Corrective Action Plans

Finding 554040 (2024-003)

Material Weakness 2024

St. Joseph County Transportation Authority

MI

Allowable Costs / Cost Principles Material Weakness

March 31, 2025 CORRECTIVE ACTION PLAN Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings, as noted in the St. Joseph County Transportation Authority (the “Authority”), Single Audit report for the year ended September 30, 2024, and c...

March 31, 2025 CORRECTIVE ACTION PLAN Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings, as noted in the St. Joseph County Transportation Authority (the “Authority”), Single Audit report for the year ended September 30, 2024, and corrective actions to be completed. Finding 2024-003 - Supporting Documentation and Review and Approval for Federal Expenditures Auditor Description of Condition and Effect. Management is responsible for verifying that federal expenditures are in compliance with allowable costs and allowable activities. The Authority had instances during Accounts Payable, Payroll, and Journal Entry testing where documentation of expenditures lacked evidence of review by senior management. As a result of this condition, the Authority is exposed to an increased risk of errors or misstatements in financial records related to the federal funds. Auditor Recommendation. The Authority should implement procedures for the independent review and approval by management over all journal entries, accounts payable, and payroll, related to federal funds. Corrective Action. We concur with the recommendation and will continue to seek out possibilities to further strengthen our internal control. Responsible Person: Allen Balog, Executive Director Anticipated Completion Date: September 30, 2025

View Audit 352668

Finding 554027 (2024-007)

Material Weakness 2024

Inglewood Unified School District

CA

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

The District acknowledges this finding and is committed to strengthening internal controls to ensure compliance with federal time accounting requirements. The State and Federal Programs Department has received training on Time and Effort procedures, and additionally training is being provided to sch...

The District acknowledges this finding and is committed to strengthening internal controls to ensure compliance with federal time accounting requirements. The State and Federal Programs Department has received training on Time and Effort procedures, and additionally training is being provided to school sites to reinforce accurate time certification and documentation for federal fund expenditures. To address the deficiencies, the district will shift from an annual to a monthly reconciliation process, ensuring that employee salaries charged to Title I accurately reflect actual work performed. The State and Federal Programs Department will collaborate with the Budget Department to systematically track employees funded through Title I and verify that all required PARs are completed and maintained.

View Audit 352638 Questioned Costs: $1

Finding 554022 (2024-005)

Significant Deficiency 2024

Eagle Academy Public Charter School

DC

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.430

U.S. Department of Education AL 84.010A Title I, Basic Grants to Local Education Agencies AL 84.010A Title I, Part A - Investment in Schools 2 AL 84.367A Title II: Improving Teacher Quality State Grants AL 84.424A Title IV: Student Support and Academic Enrichment Grants Type of Finding – Noncomplian...

U.S. Department of Education AL 84.010A Title I, Basic Grants to Local Education Agencies AL 84.010A Title I, Part A - Investment in Schools 2 AL 84.367A Title II: Improving Teacher Quality State Grants AL 84.424A Title IV: Student Support and Academic Enrichment Grants Type of Finding – Noncompliance and Significant Deficiency over Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Payroll) Repeat Finding: No Auditee’s Corrective Action Plan: The School recognizes the importance of maintaining records and ensuring adequate internal controls over activities allowed and allowable costs/costs/principles. To strengthen internal controls in this area, in July 2024, the school introduced EdOps to work on payroll and to conduct an additional layer of review in addition to the HR Manager and the CEO. The School recognizes that its documentation and record-keeping requires improvement. Should the School resume operations, it will assess review and record-keeping processes to ensure the integrity and accuracy of payroll and related documents. Contact Person: Aaron Lentner

View Audit 352637

Finding 554000 (2024-004)

Significant Deficiency 2024

Family Guidance Center of Alabama, Inc.

AL

Reporting Allowable Costs / Cost Principles Significant Deficiency

Each grant's financial report will be reviewed and approved each month, whether or not it is submitted to a funder. Individual Responsible Debbie Pinnock Completion Date Plan to be implemented as soon as possible.

View Audit 352634

Finding 553975 (2024-003)

Material Weakness 2024

Desert Aids Project, Inc.

CA

Allowable Costs / Cost Principles Material Weakness Reporting

Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Reporting – Material Weakness in Internal Control over Compliance Finding Summary Certain tables within the Universal Data System (UDS) Report did not reconcile to DAP...

Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Reporting – Material Weakness in Internal Control over Compliance Finding Summary Certain tables within the Universal Data System (UDS) Report did not reconcile to DAP Health, Inc. supporting information. The tables that did not reconcile to the supporting information include Table 4, Selected Patient Characteristics, and Table 5, Staffing and Utilization. Table 4 reports the total number of patients seen while Table 5 reports the number of clinic visits by the various types of providers. The primary causes of the differences were due to DAP Health, Inc. acquiring a large entity during the year which used a different Electronic Health Record System. The combination of bringing together information from two different systems caused the reporting to be more complicated. In addition, certain supporting documentation used to prepare the UDS report was not maintained. The review process for the UDS report was also not functioning properly. Responsible Individuals Rigo Garcia, Analytics Manager and Bill Lee, Director of Information Management Status Management of DAP Health, Inc. has already converted the 25 acquired clinics to the DAP Health, Inc. Electronic Health System, which streamlined the process for the preparation of the UDS Report for the calendar year ending December 31, 2024. In addition, management has implemented new procedures requiring supporting documentation to be maintained. Management has also implemented a formalized review procedure for the UDS Report prior to submission. Anticipated Completion Date March 31, 2025

View Audit 352630

Finding 553805 (2024-002)

Material Weakness 2024

Wisconsin Literacy, INC

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

The organization will update policies and procedures to obtain and review evidence for all cost reimbursement requests from subrecipient organizations.

View Audit 352443

Finding 553803 (2024-002)

Material Weakness 2024

City of Milano

TX

Allowable Costs / Cost Principles

The City is in the process of establishing written policies for federal awards.

View Audit 352434

Finding 553799 (2024-001)

Significant Deficiency 2024

Haverhill Cooperative School District

NH

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

Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District will ensure that any further retention bonuses be formally reviewed and approved by the School Board and Superintendent. Stipends for work performed are now included in a formal Letter of Agreeme...

Audit Finding Reference: 2024-001 Management’s Response and Planned Corrective Action: The District will ensure that any further retention bonuses be formally reviewed and approved by the School Board and Superintendent. Stipends for work performed are now included in a formal Letter of Agreement and signed by the employee and administrator. Name of Contact Person and Completion Date: Name: Kathryn Ducharme Anticipated Completion Date – July 1, 2024

View Audit 352406 Questioned Costs: $1

Finding 553783 (2024-002)

Material Weakness 2024

Legal Aid Soceity of Hawaii

HI

Allowable Costs / Cost Principles

LASH disagrees that this finding rises to the level of a "material weakness," but will proceed to address this finding through manual corrections and Legal Server improvements. From the prior fiscal year, significant progress was made to ensure the accuracy of the allocation of LSC work hours. This ...

LASH disagrees that this finding rises to the level of a "material weakness," but will proceed to address this finding through manual corrections and Legal Server improvements. From the prior fiscal year, significant progress was made to ensure the accuracy of the allocation of LSC work hours. This FY23 finding is related to an automatic allocation in Legal Server that occurs during a pay period when an exempt employee works more than the requisite hours and has charged a portion of time to LSC. The Legal Server system then automatically reallocates the time among the grants worked such that LSC may end up being charged a nominally less percentage of the total salary expense than it otherwise would have been These reallocations are deminimus, and result in less time, not more, being allocated to LSC. Therefore, LASH disagress that this finding is a "material weakness." LASH is committed to improving its performance in this area. In FY24, LASH employed a temporary Accountant who worked with staff to develop a process to indentify these misallcations and to correct them. While this manual process corrected the misallocation of LSC expenses, it did not correct the problem of employee numbers not matching up. There was one incident of employee numbers not matching in the sample of FY24. In FY25, LASH will continue to utilize the process it has proven will fix the misallocation of expenses for periods that have closed but will also attempt to move the process from after the distribution process to before and thus solve the problem up front. This move will not only identify any excess hours that triggers the problem and allow for fixing the allocations up front, but will identify mismatches in employee numbers and solve the problem identified in FY24.

View Audit 352373

Finding 553777 (2024-005)

Significant Deficiency 2024

Council on Substance Abuse Ncadd

AL

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.302

COSA implemented a new timesheet process in June 2024 that aligns with payroll and provides a more accurate alignment with employee time, time and grant expense allocations.

View Audit 352372 Questioned Costs: $1

Finding 553762 (2024-001)

Significant Deficiency 2024

Family Service Agency of Santa Barbara

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.430

Management Response and Corrective Action Plan 1. Automatic payments for recurrent utility services are covered by blanket approval to ensure timely remittances. Individual utility invoices are not individually approved but are reviewed by agency location by the Operations department during their mo...

Management Response and Corrective Action Plan 1. Automatic payments for recurrent utility services are covered by blanket approval to ensure timely remittances. Individual utility invoices are not individually approved but are reviewed by agency location by the Operations department during their monthly finance meeting. Management has elected this method as most efficient for the volume and timeliness required. Documentation of the review during the meetings will be kept as evidence of review of these expenses. 2. Management allocates payroll for exempt salaried employees on an hourly basis to fund sources based on the 80-hour period for which they are compensated. Any hours worked in excess of 80 hours by these employees are not compensated nor charged to fund sources. Exempt salaried employees have been directed to report only compensated time on timesheets. 3. We concur with this finding. Changes in pay rates for staff who perform multiple roles will be redefined to include all possibly affected program fund sources that staff may impact. Contact person(s) responsible for the corrective action: Lisa Brabo, Chief Executive Officer, lbrabo@fsacares.org Denise Cicourel, Chief Operating Officer, denise@fsacares.org Jaime Kuczkowski, Chief Financial Officer, jaime@balancefm.com Anticipated Completion Date: Education and documentation on the above have already started and will be completed by June 30, 2025.

View Audit 352353

Finding 553761 (2024-002)

Significant Deficiency 2024

Simeanna Iii, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensurereplacement reserve deposits are updated timely to ensure compliance with the HUDregulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the auditfinding....

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensurereplacement reserve deposits are updated timely to ensure compliance with the HUDregulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the auditfinding. Action taken in response to finding: Management has made an additional deposit in 2025 and developed processes to verify replacement reserve deposits are updated based on the regulatory agreement annually. Name(s) of contact person(s) responsible for corrective action: Theresa Bertram Planned completion date for corrective action plan: March 2025 If

View Audit 352352 Questioned Costs: $1

Finding 553705 (2024-002)

None 2024

American Indian Community Housing Organization

MN

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.302 § 200.305 § 200.317 § 200.326

Corrective Action Plan We are in the process of updating the Organization’s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2025

View Audit 352313

Finding 553699 (2024-002)

Significant Deficiency 2024

Invest in Kids

CO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.303

Invest in Kids updated its policies and procedures in October 2024. The updated language states “Disbursements to subrecipients of federal funds: The Director(s) and Finance & Administrative Manager will review all relevant documentation to confirm that funds were used for the approved amount and in...

Invest in Kids updated its policies and procedures in October 2024. The updated language states “Disbursements to subrecipients of federal funds: The Director(s) and Finance & Administrative Manager will review all relevant documentation to confirm that funds were used for the approved amount and intended activity, goods, or services, and that only allowable expenses are charged. Invoice payments will be delayed until the necessary supporting documentation is received and verified.” Additionally, all staff participated in the organization's annual financial management and internal controls training in October 2024 with a focus on the accounts payable and invoicing process.

View Audit 352269 Questioned Costs: $1

Finding 553698 (2024-001)

Significant Deficiency 2024

Invest in Kids

CO

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.430

Invest in Kids updated its human resources system to ensure timesheets accurately reflect time allocated across various funding sources and cost objectives. Additionally, all staff attended the organization’s annual financial management and internal controls training in October 2024, that included u...

Invest in Kids updated its human resources system to ensure timesheets accurately reflect time allocated across various funding sources and cost objectives. Additionally, all staff attended the organization’s annual financial management and internal controls training in October 2024, that included updated policies and a focus on accurate submissions of time and effort. Policy reviews have also been completed by management.

View Audit 352269 Questioned Costs: $1

Finding 553628 (2024-001)

None 2024

Nashoba Regional School District

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.309

Finding 2024-001 Condition: Costs were recorded for service periods prior to grant approval date. Corrective Action Planned: The district will implement controls to prevent the recording of costs for service periods prior to grant approval date by written guidance to all staff involved in federal ...

Finding 2024-001 Condition: Costs were recorded for service periods prior to grant approval date. Corrective Action Planned: The district will implement controls to prevent the recording of costs for service periods prior to grant approval date by written guidance to all staff involved in federal grant funds. Please note, that the practice at question is not in violation of school committee policy as we have not made any expenditures outside that entity’s approval date. Anticipated Completion Date: By July 1, 2025 Contact: Ross Mulkerin, Director of Finance and Operations

View Audit 352205 Questioned Costs: $1

Finding 553626 (2024-004)

Significant Deficiency 2024

Town of Bridgwater, Vermont

VT

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

Finding: 2024-004 Written Financial Policies- Activitities Allowable, Allowable Cost Name of responsible official: Melissa Spear -Treasurer Corrective action: Adopt suggested policies as outlined by auditor. Anticipated completion date: June 30, 2025

View Audit 352202

Finding 553591 (2024-002)

Significant Deficiency 2024

Eastern Virginia Medical School

VA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.1 § 200.403

Finding 2024-02: Indirect Costs (IDC) Views of Responsible Officials Management agrees with the finding and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the accuracy of the review over indirect costs calcu...

Finding 2024-02: Indirect Costs (IDC) Views of Responsible Officials Management agrees with the finding and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the accuracy of the review over indirect costs calculation requirements. Corrective Action Plan Effective July 1, 2024, EVMS merged with ODU and the ODU Research Foundation became the fiscal and administrative agent for EVMS’s transferring sponsored programs on behalf of ODU. As per ODU’s Memorandum of Understanding (MOU) with the ODU Research Foundation, the ODU Research Foundation has policies and processes in place to manage how the indirect costs are calculated. The ODU Research Foundation uses its own system of internal controls for IDC calculation with no reliance on ODU systems for those processes and are audited separately. As a corrective action moving forward, ODU management will notify the ODU Research Foundation management of the audit findings, so they are aware of the internal control deficiencies. ODU will request the Research Foundation to provide a copy of their single audit report to monitor continued compliance with Uniform Guidance. The corrective action plan will be completed by March 31, 2025 and the contact person for this finding is Victoria Dean.

View Audit 352191 Questioned Costs: $1

Finding 553590 (2024-002)

Significant Deficiency 2024

City of Dowagiac

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Equipment & Real Property Management

Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Ac...

Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Action: The City will implement a new policy document specifically for Uniform Grant Compliance to have one document to ensure compliance.

View Audit 352186

Finding 553584 (2024-009)

Significant Deficiency 2024

City of South Portland, Maine

ME

Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Management’s Response/Corrective Action Plan: This program received significantly more distributions in 2024 than the City had received in the past. The funds initially were not considered to be federal since the source was private companies, but staff has since taken required grant agency training...

Management’s Response/Corrective Action Plan: This program received significantly more distributions in 2024 than the City had received in the past. The funds initially were not considered to be federal since the source was private companies, but staff has since taken required grant agency training. The City is implementing workflow for purchasing and credit card transactions which will provide electronic approvals and the ability to attach receipts.

View Audit 352169

Finding 553579 (2024-006)

Material Weakness 2024

City of South Portland, Maine

ME

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Management’s Response/Corrective Action Plan: Management will have staff prepare monthly personnel activity reports for time worked on grants and will review and adjust budgeted payroll allocations accordingly. Monthly budget report have already been set up on the Google Drive for management and sta...

Management’s Response/Corrective Action Plan: Management will have staff prepare monthly personnel activity reports for time worked on grants and will review and adjust budgeted payroll allocations accordingly. Monthly budget report have already been set up on the Google Drive for management and staff to access and review.

View Audit 352169

Finding 553578 (2024-005)

Material Weakness 2024

City of South Portland, Maine

ME

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.402

Management’s Response/Corrective Action Plan: Management will reconcile reimbursement requests to general ledger detail and review available grant amounts before submitting the drawdown.

View Audit 352169 Questioned Costs: $1

Finding 553575 (2024-008)

Significant Deficiency 2024

City of South Portland, Maine

ME

Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Management’s Response/Corrective Action Plan: The Director and Operations Manager abruptly left in spring of 2024, leaving the Finance Department to take over all financial functions. The City contracted with Greater Portland Metro to run the service until we could determine next steps. The City Co...

Management’s Response/Corrective Action Plan: The Director and Operations Manager abruptly left in spring of 2024, leaving the Finance Department to take over all financial functions. The City contracted with Greater Portland Metro to run the service until we could determine next steps. The City Council approved joining Greater Portland Metro in September 2024, effective January 2025. The City no longer has a bus service.

View Audit 352169

Finding 553486 (2024-004)

None 2024

University of Southern California

CA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.403

Management’s Views and Corrective Action Plan Management response to finding 2024-004: Review over cost transfers of subrecipient expenditures Cluster Name: Research and Development Federal Awarding Agency: Various Award Name: Various Award Number: Various Award Years: Various Assistance Listing T...

Management’s Views and Corrective Action Plan Management response to finding 2024-004: Review over cost transfers of subrecipient expenditures Cluster Name: Research and Development Federal Awarding Agency: Various Award Name: Various Award Number: Various Award Years: Various Assistance Listing Title: Various Assistance Listing Number: Various Pass-through entities: Various As described in Finding 2024-004, and as a result of improper training related to the implementation of the university’s new financial system in FY22, the university lacked adequate controls to identify the proper application of indirect costs as it relates to subrecipient expenses when using the cost transfer process to make corrections. Additionally, the university failed to properly apply its policy for the classification of subawards versus direct expenditures. As such, while cost transfers are a small percentage of overall transfer activity, an update to training materials will be made by June 2025 to educate cost transfer initiators on the proper method to use for this subset of subrecipient expenditures. Since February 2025, the Sponsor Projects Accounting (SPA) representative responsible for central office review of cost transfers now reviews to ensure that all intended grant related attributes are in effect before approving any subrecipient cost transfers. Additionally, as of February 2025, the university reinforced its policy regarding the classification of subawards versus direct expenditures with both the Procurement department and the SPA staff to ensure the proper expenditure classification is set up during the onboarding process of a contractor. The SPA team has completed its analysis and review of all previous subrecipient cost transfers to verify and correct the improper application of indirect cost limits and expenditure classifications. As of March 2025, all subrecipient cost transfer errors have been identified and corrected, resulting in questioned costs of approximately $587,000. Separately, this resulted in an under-recovery of $306,000 of indirect costs that were not charged to the original award. As all awards impacted are still open and active, the correcting expenditure adjustments were applied to the awards impacted that will affect future draw downs. Contact Person: Cindy Lee, Director, Sponsored Projects Accounting, cmlee@usc.edu

View Audit 352166

Finding 553485 (2024-003)

None 2024

University of Southern California

CA

Questioned Costs Allowable Costs / Cost Principles § 200.403

Management’s Views and Corrective Action Plan Management response to finding 2024-003: Unallowable costs – Cost transfers based on budgeted amounts Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Leveraging natural phenotypic vari...

Management’s Views and Corrective Action Plan Management response to finding 2024-003: Unallowable costs – Cost transfers based on budgeted amounts Cluster Name: Research and Development Federal Awarding Agency: Department of Health and Human Services Award Name: Leveraging natural phenotypic variations of heterogenous ALS populations-in-a-dish to enable scalable drug discovery Award Number: 5R01NS131409-03 Award Years: 2022-2025 Assistance Listing Title: Extramural Research Programs in the Neurosciences and Neurological Disorders Assistance Listing Number: 93.853 Pass-through entities: Not applicable As described in finding 2024-003, the university inadvertently processed a cost transfer moving expenses from one grant to another based on budgeted figures instead of actual expenses incurred. This resulted in an amount transferred that was greater than the actual costs incurred. The administrator in question has been identified and further review of this administrator’s work has been performed to determine if additional instances occurred. Upon review of the administrator’s work, it was determined that no additional corrections were required as no other instances of this nature were identified outside of the total questioned costs. As part of the department’s efforts to minimize further cost transfer errors, training was provided to all their grant administrators beginning November 1, 2024. This training will now be held annually to ensure the department responsible for administering the award is current on the University’s existing compliance policies. Furthermore, to support accuracy and transparency, the department will allocate separate time commitments during weekly administration meetings to review any required cost transfers. This time will be dedicated to ensuring proper documentation is in place, confirming the appropriateness of the transfer, and ensuring full compliance of the transaction(s). This updated review process involves representatives from Grant Administration, Keck School of Medicine Finance Office, and Purchasing, to ensure a full comprehensive review of each transfer. As such, beginning November 2024, a cost transfer will not move forward until it has been reviewed by the group. Contact Person: Andres Chan, Director, FBS Financial Analysis, andres.chan@usc.edu

View Audit 352166 Questioned Costs: $1

Corrective Action Plans

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