Corrective Action Plans

Finding 1225676 (2022-007)

Material Weakness 2022

WA

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

Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to...

Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent NOTE: In addition, Quileute Tribal School has engaged an independent CPA firm to assist with account reconciliations and audit readiness to help ensure that financial information is complete, accurate, and properly reported. Implementation Date: July 30, 2026

View Audit 408537

Finding 1225675 (2022-006)

Material Weakness 2022

Quileute Tribal School

WA

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

Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requireme...

Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requirement and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent Implementation Date: July 30, 2026

View Audit 408537

Finding 1224463 (2022-004)

Material Weakness 2022

Monticello Housing Authority

NY

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

2022-004 – Deficiencies Noted in Documentation of Controls - Housing Choice Voucher Participant Files - Significant Deficiency Auditor Recommendations: The Authority should establish a checklist for the Housing Choice Voucher Coordinator to use during the recertification process to document the proc...

2022-004 – Deficiencies Noted in Documentation of Controls - Housing Choice Voucher Participant Files - Significant Deficiency Auditor Recommendations: The Authority should establish a checklist for the Housing Choice Voucher Coordinator to use during the recertification process to document the procedures performed to ensure all compliance requirements are met. We recommend a complete review of all Housing Choice Voucher Program tenant file regulations to ensure compliance with these policies. Response: The Executive Director will actively oversee all financial aspects of the agency. Additionally, the director will ensure that finances are current and accurate monthly. A complete review of all Housing Choice Voucher Program tenant file regulations will be performed to ensure compliance with these policies. Timeframe: By completion of the 2027 FYE audit Individual responsible for correction: Mr. Marc Starling, Executive Director

View Audit 407735

Finding 1224365 (2022-003)

Material Weakness 2022

Russellville Hospital, Inc.

AL

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.512

The hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 09/30/2026

View Audit 407672

Finding 1224134 (2022-004)

Material Weakness 2022

STRESS & TRAUMA TREATMENT CENTER INC

IL

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

Condition: During our testwork, we noted three employees were missing time and effort certifications. Plan: The Organization is implementing written policies and procedures over time and effort reporting to ensure proper documentation is always maintained or complete in all instances to properly dis...

Condition: During our testwork, we noted three employees were missing time and effort certifications. Plan: The Organization is implementing written policies and procedures over time and effort reporting to ensure proper documentation is always maintained or complete in all instances to properly distribute salary and benefit costs for employees who work in whole or in part on grant program activity in accordance with the Uniform Guidance. This includes having the documentation reviewed and formally approved by a supervisor. Anticipated Date of Completion: December 31, 2026 Name of Contact Person: Matt Buckman, Executive Director

View Audit 407517

Finding 1223029 (2022-002)

Material Weakness 2022

DELRIDGE NEIGHBORHOODS DEVELOPMENT ASSOCIATION

WA

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

Finding 2022-002 Significant Deficiency in Internal Controls Over Compliance – HOME Investment Partnerships Program Finding: The audit identified a tenant file in which a HOME-assisted unit was not properly identified on the Household Eligibility Certification form, resulting in rental charges that ...

Finding 2022-002 Significant Deficiency in Internal Controls Over Compliance – HOME Investment Partnerships Program Finding: The audit identified a tenant file in which a HOME-assisted unit was not properly identified on the Household Eligibility Certification form, resulting in rental charges that exceeded allowable limits under HOME program requirements. Corrective Action Plan: DNDA agrees with the finding and has implemented procedures to strengthen compliance monitoring and tenant file review processes. To address this finding, management has taken the following actions: o Corrected the identified tenant file and reviewed the circumstances that led to the error. o Implemented additional review procedures for Household Eligibility Certification forms to verify unit designation, household income calculations, and applicable rent restrictions. o Established a secondary review process for HOME-assisted units to ensure compliance requirements are accurately reflected in tenant records. o Provided additional training and guidance to staff responsible for tenant certifications and compliance monitoring. o Incorporated periodic compliance reviews into ongoing property management oversight activities. Responsible Party: Shannon Woodard – Interim Executive Director, Danielle Clark-Burfening – Housing Director, Misty Wilson – Area Supervisor (3rd Party Property Management – United Marketing, Inc.), Bonita Salyers – Regional Portfolio Assistant (3rd Party Property Management – United Marketing, Inc.) Implementation Date: Corrective actions began upon identification of the finding. Expected Completion Date: Implemented December 18, 2025, Quarterly Verification of Compliance by Danielle Clark-Burfening Monitoring: Management will conduct periodic reviews of HOME-assisted tenant files and certification documents to verify continued compliance with HUD and HOME program requirements.

View Audit 406594

Finding 1222697 (2022-005)

Material Weakness 2022

Veterans Transition Center of California

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.307

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA5, management agrees with the finding. Corrective actions will be ...

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA5, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years, including the establishment of policies and procedures to ensure that program income is tracked by contract and expended in accordance with applicable federal requirements.

View Audit 406305

Finding 1222695 (2022-003)

Material Weakness 2022

Veterans Transition Center of California

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.403 § 200.405 § 200.430

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA3, management agrees with the finding. Corrective actions will be ...

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA3, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. Unallowable costs will be identified and documented in the Accounting Policies and Procedures Manual and communicated to the Finance Department and the Organization’s employees. The CFO will regularly communicate these requirements to directors and staff through weekly and monthly meetings to ensure a clear understanding of allowable versus unallowable costs. In addition, quarterly budget-to-actual analyses will be prepared and reviewed to monitor expenditure and ensure costs remain within approved budget limitations.

View Audit 406305

Finding 1222694 (2022-002)

Material Weakness 2022

Veterans Transition Center of California

CA

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

Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fisca...

Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. CFDA numbers for new federal awards will be identified, along with the applicable compliance requirements in accordance with the OMB Compliance Supplement (Matrix of Federal Compliance Requirements). Policies and procedures will be established for each applicable compliance requirement and will be communicated to employees responsible for monitoring and ensuring compliance.

View Audit 406305

Finding 1216731 (2022-001)

Material Weakness 2022

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 403176

Finding 1216177 (2022-004)

Material Weakness 2022

Mental Health Kokua

HI

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

Mental Health Kokua will ensure compliance with the FAC requirement of submitting the Single Audit Package and data collection report no later than 30 days after receipt of the audit. The CFO of Mental Health Kokua will be responsible for ensuring this compliance is met.

View Audit 402656

Finding 1214956 (2022-004)

Material Weakness 2022

HOUSING AUTHORITY OF THE CITY OF LITTLE ROCK, ARKANSAS

CA

Allowable Costs / Cost Principles HUD Housing Programs Questioned Costs

Finding 2022-004 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 2022-004 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, Public and Indian Housing Program and Public Housing Capital fund Program are 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 401727

Finding 1214201 (2022-008)

Material Weakness 2022

Open Door Ministries of High Point, Inc.

NC

Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.302 § 200.303 § 200.430

Department of Housing and Urban Development and Department of Veterans Affairs 2022-008 Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a sy...

Department of Housing and Urban Development and Department of Veterans Affairs 2022-008 Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

View Audit 400920

Finding 1213939 (2022-004)

Material Weakness 2022

Barbour County Senior Center, Inc.

WV

Allowable Costs / Cost Principles § 200.302 § 200.333 § 200.403

Recommendations: Management should enhance its internal control procedures to ensure all disbursements and payroll transactions charged to the federal program are supported by complete and properly approved documentation consistent with 2 CFR Part 200 and the operating contract. This includes retain...

Recommendations: Management should enhance its internal control procedures to ensure all disbursements and payroll transactions charged to the federal program are supported by complete and properly approved documentation consistent with 2 CFR Part 200 and the operating contract. This includes retaining invoices, approvals, check copies, personnel files, and pay-rate authorizations. Management should assign clear responsibility for recordkeeping, implement periodic reviews for completeness, and provide staff training on documentation and retention expectations. Views of responsible officials and planned corrective actions: Management agrees with the findings and will ensure that all original supporting documents are maintained at the organization’s office in a secure location for a minimum of three years after an independent audit, and that every transaction is properly authorized and documented before expending monetary resources. Anticipated Completion Date: May 1, 2024

View Audit 400780

Finding 1213938 (2022-003)

Material Weakness 2022

Barbour County Senior Center, Inc.

WV

Allowable Costs / Cost Principles § 200.414 § 200.416 § 200.417

Recommendations: Management should prepare an Annual Cost Allocation Plan in accordance with the program’s operating contract and federal regulations and ensure it is consistently retained and made available for audit. Management should also establish internal controls over the preparation, approval...

Recommendations: Management should prepare an Annual Cost Allocation Plan in accordance with the program’s operating contract and federal regulations and ensure it is consistently retained and made available for audit. Management should also establish internal controls over the preparation, approval, and retention of the plan. Views of responsible officials and planned corrective actions: Management agrees with the finding and will ensure that the Annual Cost Allocation Plan is completed in a timely manner in accordance with the operating contract and the indirect cost rate submitted for reimbursement matches the Annual Cost Allocation Plan. Training on the proper Annual Cost Allocation Plan process is anticipated through the WV Transit Authority. Anticipated Completion Date: May 1, 2024

View Audit 400780

Finding 1213892 (2022-005)

Material Weakness 2022

Town of Livermore Falls

ME

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

CORRECTIVE ACTION PLAN (Concerning Finding 2022-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-005 The current Town Manager was appointed by...

CORRECTIVE ACTION PLAN (Concerning Finding 2022-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. The Select Board will review this draft at their meeting in January 2024, edits will be made and then it will be sent to legal for final review before adoption. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. Anticipated Completion Date: The processing of invoices for the warrant has been corrected as of December 2023. The Procurement Policy was approved and implemented by the Select Board on January 23, 204.

View Audit 400731

Finding 1213890 (2022-006)

Material Weakness 2022

Town of Livermore Falls

ME

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

CORRECTIVE ACTION PLAN (Concerning Finding 2022-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2022-006 The current Town Manager was appointed by the Select...

CORRECTIVE ACTION PLAN (Concerning Finding 2022-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2022-006 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and is drafting a new Internal Controls Policy that will address this deficiency. The Select Board will review this draft at their meeting in February or March 2024, edits will be made and then it will be sent to legal for final review before adoption. This policy will include sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll. Anticipated Completion Date: It is anticipated that the Internal Controls Policies and Procedures will be approved and adopted by June 2024 by the Select Board. Implementation will be July 1, 2025 with the new chart of accounts.

View Audit 400731

Finding 1213888 (2022-003)

Material Weakness 2022

Town of Livermore Falls

ME

Allowable Costs / Cost Principles § 200.303

CORRECTIVE ACTION PLAN (Concerning Finding 2022-003) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-003 The current Town Manager was appointed by...

CORRECTIVE ACTION PLAN (Concerning Finding 2022-003) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the Treasurer and the Select Board. She has implemented a process of having the Treasurer complete a warrant each week. The Select Board meets bi-monthly and the Town Manager has the Select Board review and approve all warrants as a regular action item in their meeting. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. Anticipated Completion Date: This corrective action has been implemented as of October 2023.

View Audit 400731

Finding 1211142 (2022-003)

Material Weakness 2022

Carestl Health

MO

Allowable Costs / Cost Principles § 200.302 § 200.403

Recommendation We recommend that management: ▪ Implement procedures requiring complete supporting documentation for all costs charged to federal awards ▪ Ensure costs are reviewed for allowability, reasonableness, and allocability prior to recording ▪ Establish and document formal cost allocation me...

Recommendation We recommend that management: ▪ Implement procedures requiring complete supporting documentation for all costs charged to federal awards ▪ Ensure costs are reviewed for allowability, reasonableness, and allocability prior to recording ▪ Establish and document formal cost allocation methodologies ▪ Require approval and documentation of all journal entries affecting federal programs ▪ Provide training to staff on Uniform Guidance cost principles (2 CFR 200 Subpart E) ▪ Conduct periodic internal reviews to ensure compliance

View Audit 400353

Finding 1211141 (2022-002)

Material Weakness 2022

Carestl Health

MO

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

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Per...

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations

View Audit 400353

Finding 1210508 (2022-007)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division wi...

REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division will ensure proper documentation of the weight of items distributed is retained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745

View Audit 399930

Finding 1210493 (2022-005)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget p...

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

View Audit 399930

Finding 1206309 (2022-007)

Material Weakness 2022

Island Health, Inc.

MA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.308 § 200.309 § 200.403

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.

View Audit 398372

Finding 1206308 (2022-003)

Material Weakness 2022

Island Health, Inc.

MA

Allowable Costs / Cost Principles Questioned Costs § 200.40 § 200.430

Item 2022.003 - Activities Allowed or Unallowed Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistent...

Item 2022.003 - Activities Allowed or Unallowed Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the timesheet and payrates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonpayroll expenditures to ensure all expenditures were approved by the appropriate supervisor. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: Timesheet and Payrate Review and Approval: • Standardize timesheet submission and approval process • Utilize an electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, reviews, and approvals by supervisors • Conduct regular audits to verify timesheets and payrates are reviewed and approved by supervisors NonPayroll Expenditures: • Evaluate and improve upon existing processes to ensure internal controls over nonpayroll expenditures are working. This includes enforcement of approval policies with mandatory documentation and regular monitoring throughout the process for a clear audit trail • Conduct regular audits to verify nonpayroll expenditures have been reviewed and approved by supervisors

View Audit 398372

Finding 1206170 (2022-006)

Material Weakness 2022

Native Village of Barrow

AK

Allowable Costs / Cost Principles Significant Deficiency

Lack of Internal Controls over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss o...

Lack of Internal Controls over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.

View Audit 398166

Corrective Action Plans

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