Corrective Action Plans

Finding 555642 (2024-001)

None 2024

ME

Reporting Allowable Costs / Cost Principles § 200.512

Views of Responsible Offices and Planned Corrective Action: We plan on verifying that the submission to the Federal Audit Clearinghouse is completed in a timely manner.

View Audit 354240

Finding 555600 (2024-002)

Significant Deficiency 2024

Wings Academy I

OH

Questioned Costs Allowable Costs / Cost Principles § 200.303

Finding Number: 2024-002 Planned Corrective Action: The school acknowledges the lack of sufficient internal controls in place to ensure that only allowable costs are charged to federal grants. These funds as identified under audit, will be repaid to the appropriate agency, accordingly. A corrective ...

Finding Number: 2024-002 Planned Corrective Action: The school acknowledges the lack of sufficient internal controls in place to ensure that only allowable costs are charged to federal grants. These funds as identified under audit, will be repaid to the appropriate agency, accordingly. A corrective action will be implemented, to include a review the federal award allowable uses and implementation of a process to ensure that costs are allowable prior to payment. Anticipated Completion Date: June 30, 2025 Responsible Contact Person: Stephanie Ataya, Treasurer

View Audit 354101 Questioned Costs: $1

Finding 555554 (2024-003)

Material Weakness 2024

San Bernardino City Unified School District

CA

Allowable Costs / Cost Principles Reporting Subrecipient Monitoring

When this matter was brought to the District's attention it was too late to adjust for FY 2023-2024 but the District took steps to ensure all ESSER Funds impacted were fully expended and the indirect charges were ultimately balanced out.

View Audit 354064

Finding 555545 (2024-002)

Material Weakness 2024

San Bernardino City Unified School District

CA

Questioned Costs Allowable Costs / Cost Principles

When this matter was brought to the District's attention it was too late to adjust for FY 2023-2024 but the District took steps to ensure all ESSER Funds impacted were fully expended and the indirect charges were ultimately balanced out.

View Audit 354064 Questioned Costs: $1

Finding 555534 (2024-004)

Material Weakness 2024

San Bernardino City Unified School District

CA

Questioned Costs Allowable Costs / Cost Principles

When this matter was brought to the District's attention it was too late to adjust for FY 2023-2024 but the District took steps to ensure all federal funds impacted were fully expended and the indirect charges were ultimately balanced out.

View Audit 354064 Questioned Costs: $1

Finding 555525 (2024-001)

None 2024

Indiana Housing and Community Development Authority

IN

Questioned Costs Allowable Costs / Cost Principles § 200.403

Corrective Action Plan for finding number 2024-001 Corrective action to be taken: The COVID-19 Emergency Rental Assistance program ceased accepting new applications on March 28, 2025. Prior to that a quality control process was in place to review applications before they were approved for payment ...

Corrective Action Plan for finding number 2024-001 Corrective action to be taken: The COVID-19 Emergency Rental Assistance program ceased accepting new applications on March 28, 2025. Prior to that a quality control process was in place to review applications before they were approved for payment to try to catch errors such as this. No further benefit payments will be issued as the program is being closed out. We have created a new internal review section that will focus on reviewing all potential issues identified. We have also engaged KPMG, LLP to audit any payments made that may be subject to recapture. Anticipated completion date All efforts are already under way and every attempt will be made to recapture any overpayments prior to monitoring (yet to be announced) by the U.S Department of the Treasury. Contact for the corrective action S. Kyleen Welling, Chief of Staff and Chief Operating Officer

View Audit 354055 Questioned Costs: $1

Finding 555439 (2024-005)

Significant Deficiency 2024

Grant County

NM

Cash Management Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.302 § 200.318

Views of Responsible Officials and Planned Corrective Action The County has a written policy regarding Federal Grants that was passed by the Grant County Commissioners in January 2025. Finding resolution timeline: Resolved. Designation of employee position responsible for meeting this deadline: ...

Views of Responsible Officials and Planned Corrective Action The County has a written policy regarding Federal Grants that was passed by the Grant County Commissioners in January 2025. Finding resolution timeline: Resolved. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager

View Audit 354003

Finding 555374 (2024-001)

Significant Deficiency 2024

Topos Institute

WA

Questioned Costs Allowable Costs / Cost Principles

Finding Number 2024-001 Contact Persons: Brendan Fong and Beth Williams Topos will follow the following steps: Corrective action planned Anticipated Completion Date Add a step in the month-end close process to include a review of costs at least quarterly (if not monthly) to identify inaccurately cod...

Finding Number 2024-001 Contact Persons: Brendan Fong and Beth Williams Topos will follow the following steps: Corrective action planned Anticipated Completion Date Add a step in the month-end close process to include a review of costs at least quarterly (if not monthly) to identify inaccurately coded transactions. Feb-Apr 2025 Create an unallowable cost tag for entries and re-train the Office Manager to better identify unallowable costs at the point of entry. Done Second party review prior to match in QBO for unallowable cost and prepaid identification. Feb 2025 Prepare an initial draft of the indirect cost proposal at fiscal year end (prior to YE close). Nov 2025 Communicate reminder to PIs about internal controls policies and procedures for expenses reimbursed by federal grants, including ensuring all expenses should be made within the period of performance, and getting written approval from program managers for changes. Mar 2025 Topos considers the above steps sufficient and adequate to close the gaps in the coding errors of transactions that may have permitted unallowable costs. These steps will increase the effectiveness of identifying transactions and allow for appropriate tracking of costs. This will remedy the lapse in effectiveness experienced by Topos’ internal controls over allowable costs.

View Audit 353994 Questioned Costs: $1

Finding 555356 (2024-003)

Material Weakness 2024

Micro Entrerprise Services of Oregon

OR

Allowable Costs / Cost Principles Material Weakness

Finding # 2024-003 Type: Material weakness over allowable costs A.L. 14.218 U.S. Department of Housing and Urban Development A.L. 21.027 U.S. Department of Treasury Material Weakness Invoices submitted to funding agencies did not have documented review and approval for 8 of 13 invoices reviewed....

Finding # 2024-003 Type: Material weakness over allowable costs A.L. 14.218 U.S. Department of Housing and Urban Development A.L. 21.027 U.S. Department of Treasury Material Weakness Invoices submitted to funding agencies did not have documented review and approval for 8 of 13 invoices reviewed. Corrective Action: As of February 2025, we have implemented a process to document the review and approval of invoices by the grants manager. Anticipated Completion Date February 28, 2025

View Audit 353993

Finding 555350 (2024-002)

Material Weakness 2024

Micro Entrerprise Services of Oregon

OR

Allowable Costs / Cost Principles Material Weakness

Finding # 2024-002 Type: Material weakness Type: Material noncompliance over allowable costs A.L. 14.218 U.S. Department of Housing and Urban Development A.L. 21.027 U.S. Department of Treasury Material Weakness/Material Noncompliance Personnel expenses charged to federal awards must be supporte...

Finding # 2024-002 Type: Material weakness Type: Material noncompliance over allowable costs A.L. 14.218 U.S. Department of Housing and Urban Development A.L. 21.027 U.S. Department of Treasury Material Weakness/Material Noncompliance Personnel expenses charged to federal awards must be supported records that reflect the time worked charged to the award. The Organization charged personnel expenses based on approved budgeted amounts in the award agreement for 12 of 64 items tested. Corrective Action: We will implement additional training with employees on tracking time as well as develop an improved timesheet process. We are also in the process of implementing a new payroll system to ensure integration with the accounting system. Anticipated Completion Date July 1, 2025

View Audit 353993

Finding 555344 (2024-003)

Material Weakness 2024

California State University

CA

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

The University concurs with the recommendations. The University will review and enhance its procedures and internal controls to monitor or ensure the completeness and accuracy of all federal grants, to ensure they are separately recorded within the general ledger and all expenditures and activities ...

The University concurs with the recommendations. The University will review and enhance its procedures and internal controls to monitor or ensure the completeness and accuracy of all federal grants, to ensure they are separately recorded within the general ledger and all expenditures and activities are processed in accordance with applicable federal guidelines. The University will implement effort reporting procedures for the SNAP Cluster program that include accounting for all employee activities for the program and implement appropriate controls to ensure costs charges to the SNAP program are based on actual costs incurred and are properly determined and calculated based upon the Uniform Guidance allowable costs criteria.

View Audit 353990 Questioned Costs: $1

Finding 555210 (2024-002)

Significant Deficiency 2024

Housing Authority of the Township of Neptune

NJ

Allowable Costs / Cost Principles HUD Housing Programs § 200.438

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Section 8 Vouchers Programs to ensure that established internal control policies are being followed on a t...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Section 8 Vouchers Programs to ensure that established internal control policies are being followed on a timely basis. Bart Cook, Executive Director, is responsible for implementing this corrective action by September 30, 2025.

View Audit 353830

Finding 555173 (2024-004)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director ...

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limted to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555172 (2024-003)

None 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

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

Identifying Number: 2024-003 Finding: Reporting Context: An incorrect progress report was submitted to the grantor. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-...

Identifying Number: 2024-003 Finding: Reporting Context: An incorrect progress report was submitted to the grantor. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational cjanges such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequesntly. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775

Finding 555171 (2024-002)

Material Weakness 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office...

Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Correcting the gaps between invoicing processes and collecting the Departments/AP proof of payment b. Returning overpayments, if applicable c. Implementing organizational changes such as updated policies and/or procedures d. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices duing the Grant management processes. Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Create processes in which we will adopt verification procedures for invoices and collections. - Create/update Standard Operating Procedures (SOPs) - Provide our team with updated training material (working practice guidelines - WPGs), so they have clear expectations and understand our compliance mechanism. - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555170 (2024-001)

None 2024

Miami Children's Health System, Inc. D/b/a Nicklaus Children's Health

FL

Questioned Costs Allowable Costs / Cost Principles

Identifying Number: 2024-001 Finding: Allowable Costs/Cost Principles Context: The System received funding that was not net of appliccable credits. The funding received from the grantor was the full invoice amount, howver, the actual expenditure was net of applicable credits ($6,945). Corrective Act...

Identifying Number: 2024-001 Finding: Allowable Costs/Cost Principles Context: The System received funding that was not net of appliccable credits. The funding received from the grantor was the full invoice amount, howver, the actual expenditure was net of applicable credits ($6,945). Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Correcting the gaps between invoicing processes and collecting the Departments/AP proof of payment b. Returning overpayments, if applicable c. Implementing organizational changes such as updated policies and/or procedures d. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process Planning Process Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Processes in which we will adopt verification procedures for invoices and collections. - Create/update Standard Operating Procedures (SOPs). - Provide our team with updated training material (working pratice guidelines -WPGs), so they have clear expectations and understand our compliance mechanism. - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP tean, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implemeting new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processes more frequently. Deadline for Implementation: Immediate action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs). Checklists and training/retraining sessions for stakeholders and OSP team members.

View Audit 353775 Questioned Costs: $1

Finding 555167 (2024-001)

Material Weakness 2024

Movement Strategy Center

CA

Questioned Costs Allowable Costs / Cost Principles § 200.430

FINDINGS – Single Audit Audit Finding Summary: 2024-001 The organization failed to implement adequate internal controls to ensure compliance with federal timekeeping and documentation requirements for personnel expenses. Additionally, there appears to be a lack of understanding of the documentation...

FINDINGS – Single Audit Audit Finding Summary: 2024-001 The organization failed to implement adequate internal controls to ensure compliance with federal timekeeping and documentation requirements for personnel expenses. Additionally, there appears to be a lack of understanding of the documentation and certification requirements under 2 CFR Part 200, Subpart E. Corrective Action Plan: Contact Person Responsible for Corrective Action: Marilyn Lovelace-Grant, Chief People and Culture Officer marilyn@movementstrategy.org | (510) 414-2674 Planned Action: MSC acknowledges the importance of accurate time and effort reporting in accordance with 2 CFR 200.430. To address the identified deficiencies, we will implement the following corrective measures. Policy and Procedure Enhancement: MSC is developing and implementing updated policies to ensure compliance with federal grant requirements. Employees who charge 100% of their time to a federal grant will be required to submit semi-annual certifications, while those working across multiple activities will maintain detailed time and effort reports aligned with federal guidelines. Improved Documentation and Controls: A standardized timekeeping and certification system will be enforced, requiring supervisory review and approval for all-time records. This will ensure that all reported work is properly documented and verified. Training and Compliance Monitoring: MSC will provide training for employees and supervisors to enhance their understanding of federal grant timekeeping and documentation requirements. Regular Internal Reviews: A periodic internal review process will be established to verify the accuracy and completeness of timekeeping records and ensure compliance with federal regulations. Resolution of Questioned Costs: MSC will work directly with the federal awarding agency to resolve the identified $50,000 in questioned costs and implement any additional corrective actions deemed necessary Expected Completion Date: September 30, 2025

View Audit 353769 Questioned Costs: $1

Finding 555112 (2024-002)

Material Weakness 2024

Urban Affairs Coalition

PA

Allowable Costs / Cost Principles Material Weakness Reporting

2024-002 Material Weakness in Internal Control over Compliance 21.023- Emergency Rental Assistance 93.914 – HIV Prevention 93.959 – Block Grants for Prevention and Treatment of Substance Abuse City of Philadelphia, Office of Addition Services (Contract # 22-20537-01) City of Philadelphia, Divi...

2024-002 Material Weakness in Internal Control over Compliance 21.023- Emergency Rental Assistance 93.914 – HIV Prevention 93.959 – Block Grants for Prevention and Treatment of Substance Abuse City of Philadelphia, Office of Addition Services (Contract # 22-20537-01) City of Philadelphia, Division of HIV Health (Contract #21-20003-03 and 22-20537-02) Philadelphia Housing Development Corporation (Contract # 21-20469) Condition: As part of the audit management was to provide us with a complete final trial balance where balances agree to the supporting schedules, reconciliations and documentation provided by management. We noted that the trial balance and general ledger detail reports originally provided by management were (a) delayed, (b) included unreconciled material account balances, (c) multiple journal entries (material and not material), (c) transactions missing from the trial balance, and (d) some reconciliations that either did not agree with the trial balance or individual transactions could not be traced back from the documentation provided to the general ledger. This had caused delays in the completion of the audit, preparation of financial statements, and associated disclosures and the timely arrival of our audit and single audit conclusion. Recommendation: We recommend that management implement policies and procedures as it relates to the reconciliation of accounts, tracking of transactions, and regular review to ensure that calculations of general ledge account balances are accurate and complete. In addition, we continue to recommend that management revisit its financial closing and reporting policies to include updates to its procedures for year-end closes and the timing of when final journal entries and analysis are performed. Repeat Finding: Yes Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Management recognizes the recent delays in timely and accurate financial information and is committed to improving. We will implement updated procedures to ensure the swift and precise presentation of a complete final trial balance that aligns perfectly with the supporting schedules, reconciliations, and documentation. Our enhanced processes will involve promptly recording revenues and expenses, regularly reconciling bank records with accounts, and minimizing journal entries outside the appropriate period. The accounting staff has faced challenges meeting deadlines due to unexpected health issues and recent turnover within the team. Despite these obstacles, we are focused on optimizing our resources and enhancing our efficiency to ensure that tasks are completed on time. Planned completion date for corrective action plan: June 30, 2025

View Audit 353710

Finding 555100 (2024-002)

Material Weakness 2024

Human Resource Development Institute

IL

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

The Organization will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hir...

The Organization will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll and Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist. • The Organization’s Human Resources has implemented quarterly audits on all new staff to verify each new staff member hired within the last year has a signed employee offer and appropriate backup support to support each employee’s annual salary. • The Organization has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • The Organization has implemented a new payroll and human resources IT solution – UKG. All manual and onboarding processes have been implemented within the system for tracking and auditing purposes. • The Organization will implement an established month-end checklist for all monthly entries to be completed by assigned finance staff. We will ensure that all staff are trained adequately to handle any assigned task. All monthly entries are required to be reviewed and approved by the Chief Financial Officer prior to posting to the general ledger within our new Accounting Software. All appropriate backup documentation will be saved and stored within the accounting software. • All grant related year-end audit procedures has been transitioned to the Grant Accountant who has experience with audits, compliance, and reporting for City, State, and Federal grants. • The Organization has documented accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies. • The Organization will ensure that Finance personnel receive a minimum of twenty-five (25) hours of training annually of relevant accounting topics including updates to generally accepted accounting principles, generally accepted government accounting principles, nonprofit and governmental financial reporting, and other related accounting trainings. • The Organization will ensure that any personnel involved in financial reporting have the technical expertise to help with the preparation, review, and analysis of the financial statements and supplementary information. The target date for implementation is April 2025. The responsible party for the planned resources will be Raheel Shahzad, Chief Financial Officer (708) 288-7897. Our address is 340 E. 51st St., Chicago, IL 60615.

View Audit 353697

Finding 554986 (2024-003)

Significant Deficiency 2024

Baptist Health Deaconess Madisonville, Inc.

KY

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding 2024-003 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities All...

Finding 2024-003 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: BHD, LLC calculated their indirect cost rate based on the total grant budget and claimed an equal amount of indirect costs per month instead of calculating the indirect cost rate per direct expenditures for each month. Responsible Individuals: Valarie Howard, Chief Financial Officer Corrective Action Plan: Historically, the indirect cost received by this grant has not been dependent of the direct expenditures. Based on verbal conversations with the HRSA grant project manager, requesting reimbursement for the indirect costs evenly over the year based on the budget submitted was acceptable. Therefore, the accounting treatment has been reflective of that. However, management agrees that recording the indirect cost based on the direct cost expenditures monthly is reasonable and appropriate and will make the change accordingly. Anticipated Completion Date: March 31, 2025.

View Audit 353595

Finding 554985 (2024-001)

Significant Deficiency 2024

New Mexico Veterans Integration Centers

NM

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.403 § 200.414

View of Responsible Officials and Corrective Action Plan We acknowledge the findings and appreciate the diligence of the audit team in identifying the discrepancies in our indirect cost calculations and reporting as outlined in the draft findings. The Veterans Integration Center (VIC) is committed t...

View of Responsible Officials and Corrective Action Plan We acknowledge the findings and appreciate the diligence of the audit team in identifying the discrepancies in our indirect cost calculations and reporting as outlined in the draft findings. The Veterans Integration Center (VIC) is committed to maintaining the highest standards of compliance with all federal regulations and grant requirements. Corrective Action Plan 1. Training and Guidelines: All relevant staff will undergo training to understand and implement the correct procedures for calculating indirect costs. Comprehensive guidelines will be developed and disseminated to ensure consistency across all calculations and reporting. 2. Completion of SF-425 Jointly: The COO, and VIC’s contracted Accountant will confirm the accurate Modified Total Direct Costs (MTDC) which is to be used in completing the SF-425, then prepare the GPD SF-425 jointly to ensure its accuracy. 3. Review and Approval Process: An additional layer of review and approval will be established for all indirect cost calculations before they are reported. This step will involve our Chief Executive Officer (CEO) to ensure accuracy and compliance. Corrective Action Plan Timeline • Staff Training and Guidelines Distribution: Completed by Q4 2025 • Completion of SF-425 Jointly: Starting Q3 2025 with SF-425 revision • Review and Approval Process: Effective immediately, with CEO, reviews starting Q3 2025 Designation of Employee Position Responsible for Meeting Deadline The Chief Operating Officer (COO) will be responsible for the oversight and successful implementation of the corrective action plan. The COO will coordinate with the contracted internal Accountant to ensure all actions are taken within the stipulated timelines and report directly to the Chief Executive Officer on the progress.

View Audit 353588 Questioned Costs: $1

Finding 554967 (2024-004)

Material Weakness 2024

Herron High School, Inc.

IN

Allowable Costs / Cost Principles Significant Deficiency § 200.430

Education Stabilization Fund – AL #84.425 2024-004 Noncompliance – Payroll Allocation Support Significant Deficiency Recommendation: The Auditor recommended the Organization develop internal controls to ensure proper documentation to support the allocation of payroll is maintained. Planned Correctiv...

Education Stabilization Fund – AL #84.425 2024-004 Noncompliance – Payroll Allocation Support Significant Deficiency Recommendation: The Auditor recommended the Organization develop internal controls to ensure proper documentation to support the allocation of payroll is maintained. Planned Corrective Action: Due to personnel changes, the necessary documentation of payroll allocations was not properly maintained. Clear records, with support regarding how amounts were determined for each payroll, shall be documented and matched to accounting files. Michelle Krauter, VP, Chief Financial Officer, will ensure the work performed and corresponding wages applicable to the grant programs is not only within budget but easily identifiable as a proper calculation. www.herronclassical.org Diverse. Tuition-Free. College Prep. If the U.S. Department of Education has questions regarding this plan, please call Michelle Krauter, Vice President, Chief Financial Officer at 317.231.0010

View Audit 353584

Finding 554946 (2024-002)

Significant Deficiency 2024

Ascentria Community Services, Inc.

MA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: It is recommended that the Organization design controls to ensure expenses are supported by source documentation and allowable...

U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: It is recommended that the Organization design controls to ensure expenses are supported by source documentation and allowable costs under the grant or contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing standard operating procedures with the program staff. All expenses will be supported with source documentation. Management will perform periodic reviews to ensure expenses are supported by source documentation and allowable expenses under the grant. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris Planned completion date for corrective action plan: June 30, 2025

View Audit 353549 Questioned Costs: $1

Finding 554942 (2024-003)

Significant Deficiency 2024

Community Health & Wellness Partners of Logan County

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Reimbursement requests should be reviewed by the CFO for all grants before submission to the grantor ...

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Reimbursement requests should be reviewed by the CFO for all grants before submission to the grantor to ensure that employees charged to the grants are different, in addition, timesheets should be reviewed during the grant reimbursement process to ensure time supports the specific grant and allowable costs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The CFO will review all grant submissions based on personnel costs each month and ensure that there are no duplicate billings and that timesheets appropriately reflect staff involvement. Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025

View Audit 353547 Questioned Costs: $1

Finding 554940 (2024-001)

Significant Deficiency 2024

Community Health & Wellness Partners of Logan County

OH

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information...

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information is complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CHWP has made enhancements to its financial reporting structure and used this in calculating the UOS data for CY 2024. We believe that we documented the numbers appropriately but will make sure that we continue to comply with this requirement in future UOS reporting, Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025.

View Audit 353547

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