakness 2024

Foothills Community Health Care, Inc.

SC

Questioned Costs Allowable Costs / Cost Principles

In Finding 2024-004, it was reported that time and activity report are not maintained for salaried employees. The Organization’s operating processes in place do not require salaried employees to certify time and efforts on a monthly basis. Procedures will be established to maintain time and effort ...

In Finding 2024-004, it was reported that time and activity report are not maintained for salaried employees. The Organization’s operating processes in place do not require salaried employees to certify time and efforts on a monthly basis. Procedures will be established to maintain time and effort certifications by all salaried employees. Procedures will be established to ensure that salaried employees certify time and effort that coincide with the Organization’s payroll cycle (at least on a monthly basis).

View Audit 320434

Finding 497401 (2024-001)

Material Weakness 2024

Charter Township of Clinton

MI

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding Number: 2024-001 Condition: We noted no formal evidence that required inspections were performed prior to contract approval in one instance. We also noted no formal evidence that inspections were performed upon project completion to ensure that work was carried out in accordance with contrac...

Finding Number: 2024-001 Condition: We noted no formal evidence that required inspections were performed prior to contract approval in one instance. We also noted no formal evidence that inspections were performed upon project completion to ensure that work was carried out in accordance with contract specifications in one instance. Planned Corrective Action: After the inspector has done the initial walk through to identify required repairs, a full comprehensive write-up and cost is established for all rehabilitation projects that document additional repairs to be completed that are more preventative in nature. Any additional items discovered during the project or requested by the homeowner will be added to the write-up. For any emergency repairs, a memorandum will be added to the file. To ensure that pre_x0002_rehabilitation and post-rehabilitation inspections are taking place, the Assistant Planning Director will review a list of ongoing rehabilitation projects at a minimum on a monthly basis. Contact person responsible for corrective action: Edwin Manninen Anticipated Completion Date: Immediately

View Audit 320150

Finding 496411 (2024-001)

Material Weakness 2024

Full Harvest Housing, Inc.

IA

Allowable Costs / Cost Principles Questioned Costs Special Tests & Provisions

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended March 31, 2024. Finding 2024-001 Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements A/B - Activities Allowed or Unallowed and Allowable Costs/Cost Principles, C – Cash Management, E – Eligibility, L – Reporting, and N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management reported that the failure(s) involved records related to the period managed by the predecessor management company. We will request and keep all required documentation from HUD and establish processes and procedures to ensure compliance with the Regulatory Agreement. Anticipated Completion Date September 30, 2024

View Audit 319319

Finding 485611 (2024-002)

Significant Deficiency 2024

Fulton County Community Unit School District No. 3

IL

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.

View Audit 318383

Finding 485334 (2024-002)

Material Weakness 2024

Fetter Health Care Network, Inc.

SC

Questioned Costs Allowable Costs / Cost Principles

In Finding 2024-002, it was reported that time and activity reports were not maintained for salaried employees. Although the Organization’s policies require that time records be maintained by salaried employees, current operating procedures are not in place to ensure the time records are completed. ...

In Finding 2024-002, it was reported that time and activity reports were not maintained for salaried employees. Although the Organization’s policies require that time records be maintained by salaried employees, current operating procedures are not in place to ensure the time records are completed. Procedures will be established to require all salaried employees to maintain time and effort certifications that coincide with the Organization’s payroll cycle (at least on a monthly basis) in accordance with the Organization’s policies.

View Audit 318078

Finding 485274 (2024-005)

None 2024

Village of Kingsley

MI

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...

This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village Manager. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.

View Audit 318038

Finding 485250 (2024-007)

None 2024

Village of Baldwin

MI

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

This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...

This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.

View Audit 318008

Finding 485144 (2024-001)

Significant Deficiency 2024

East Central Kansas Economic Opportunity Corporation

KS

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...

August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation

View Audit 317959

Finding 1229969 (2023-003)

Material Weakness 2023

Northwoods Stewardship Center

VT

Allowable Costs / Cost Principles § 200.430

View of responsible officials and planned corrective action: NorthWoods management will train Program Directors to add a USFW code to their current time sheet tracking for all USFWS activities in September 2025. This will be reviewed regularly in current time sheet review procedures for accuracy. Se...

View of responsible officials and planned corrective action: NorthWoods management will train Program Directors to add a USFW code to their current time sheet tracking for all USFWS activities in September 2025. This will be reviewed regularly in current time sheet review procedures for accuracy. Semi-annually, program director match contributions will be reconciled from time sheet reports with the general ledger for USFW agreements by the Business Manager, and reviewed by the Program Directors. Northwoods management will obtain a review of matching contributions documentation procedures from a qualified non-profit accountant.

View Audit 411190

Finding 1229677 (2023-013)

Material Weakness 2023

Municipality of Anchorage, Alaska

AK

Allowable Costs / Cost Principles § 200.303

Allowable Costs – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing enhanced grant compliance review procedures to ensure expenditures are allowable, adequately supported, and incurred within the applicable pe...

Allowable Costs – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing enhanced grant compliance review procedures to ensure expenditures are allowable, adequately supported, and incurred within the applicable period of performance. Standardized documentation, supervisory review, and monitoring procedures will be incorporated into routine grant administration. Management will evaluate the effectiveness of these controls through completion of a full audit cycle. Anticipated Completion Date June 30, 2027

View Audit 410871

Finding 1229423 (2023-002)

Material Weakness 2023

Neighborhoods, Inc. of Battle Creek

MI

Allowable Costs / Cost Principles Material Weakness Reporting

Finding 2023-002: Internal Control Over Financial Reporting – Internal Control Evidence Management’s Response Now that disbursements are 100% in-house, the President & CEO provides final written approval on all timecards and payables. Chairman of the Loan & Finance Committee remotely reviews journal...

Finding 2023-002: Internal Control Over Financial Reporting – Internal Control Evidence Management’s Response Now that disbursements are 100% in-house, the President & CEO provides final written approval on all timecards and payables. Chairman of the Loan & Finance Committee remotely reviews journal entries in accounting software monthly. Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024

View Audit 410819

Finding 1229212 (2023-003)

Material Weakness 2023

City of Jacksonville Arkansas

AR

Allowable Costs / Cost Principles § 200.430

Finding #2023-003 – Statement of Condition: During our testing of payroll costs charged to ALN 97.036, we identified one instance in which employee's payroll cost was calculated using an incorrect pay rate. As a result, the payroll expenditure charged to the federal program was overstated. Response:...

Finding #2023-003 – Statement of Condition: During our testing of payroll costs charged to ALN 97.036, we identified one instance in which employee's payroll cost was calculated using an incorrect pay rate. As a result, the payroll expenditure charged to the federal program was overstated. Response: Management concurs with the finding and will enhance its payroll review procedures to verify that payroll costs charged to federal awards are calculated using the correct authorized pay rates. The matter was corrected by December 31, 2024

View Audit 410701

Finding 1229118 (2023-004)

Material Weakness 2023

YWCA Dayton

OH

Allowable Costs / Cost Principles Special Tests & Provisions

The organization is in the process of updating its policies to outline the required documentation on the rent reasonableness forms and the documentation retention requirements for the rent reasonableness forms.

View Audit 410608

Finding 1229114 (2023-002)

Material Weakness 2023

YWCA Dayton

OH

Allowable Costs / Cost Principles Eligibility

The organization is in the process of updating its policies to outline the required documentation on the intake forms and the documentation retention requirements for the intake forms.

View Audit 410608

Finding 1228735 (2023-005)

Material Weakness 2023

Activate Work Inc.

CO

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.308

Action Taken in Response to Finding: Budget-to-actual comparisons began in 2024 and were subsequently standardized and incorporated into Financial Policies and Procedures. As of 2026, budget-to-actual comparisons are performed on a monthly basis as part of the month-end (EOM) close, prior to the pre...

Action Taken in Response to Finding: Budget-to-actual comparisons began in 2024 and were subsequently standardized and incorporated into Financial Policies and Procedures. As of 2026, budget-to-actual comparisons are performed on a monthly basis as part of the month-end (EOM) close, prior to the preparation and submission of Federal reimbursement requests. This ensures that: • Expenditures are reviewed against approved grant budgets prior to reimbursement • Variances are identified and evaluated • Costs charged to Federal awards align with approved budgets and allowable use requirements Additionally, Budget and Program Revisions and Allowable Use of Funds policies were incorporated into the Financial Policies and Procedures to formalize requirements for budget compliance and modification. Control Enhancement: A standardized budget-to-actual review has been implemented across all applicable Federal awards. This process: • Compares actual expenditures to approved grant budgets on a monthly basis • Identifies variances requiring review or correction • Ensures expenditures are aligned with budget categories and allowable cost requirements • Requires budget review prior to submission of reimbursement requests Monitoring & Review: • Budget-to-actual comparisons are performed monthly as part of EOM close • Initial review is completed by Finance • Secondary review is performed by the Director of Finance & Operations • Program staff are engaged as needed to validate alignment with program activities • Any required budget modifications are identified and addressed prior to reimbursement Testing & Validation: • Beginning in June 2026, quarterly internal reviews will be conducted to validate that budget monitoring controls are operating effectively • Testing will confirm that: o Budget-to-actual reviews are completed consistently o Variances are appropriately identified and addressed o Reimbursements align with approved budgets Documentation & Evidence: • Budget-to-actual reports maintained in Teams / Sharepoint • Supporting documentation for budget revisions retained • Approval and review evidenced via email/workflow/sign-off Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Director of Finance & Operations, with executive oversight by the Chief Executive Officer Anticipated Completion Date: All corrective actions will be implemented by June 30, 2026. Ongoing monthly monitoring and quarterly validation will continue. Status: • Budget-to-actual comparisons (limited): Implemented 2024 • Standardized monthly workflow (EOM close): Implemented April 2026 • Policy integration into Financial Policies and Procedures: Completed May 2026 • Quarterly internal reviews will be conducted to validate that budget monitoring controls are operating effectively: June 2026

View Audit 410398

Finding 1228734 (2023-004)

Material Weakness 2023

Activate Work Inc.

CO

Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.307 § 200.403

Action Taken in Response to Finding: Financial practices addressing program income were in place; however, processes were formalized to ensure full compliance with 2 CFR §200.307. ActivateWork developed and implemented a Program Income Policy as part of its Financial Policies and Procedures, adopted...

Action Taken in Response to Finding: Financial practices addressing program income were in place; however, processes were formalized to ensure full compliance with 2 CFR §200.307. ActivateWork developed and implemented a Program Income Policy as part of its Financial Policies and Procedures, adopted May 2026. As of March 2026, a standardized program income tracking and reconciliation is performed monthly as part of the month-end (EOM) close. This process includes: • Identification and tracking of program income by funding source • Application of program income to actual allowable expenses • Mapping of Federal reimbursement requests to underlying expenses to ensure program income is applied prior to reimbursement • Validation that no duplication of funding occurs between program income and Federal reimbursements These enhancements establish a structured and auditable framework for program income tracking, application, and compliance. Control Enhancement: Program income is tracked and recorded within a standardized Excel-based tool (Program Income vs. Unreimbursed Cost Analysis) and applied in accordance with federal requirements. A standardized program income tracker: • Applies program income to actual expenses • Links expenses to reimbursement requests • Ensures program income is fully utilized prior to requesting Federal reimbursement, unless otherwise specified by award terms • Prevents duplication of income and reimbursement Monitoring & Review: • Program income tracking is reviewed monthly as part of the EOM close process • Review is performed by the Senior Accountant • A secondary review is performed by the Director of Finance & Operations to validate completeness and compliance • Any discrepancies are identified and resolved prior to reimbursement submission Testing & Validation: • Beginning in June 2026, quarterly internal reviews will be conducted to validate program income tracking and application • Testing will confirm that: o Program income is accurately recorded o Program income is applied prior to reimbursement o No duplication of funding exists • Results will be documented and tracked for remediation Documentation & Evidence: • Program income tracker maintained in Teams / SharePoint • Supporting documentation tied to underlying expenses Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Helen Young Hayes, Founder / Chief Executive Officer, in coordination with the Director of Finance & Operations and Finance Staff Anticipated Completion Date: All corrective actions will be implemented by June 30, 2026. Ongoing monthly monitoring, reconciliation, and quarterly validation will continue. Status: • Program Income Policy: Implemented May 2026 • Program income tracking process: Implemented April 2026 • Monthly reconciliation and application (EOM Close): Implemented May 2026 • Quarterly internal reviews will be conducted to validate program income tracking and application: June 2026.

View Audit 410398

Finding 1228719 (2023-001)

Material Weakness 2023

Activate Work Inc.

CO

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Material Weakness § 200.302 § 200.403

Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on ac...

Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on actual costs incurred, supported by documentation such as timesheets and receipts. As of October 2025, CDHS no longer required supporting documentation at the time of submission; however, supporting documentation continues to be maintained and is provided upon request for monitoring or audit purposes. Standardized Excel-based tools provided by CDHS are utilized for reimbursement submission (Invoice and Ledger). Transaction-level cost tracking was implemented to ensure allowable and eligible costs are recorded and supported. Financial and grant-related policies were standardized and incorporated into Financial Policies and Procedures in May 2024, with a comprehensive grant management framework implemented in May 2026. Control Enhancement: Beginning in 2025, all grant-related expenditures are recorded and tracked at the transaction level within the accounting system. Each transaction must include appropriate supporting documentation and be coded to the correct funding source. A standardized payroll-to-invoice reconciliation process has been implemented to ensure that all costs charged to federal awards are allowable, allocable, and properly supported. Monitoring & Review: • Costs are reviewed by the Senior Accountant prior to inclusion in reimbursement requests • A secondary monthly review is performed by the Director of Finance & Operations to validate allowability, completeness, and alignment with funding requirements • Exceptions are documented and resolved prior to submission Testing & Validation: • Beginning in June 2026, quarterly internal reviews will be conducted to test a sample of transactions for compliance with documentation and allowability requirements • Results will be documented and tracked, and any identified deficiencies will require corrective action Documentation & Evidence: • Supporting documentation is maintained in Microsoft Teams / SharePoint • Review and approval are evidenced via email approval and retained as part of the audit record Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Helen Young Hayes, Founder / Chief Executive Officer, in coordination with the Finance Staff Anticipated Completion Date: All corrective actions will be implemented as of June 30, 2026. Ongoing monitoring, quarterly testing, and policy updates will continue.

View Audit 410398

Finding 1228547 (2023-005)

Material Weakness 2023

Mental Health Kokua

HI

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512

Management agrees with the finding. The Organization will implement procedures to monitor reporting deadlines and assign responsibility for the timely submission of the single audit reporting package and Data Collection Form to the Federal Audit Clearinghouse. Management will also establish a review...

Management agrees with the finding. The Organization will implement procedures to monitor reporting deadlines and assign responsibility for the timely submission of the single audit reporting package and Data Collection Form to the Federal Audit Clearinghouse. Management will also establish a review process to ensure all future filings are completed within the required timeframe. Anticipated Completion Date: September 30, 2026.

View Audit 410168

Corrective Action Plans

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