Corrective Action Plans

Finding 574141 (2024-002)

Significant Deficiency 2024

Aurora/arapahoe Battered Women's Shelter, Inc. Dba Gateway Domestic Vi

CO

Allowable Costs / Cost Principles § 200.303 § 200.430

Gateway Domestic Violence Services, in 2024, was utilizing paper timesheets that included the funder allocation for each staff person. The funder allocations were then entered into QuickBooks spreadsheets. In February of 2025, we engaged with Paychex Payroll Services which utilizes simple online so...

Gateway Domestic Violence Services, in 2024, was utilizing paper timesheets that included the funder allocation for each staff person. The funder allocations were then entered into QuickBooks spreadsheets. In February of 2025, we engaged with Paychex Payroll Services which utilizes simple online software built to streamline payroll and automate taxes. It does include a job costing process that allows for identifying payroll costs to be distributed appropriately to funders. This electronic payroll system decreases the chances of human error. Also in August of 2025, there is a change in personnel to Finance & Operations Director rather than Finance and Operations Manager. The new position comes with increased responsibilities and increased skills. This position will be responsible for reconciling payroll allocations from Paychex to Payroll allocations in QuickBooks to government funding reports to ensure accuracy. These changes along with the systems that we have had in place should help prevent this issue from being repeated.

View Audit 364709

Finding 574131 (2024-004)

Material Weakness 2024

Legacy Medical Care Inc.

IL

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

Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025

View Audit 364705

Finding 574123 (2024-001)

Significant Deficiency 2024

Response of Suffolk County, Inc.

NY

Allowable Costs / Cost Principles § 200.430

2024-001. Allowable Costs/Cost Principles United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Passed Through Vibrant Emotional Health: Substance Abuse and Mental Health Services Administration - 988 National Suicide Prevention Lifeline ALN...

2024-001. Allowable Costs/Cost Principles United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Passed Through Vibrant Emotional Health: Substance Abuse and Mental Health Services Administration - 988 National Suicide Prevention Lifeline ALN: 93.243 Substance Abuse and Mental Health Services Administration - Disaster Distress Helpline ALN: 93.243 Passed Through New York State Office of Mental Health: Substance Abuse and Mental Health Services Administration - 988 S11MY1 ALN: 93.243 Condition: Time records prepared by employees reflect the total hours worked for the day, but do not reflect the actual time spent on programs funded by each federal award, rather they are based on budgeted hours. Recommendation: The Organization’s use of Personnel Activity Report (PAR) equivalent documentation should allow each employee to accurately reflect the time work is performed for each federal award. Corrective Action: The Organization will complete the implementation of procedures for its time keeping records, which will provide information for PAR equivalent documentation. Actual time worked performing duties funded by each federal award will be reflected. Responsible Contact Person(s): Meryl Cassidy, Executive Director Response of Suffolk County, Inc., - P.O. Box 300 - Stony Brook, New York 11790 Anticipated Completion Date: December 31, 2025.

View Audit 364704

Finding 574107 (2024-001)

Significant Deficiency 2024

Town of Ramah, Colorado

CO

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

The Town of Ramah is in the process of creating a Procurement Policy.

View Audit 364684

Finding 574079 (2024-001)

Material Weakness 2024

Chippewa County

MN

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

Finding Number: 2024-001 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal & Support Services Supervisor Corrective Action Planned: Due to ...

Finding Number: 2024-001 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal & Support Services Supervisor Corrective Action Planned: Due to overlap of when we found the errors from 2023 and the corrections of those in 2024, this triggered other areas we knew would have to change in 2024. This included more movement in personnel expenses for programs not considered under federal financial participation. These programs were all removed from the Family Services budget by January 1, 2025. The corrections to our internal systems were corrected in 2025. Chippewa County staff will connect with DHS to review the corrections made in our system as it pertains to the quarterly reports and will adjust as they instruct. For the Administrative split being used each year, we will use the A87 Report to determine the rate. It will be shared with the Payroll department, the County Auditor/Treasurer’s department and Family Services accounting staff prior to the start of the year or prior to any mid-year change. More oversight will be given to placement of “Other” charges that are paid in County systems and to make sure placement of those are correct in the quarterly reports. Anticipated Completion Date: December 2025

View Audit 364657

Finding 574054 (2024-005)

Significant Deficiency 2024

Easter Seals Serving Dc/md/va

MD

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management § 200.403 § 200.412

• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review firs...

• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review first three months of FY26 by 12/31/25

View Audit 364634

Finding 574051 (2024-001)

Significant Deficiency 2024

City of Dover

NH

Reporting Allowable Costs / Cost Principles Cash Management § 200.510

The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Direct...

The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Director and approved by the Finance Director prior to submission to the auditing firm. In addition to federal grants adopted as part of the City's annual operating budget, after adoption of the annual operating budget any federal grant approved by City Council for acceptance and expenditure will be maintained in the City's electronic archival system. The SEFA will be compard to the list of budgeted grants and the grants accepted after adoption of the annual operating budget to ensure grants are appropriately reported on SEFA.

View Audit 364631

Finding 574028 (2024-003)

Significant Deficiency 2024

The Food Trust

PA

Cash Management Allowable Costs / Cost Principles

During our testing, we noted there was no documentation of review or approval on the calculation for the draw of funding for the program. In addition, draws are not performed in a timely manner after the expenditures are incurred. Recommendation: We recommend The Food Trust implement a clear approv...

During our testing, we noted there was no documentation of review or approval on the calculation for the draw of funding for the program. In addition, draws are not performed in a timely manner after the expenditures are incurred. Recommendation: We recommend The Food Trust implement a clear approval process for the drawing of federal funding. In addition, it is important to establish a clear process and timeline for performing draws. This may involve regular monitoring of expenditures, timely submission of draw requests, and efficient processing of those requests. By implementing an approval and a timely draw process, the organization can enhance internal controls, reduce the risk of fraud, and ensure the accuracy and integrity of the fund draw process, and can better manage its cash flow, meet its financial obligations, and maintain the smooth operation of the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement an electronic approval system, and draws will be completed within 30 days of month end. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: the planned corrective action will be completed by August 2025.

View Audit 364615

Finding 574021 (2024-002)

Significant Deficiency 2024

The Food Trust

PA

Allowable Costs / Cost Principles Reporting Significant Deficiency

During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort ...

During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement processes and tools to ensure that all employee time and effort charged to federal grants is appropriately documented. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by October 2025.

View Audit 364615

Finding 573967 (2024-001)

Significant Deficiency 2024

Old Pueblo Community Services

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.

View Audit 364575

Finding 573909 (2024-003)

Significant Deficiency 2024

Sicangu Oyate Ho, INC

SD

Allowable Costs / Cost Principles § 200.302 § 200.430

Management Response: We have had significant turnover in HR and Payroll and documentation was not maintained properly. We have a new HR Director and new Payroll Manager who will work closely together and are aware of record keeping and maintaining files for compliance. A checklist has been created t...

Management Response: We have had significant turnover in HR and Payroll and documentation was not maintained properly. We have a new HR Director and new Payroll Manager who will work closely together and are aware of record keeping and maintaining files for compliance. A checklist has been created to ensure all required documents are on file. Anticipated Completion Date: We are conducting a file review and will ensure all documents are in order by September 30, 2025. Responsible Party: HR Director, Payroll Manager, Benefits Coordinator and Business Manager will have oversight.

View Audit 364557

Finding 573892 (2024-002)

Material Weakness 2024

Aids Council of Northeastern New York, Inc. D/b/a Alliance for Positive Health

NY

Allowable Costs / Cost Principles § 200.414

Starting in May 2024, the Alliance adapted its monthly Time and Effort Report that is reviewed by Kim Atkins, Executive Director, to be used for allocation of expenses other than payroll. This ensures a consistent, reviewed and authorized report is being used for expense allocation. This report is s...

Starting in May 2024, the Alliance adapted its monthly Time and Effort Report that is reviewed by Kim Atkins, Executive Director, to be used for allocation of expenses other than payroll. This ensures a consistent, reviewed and authorized report is being used for expense allocation. This report is shared monthly with the Alliance’s funding agencies along with the submission of monthly vouchers for processing. During the year ended June 30, 2025, the Alliance has ensured that allocations were signed off on by Kim and has significantly reduced the amount of finance staff time required to process the allocation of administrative costs. As of July 1, 2025, the approved staff allocations are being uploaded into ADP in the anticipation of a direct link between ADP and the NetSuite general ledger so that personnel costs will be allocated automatically going forward. As of July 1, 2025 the Alliance is modifying all of its grants to adopt the 15% de minimis cost rate for all expenses other than personnel, direct program, and space costs.

View Audit 364554

Finding 573853 (2024-001)

Significant Deficiency 2024

Enterprisekc

KS

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Corrective Action Plan 2024-001: Management has since performed the suspension and debarment check for the vendor and included the check in the contract file for all covered transactions. Anticipated Completion Date: July 2025 Contact Person: Jay Konomos, Pillar Leader

View Audit 364498

Finding 573826 (2024-014)

Material Weakness 2024

Caddo County

OK

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

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 364483

Finding 573825 (2024-013)

Material Weakness 2024

Caddo County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 364483

Finding 573824 (2024-012)

Material Weakness 2024

Caddo County

OK

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

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 364483

Finding 573823 (2024-010)

Material Weakness 2024

Caddo County

OK

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 364483

Finding 573781 (2024-002)

Significant Deficiency 2024

Opportunity Alabama, Inc.

AL

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Finding 2024-002 Lack of documentation – Significant Deficiency Corrective Action Plan: In June of 2025, Opportunity Alabama Inc created a formal signoff procedure for our bank reconciliation process that includes steps for reviewing at the transaction level for expenditures related to grants. ...

Finding 2024-002 Lack of documentation – Significant Deficiency Corrective Action Plan: In June of 2025, Opportunity Alabama Inc created a formal signoff procedure for our bank reconciliation process that includes steps for reviewing at the transaction level for expenditures related to grants. Contact person: Megan Warren, Chief Compliance Officer and Director of Accounting; (205) 319- 6688; megan@opportunityalabama.com

View Audit 364454

Finding 573778 (2024-001)

Significant Deficiency 2024

Huntington County

IN

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

FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: County Commissioners & Auditor Jill Landrum Contact Phone Number and Email Address: 260-358-4805; jill.landrum@huntington.in.us ...

FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: County Commissioners & Auditor Jill Landrum Contact Phone Number and Email Address: 260-358-4805; jill.landrum@huntington.in.us Views of Responsible Officials: While the Auditor implemented a procedure for verifying that persons and entities related to contracts or covered transactions were not suspended, debarred, or otherwise excluded, she concurs with Finding 2024-001, in that no internal control procedure was documented that a second person had reviewed the procedure to ensure compliance with the requirements. Description of Corrective Action Plan: The Auditor will work with the Commissioner’s Office Manager Gretchen Lenfestey to discuss changes needed for the previous policy implemented. The new County Attorney has already addressed the need to include Suspension and Debarment language in the contracts that the County signs. If the language is not included, the contractors/vendors will be asked to sign a statement that they have not been suspended, debarred, or otherwise excluded from participating in federal programs. Prior to the Commissioners signing a contract, their Office Manager will be responsible for verifying that each contract contains the Suspension and Debarment language, or that the County has a statement on file from the Contractor/Vendor that they have not been suspended, debarred, or otherwise excluded. The Office Manager will maintain an annual list of all County contracts and will verify with his/her initials that the Suspension and Debarment language is contained in the contract or that there was a separate statement obtained. The Office Manager will send a copy of all signed contracts and signed statements to the Auditor and the Accounts Deputy. On a monthly basis, the Commissioner’s Office Manager will also e-mail an updated list of contracts indicating the documents verified, so the Auditor’s office can verify their records. The Auditor’s Accounts Payable (AP) Deputy will also generate a report from the Financial Software each January to create a list of vendors that were paid more than $25,000 in the previous year. A letter will be mailed requesting the Vendor’s signature on a Suspension and Debarment Certification. They will be asked to return the certification form to the Auditor’s Office by e-mail or mail within 30 days. The AP Deputy will be responsible for keeping a file of the forms received and updating the list with his/her initials. After the 30-day timeframe passes, the Accounts Deputy will double-check the received forms against the mailing list and initial that he/she has verified. The Accounts Deputy, or the Auditor’s designee will conduct a search for exclusions on the Sam.gov website for all vendors that did not return a certification form. A copy of the sam.gov verification will be saved, and the vendor list will be updated & initialed. The Accounts Payable Deputy will double check the verifications to make sure all vendors have either provided a signed certification or that a sam.gov verification was obtained. Anticipated Completion Date: December 31, 2025 Respectfully submitted, Jill M. Landrum Huntington County Auditor INDIANA STATE

View Audit 364450

Finding 573727 (2024-003)

Material Weakness 2024

West Virginia Community Development Hub, Inc.

WV

Allowable Costs / Cost Principles Material Weakness Reporting

Planned Corrective Action: The Hub implemented a new software system with fully integrated payroll and timekeeping functionality. Name of Contact Person: Cindy Heltzel, CPA, CFO c.heltzel@wvhub.org Anticipated completion date: Completed

View Audit 364385

Finding 573704 (2024-006)

Material Weakness 2024

Rogers County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

The Board of County Commissioners will work with all elected officials, the third-party administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and rep...

The Board of County Commissioners will work with all elected officials, the third-party administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements.

View Audit 364369

Finding 573697 (2024-001)

Material Weakness 2024

Walker Basin Conservancy

CA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.403

Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Since notification of the recommendation WBC has verified the Suspension and Debarment status for each of the eight Vendors identified. None of the vendors identi...

Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Since notification of the recommendation WBC has verified the Suspension and Debarment status for each of the eight Vendors identified. None of the vendors identified have been suspended or debarred or otherwise excluded from participating in the transaction. WBC has hired an Operations Manager. The Operations Manager is responsible for oversight and management of the WBC Procurement Policy in coordination with Finance. This includes ensuring Suspension and Debarment Status is verified as required by the policy. Weekly procurement staff meetings will be held to discuss and review current procurement transactions and issues. WBC will also hold an all-staff meeting focusing on the procurement policy and the responsibilities of all staff in compliance with the policy. Name(s) of the contact person(s) responsible for corrective action: Peter Stanton Planned completion date for corrective action plan: August 4, 2025. If the U.S. Department of the Interior - BOR has questions regarding this plan, please call Peter Stanton at 775-463-9887, Ext 101.

View Audit 364339

Finding 573665 (2024-002)

Material Weakness 2024

Trilogy, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.308 § 200.309 § 200.403

Action taken in response to finding: Trilogy will conduct a thorough review of our current cost allocation procedures to identify gaps related to the timing and eligibility of expenses. Based on this review, we will revise our process to ensure that only allowable costs incurred within the grant’s p...

Action taken in response to finding: Trilogy will conduct a thorough review of our current cost allocation procedures to identify gaps related to the timing and eligibility of expenses. Based on this review, we will revise our process to ensure that only allowable costs incurred within the grant’s period of performance are charged. A multi-tiered review process will be established, to verify expense timing and relevance and to confirm compliance with grant terms. Staff will review descriptions and flag transactions that fall outside the grant’s period of performance. These controls will prevent such costs from being allocated unless properly justified and approved. Staff involved in grant management will receive updated training on federal cost principles, including the importance of period-of-performance compliance. Written guidance will be distributed to reinforce expectations. Name(s) of the contact person(s) responsible for corrective action: Shunita Rhodes & Hagar Buster Planned completion date for corrective action plan: July 2025

View Audit 364306 Questioned Costs: $1

Finding 573664 (2024-001)

Material Weakness 2024

Trilogy, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Action taken in response to finding: Trilogy has recently implemented a new payroll system UKG in January 2024 that includes enhanced functionality for tracking staff allocations across multiple grants and programs. This system also allows employees to self-report hours worked on specific grants or ...

Action taken in response to finding: Trilogy has recently implemented a new payroll system UKG in January 2024 that includes enhanced functionality for tracking staff allocations across multiple grants and programs. This system also allows employees to self-report hours worked on specific grants or non-grant activities if the varies from primary allocations ensuring that payroll costs are distributed based on actual effort. Allocations are reviewed monthly with program staff and updated as needed based, which improves the accuracy of cost distribution and ensures that payroll charges reflect current work assignments. Timecard hours are reviewed and approved by supervisors to maintain oversight. Staff involved in time reporting with grant management received training on the new system, allocation procedures, and federal requirements for payroll cost documentation. We are updating our timekeeping and payroll allocation policies to reflect the new system’s capabilities and to reinforce compliance with Uniform Guidance (2 CFR §200.430). These policies will include clear guidance on documenting effort and allocating wages across cost objectives. Name(s) of the contact person(s) responsible for corrective action: Shunita Rhodes and Hagar Buster Planned completion date for corrective action plan: January 2024

View Audit 364306 Questioned Costs: $1

Finding 573540 (2024-005)

Material Weakness 2024

Village of Bellevue

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.305 § 200.318

Finding 2024-005 – Lack of Written Policies Required by the Uniform Grant Guidance Contact Person: Nicole Roberts, Village Manager Planned Corrective Action: The Village will develop and adopt written policies and procedures to comply with Uniform Guidance requirements, including internal controls, ...

Finding 2024-005 – Lack of Written Policies Required by the Uniform Grant Guidance Contact Person: Nicole Roberts, Village Manager Planned Corrective Action: The Village will develop and adopt written policies and procedures to comply with Uniform Guidance requirements, including internal controls, procurement, cash management, and allowable costs. Anticipated Completion Date: December 31, 2026

View Audit 364269

Corrective Action Plans

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