Corrective Action Plans

Finding 1176727 (2021-001)

Material Weakness 2021

AK

Allowable Costs / Cost Principles Reporting

Chuloonawick Native Village agrees with the finding and will retain documentation supporting its expenditures for subsequent audits and train all new staff correct filing procedures.

View Audit 390654

Finding 1176708 (2021-005)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Questioned Costs Cash Management

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calcu...

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calculation was incorporated into the Period 4 PRF submission. To prevent recurrence, the Organization has strengthened its internal review protocols for reporting, including mandatory reconciliation of all revenue inputs to audited financial statements and secondary review by the Regional Controller prior to submission. These enhanced controls ensure that future lost revenue calculations are accurate, supportable, and compliant with HRSA reporting requirements.

View Audit 390602

Finding 1176707 (2021-004)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Questioned Costs Cash Management

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Defi...

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Definitive guidance clarifying this requirement was not released until August 2021, after the close of the reporting period. As a result, the Organization applied the best available interpretation at the time of close. To prevent similar issues, the Organization will incorporate ongoing monitoring of updated directives, strengthen pre submission technical reviews, and consult with external advisors to validate compliance with period of availability rules prior to future filings.

View Audit 390602

Finding 1176706 (2021-003)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Questioned Costs Cash Management

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology ...

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology with full underlying documentation in line with PRF reporting requirements.

View Audit 390602

Finding 1171351 (2021-002)

Material Weakness 2021

Ekentucky Advanced Manufacturing Institute INC

KY

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

We concur with the recommendation. The required filings are done in conjunction with the audits of the organization's financial statements. The organization is actively working to get the audits and the required filings current. The organization will submit the infomrntion lo the audit firm for 2022...

We concur with the recommendation. The required filings are done in conjunction with the audits of the organization's financial statements. The organization is actively working to get the audits and the required filings current. The organization will submit the infomrntion lo the audit firm for 2022 by January 3 1, 2026. The information for audits of the subsequent years' financial statements will be submitted within 30 days of the completion of the prior year audit. The organization expects to be current on the audits and filings by December 31, 2027.

View Audit 384645

Finding 1169706 (2021-003)

Material Weakness 2021

Pittsburg County

OK

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303

The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will requ...

The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will require approval by the BOCC before any action can be taken. BOCC will determine the validity of each transaction to ensure compliance with grant requirements.

View Audit 382719

Finding 1169705 (2021-002)

Material Weakness 2021

Pittsburg County

OK

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

The BOCC will develop internal control procedures to help ensure that federal grant funding is monitored more closely and that expenditures are verified to be in compliance with grant requirements. Future grant recipients will be required to have BOCC approval before expenditures can be turned in fo...

The BOCC will develop internal control procedures to help ensure that federal grant funding is monitored more closely and that expenditures are verified to be in compliance with grant requirements. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be required to have BOCC approval before depositing grant funds. This should ensure that all transactions are in compliance with grant requirements.

View Audit 382719

Finding 1169704 (2021-001)

Material Weakness 2021

Pittsburg County

OK

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

The BOCC will ensure that internal controls are developed and that procedures are adopted and implemented to help ensure compliance with federal grants. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be requ...

The BOCC will ensure that internal controls are developed and that procedures are adopted and implemented to help ensure compliance with federal grants. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be required to have BOCC approval before depositing grant funds. This should ensure that all transactions are in compliance with grant requirements.

View Audit 382719

Finding 1167055 (2021-009)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 37 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025 The individual responsible for ensuring these issues are resolved is Michelle Bryant, Interim CEO. If there are questions regarding these plans, please call Michelle Bryant at 757-858-1360. Michelle Bryant, Interim CEO

View Audit 378149

Finding 1167054 (2021-008)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 37 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025 The individual responsible for ensuring these issues are resolved is Michelle Bryant, Interim CEO. If there are questions regarding these plans, please call Michelle Bryant at 757-858-1360. Michelle Bryant, Interim CEO

View Audit 378149

Finding 1167053 (2021-007)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 36 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

View Audit 378149

Finding 1167052 (2021-006)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 36 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

View Audit 378149

Finding 1167051 (2021-005)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Community Services Block Grant (CSBG)-Federal Assistance Listing Number 93.569 - Material Weakness in Internal Control over Compliance Finding 2021-004 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-005 Noncompliance with Eligibility Recommendatio...

Community Services Block Grant (CSBG)-Federal Assistance Listing Number 93.569 - Material Weakness in Internal Control over Compliance Finding 2021-004 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-005 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. 35 • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present, STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform. Wipfli, LLP was engaged for accounting services in August of 2023 and subsequently, implemented Bill.com to facilitate accounts payable approval processes and document retention. The software has established hierarchies built within the system to ensure all invoices are properly reviewed and approved prior to processing. All staff included in the approval process were trained to utilize the system for processing. Wipfli staff is engaged for the accounts payable processing activities in the system. All STOP staff have or will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

View Audit 378149

Finding 1167050 (2021-004)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Community Services Block Grant (CSBG)-Federal Assistance Listing Number 93.569 - Material Weakness in Internal Control over Compliance Finding 2021-004 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-005 Noncompliance with Eligibility Recommendatio...

Community Services Block Grant (CSBG)-Federal Assistance Listing Number 93.569 - Material Weakness in Internal Control over Compliance Finding 2021-004 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-005 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. 35 • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present, STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform. Wipfli, LLP was engaged for accounting services in August of 2023 and subsequently, implemented Bill.com to facilitate accounts payable approval processes and document retention. The software has established hierarchies built within the system to ensure all invoices are properly reviewed and approved prior to processing. All staff included in the approval process were trained to utilize the system for processing. Wipfli staff is engaged for the accounts payable processing activities in the system. All STOP staff have or will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

View Audit 378149

Finding 1165035 (2021-007)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Finding Number 2021-007: No Review of Reimbursement Requests Before Submission (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not review reimbursement requests before submission PCOA personnel responsible for enacting corrective action plan: Ja...

Finding Number 2021-007: No Review of Reimbursement Requests Before Submission (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not review reimbursement requests before submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  Reimbursement requests now undergo formal internal review prior to submission.  A checklist-based review process was developed with assistance from the Director of Contracts, and compliance is enforced by the Finance Director.  Additional accounting staff are being hired to support the month-end closing process and ensure reimbursement requests are reconciled and supported appropriately. Completion Date: July 31, 2025

View Audit 375125

Finding 1165034 (2021-006)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Significant Deficiency

Finding Number 2021-006: Missing or Inaccurate Personnel Action Notices (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA had missing or inaccurate personnel action notices PCOA personnel responsible for enacting corrective action plan: Jay Huffstutle...

Finding Number 2021-006: Missing or Inaccurate Personnel Action Notices (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA had missing or inaccurate personnel action notices PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org; Jennifer Billa, Human Resources Director, Jbilla@pcoa.org The corrective action plan:  PCOA has standardized its personnel documentation process, including personnel action notices (PAN) and approval workflows.  HR and finance implemented policy and procedures to align pay rate documentation with payroll data.  All personnel changes are now signed off by the Finance and HR Director  Additional skilled personnel are being recruited to ensure accuracy and control around personnel changes. Completion Date: July 31, 2025

View Audit 375125

Finding 1165033 (2021-005)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Significant Deficiency

Finding Number 2021-005: Payroll Registers Not Approved by CFO (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not have payroll registers reviewed by the CFO PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Financ...

Finding Number 2021-005: Payroll Registers Not Approved by CFO (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not have payroll registers reviewed by the CFO PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan: Background: Previous CFO established this control in collaboration with PCOA leadership.  Approval controls over payroll have been reinstated. All payroll registers are now reviewed and approved prior to submission.  Oversight of payroll controls will be led by the new Finance Director  New staff are being hired to support payroll processing and ensure adherence to internal protocols. Completion Date: July 31, 2025

View Audit 375125

Finding 1165032 (2021-004)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles

Finding Number 2021-004: – Employee Time Not Tracked by Program (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not track actual employee time by program PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Di...

Finding Number 2021-004: – Employee Time Not Tracked by Program (Allowable Costs/Cost Principles), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not track actual employee time by program PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan: PCOA recognizes the importance of accurately tracking employee time by program to ensure compliance with federal cost principles. In FY2025, PCOA has implemented a new process within the payroll system to directly capture time spent on each program rather than relying on allocation methodologies.Process: Each employee is now required to log in and out of the payroll system by program throughout the workday. Program managers assign employees to the specific programs they are authorized to charge time to. These program codes are built into the payroll system for selection during time entry. Employees record their hours by selecting the appropriate program each time they begin or complete work on that program. This ensures that the payroll system reflects actual hours worked on each program on a daily basis. Program managers review timesheets monthly to confirm that time recorded aligns with program assignments and activities. Finance staff reconcile program time entries against payroll records to ensure accurate posting to the general ledger and federal grant reporting. Commitment: This new process establishes a consistent, auditable method of tracking employee time by program. PCOA is committed to ongoing monitoring of the system and regular reviews to ensure accuracy, compliance with Uniform Guidance, and proper documentation for audit purposes. Completion Date: August 18, 2025

View Audit 375125

Finding 1165031 (2021-003)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Cash Management Reporting

Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting correcti...

Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting corrective action plan: Francine McGetrick, Contracts Director, Fmcgetrick@pcoa.org The corrective action plan: 1. PCOA has implemented procedures requiring internal review of all client sign-in sheets related to meals billed for reimbursement. 2. While the required sign-in documentation was completed and retained, it was stored in the contracts area and not submitted with the DES files. A new process has been established to ensure that sign-in sheets are filed along with the corresponding summary information at the time of submission. 3. PCOA has designed the updated process and trained staff to ensure proper documentation is verified prior to billing. 4. Ongoing compliance is now overseen by the Director of Contracts, and operational staff have been re-trained to ensure consistent execution. Completion Date: June 30th, 2025

View Audit 375125

Finding 1164240 (2021-004)

Material Weakness 2021

Portsmouth Redevelopment and Housing Authority

VA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over allowable costs to ensure all documentation is maintained at the time expenses are paid. Explanation of disagreement with audit finding: There is no disagreemen...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over allowable costs to ensure all documentation is maintained at the time expenses are paid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority is prioritizing completion of outstanding audits to ensure records can be located promptly when requested. All invoices will continue to require proper approval signatures prior to payment, and payment authorization will serve as an additional layer of verification to confirm compliance with internal control procedures. This instance involved only one of forty (40) accounts payable items that was not available in the document imaging system at the time of review so it needed to be recreated by printing off the invoice and it was paid online. The payment would have had to be pre-approved by CFO prior to payment. Name(s) of the contact person(s) responsible for corrective action: Shannon Sterling, CFO Planned completion date for corrective action plan: 12/1/25

View Audit 373527 Questioned Costs: $1

Finding 1163085 (2021-002)

Material Weakness 2021

J-TECH INSTITUTE, INC.

CA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.512

Audit Finding: Finding 2021-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...

Audit Finding: Finding 2021-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately

View Audit 372661

Finding 1163013 (2021-006)

Material Weakness 2021

Ruth Ellis Center, Inc.

MI

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.

View Audit 372604

Finding 1163012 (2021-005)

Material Weakness 2021

Ruth Ellis Center, Inc.

MI

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303

View of Responsible Officials and Corrective Action Plan – The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check payment from approved by the Grant...

View of Responsible Officials and Corrective Action Plan – The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check payment from approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the change to the specific grant.

View Audit 372604 Questioned Costs: $1

Finding 1163011 (2021-004)

Material Weakness 2021

Ruth Ellis Center, Inc.

MI

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.

View Audit 372604

Finding 1162828 (2021-011)

Material Weakness 2021

Chester Upland School District

PA

Allowable Costs / Cost Principles Period of Performance

Finding 2021-011 - Repeat of 2020-008; Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Description of Finding: The School District was unable to provide supporting documentation for all expenses. District Position: The School District concurs with the finding....

Finding 2021-011 - Repeat of 2020-008; Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance Description of Finding: The School District was unable to provide supporting documentation for all expenses. District Position: The School District concurs with the finding. Corrective Action to be Taken: The District has appointed a Federal Programs Coordinator who is familiar with the Single Audit requirements of the Uniform Guidance. Management has restructured its business office and is working with third party consultants in conjunction with the Federal Programs Coordinator to implement policies and procedures to properly document federal grant expenditures. These policies and procedures include maintaining proper source documentation for federal award program activities and reconciling that documentation with amounts recorded in the general ledger within the District’s accounting software on a consistent basis. Timetable for Implementation: Implemented for 2022-2023 fiscal year Monitoring to be Performed: The Receiver and Business Manager will monitor timely and continued implementation. Responsible Person with Scope of Authority: Receiver and Business Manager

View Audit 372470

Corrective Action Plans

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