Corrective Action Plans

Finding 1157179 (2024-001)

Material Weakness 2024

NV

Questioned Costs Allowable Costs / Cost Principles Eligibility

The Just One Project's CSFP team will maintain a filing system organized by service site, alphabetical client name, and month and year of registration. The team will also utilize the Salesforce system to track registered clients, recertification dates, and services provided each day. Effective immed...

The Just One Project's CSFP team will maintain a filing system organized by service site, alphabetical client name, and month and year of registration. The team will also utilize the Salesforce system to track registered clients, recertification dates, and services provided each day. Effective immediately, designated CSFP staff will visit all active distribution sites each business day to collect new registration and recertification forms, cross-check them and previously filed forms against the day's Salesforce distribution list, and file new forms in the designated system. This will ensure every client record is complete and current. In addition, the team will conduct an internal audit at least annually to confirm that all participant files contain required documents and certifications, promptly address any deficiencies, and document corrective steps. Staff will also receive periodic refresher training to reinforce record-keeping standards and sustain compliance.

View Audit 369485

Finding 1157177 (2024-004)

Material Weakness 2024

Big Valley Rancheria Band of Pomo Indians

CA

Allowable Costs / Cost Principles Questioned Costs § 200.303

Individual(s) Responsible: Enrique Martinez, Grant Manager and Program Director Action: Management will implement a process to ensure all expenditures are properly documented and reviewed for allowability before being charged to the Program. Staff will be trained on documentation and compliance requ...

Individual(s) Responsible: Enrique Martinez, Grant Manager and Program Director Action: Management will implement a process to ensure all expenditures are properly documented and reviewed for allowability before being charged to the Program. Staff will be trained on documentation and compliance requirements. Internal controls will be strengthened to prevent unallowable costs. Anticipated Completion Date: December 31, 2025

View Audit 369484 Questioned Costs: $1

Finding 1157171 (2024-003)

Material Weakness 2024

Transition Resource Action Center

TX

Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.430

The exceptions resulted from delays in updating payroll/timekeeping systems and insufficient documentation to support allocation changes. To correct this, TRAC has implemented a Position Control Update process: any change to an employee’s grant allocation must be documented on a Position Control Upd...

The exceptions resulted from delays in updating payroll/timekeeping systems and insufficient documentation to support allocation changes. To correct this, TRAC has implemented a Position Control Update process: any change to an employee’s grant allocation must be documented on a Position Control Update form, signed by the Finance Director, and entered into the payroll system within 5 business days of the change. Additionally, the Finance team performs monthly reconciliations between timecards, payroll registers, and the general ledger to ensure that payroll charges are accurate and properly supported before being billed to grants. Completion Date: October 1, 2025. Responsible Parties: Nicole Binkley, Chief Executive Officer Josh Runnels, Director of Finance and Operations

View Audit 369477

Finding 1157170 (2024-002)

Material Weakness 2024

Transition Resource Action Center

TX

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs § 200.430

At the time of the audit period, TRAC was newly independent from CitySquare and had not yet integrated supervisor approval of timecards into its internal control systems. This gap contributed to missing approvals during the transition year. As of September 2024, TRAC implemented employee and supervi...

At the time of the audit period, TRAC was newly independent from CitySquare and had not yet integrated supervisor approval of timecards into its internal control systems. This gap contributed to missing approvals during the transition year. As of September 2024, TRAC implemented employee and supervisor approvals of timecards within the time keeping system. Additionally, the organization has and will continue to implement a thorough review process that will include the following:  Employee acknowledgement of their individual grant allocation  Employee approval of their timecard  Manager acknowledgment of their individual grant allocation as well as the allocation of each employee they supervise  Manager approval of each employee’s timecard  The finance team will review each timecard individually prior to charging salary costs to grants. This process ensures that time and effort documentation is complete, approved, and compliant with federal and state requirements. Compliance with this policy will be monitored monthly by the Finance Director to ensure continued adherence.Completion Date: October 1, 2025.Responsible Parties: Nicole Binkley, Chief Executive Officer Josh Runnels, Director of Finance and Operations

View Audit 369477

Finding 1157133 (2024-002)

Material Weakness 2024

Edna Martin Christian Center, Inc.

IN

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.308

The purchase of the grant management system will interface directly with the organization’s accounting software, allowing for the automated extraction of financial data. This data will be systematically mapped to the corresponding budgetary lines of each grant to ensure accurate tracking and reporti...

The purchase of the grant management system will interface directly with the organization’s accounting software, allowing for the automated extraction of financial data. This data will be systematically mapped to the corresponding budgetary lines of each grant to ensure accurate tracking and reporting. On a monthly basis, the Financial Grant Coordinator will collaborate with Senior Directors and Program Directors to review financial activity. These reviews aim to verify that expenditure aligns with the allowable costs defined by each grant, ensuring full compliance with funding requirements. Corrective: Budget vs. actual reviews are conducted with senior directors to evaluate financial performance and ensure alignment with programmatic, administrative, and funding guidelines. During these reviews, directors assess which costs are permissible and identify any expenditure that falls outside allowable parameters. Non-compliant costs are reallocated to appropriate programs that permit such expenses or to administrative accounts as necessary.

View Audit 369464

Finding 1157132 (2024-001)

Material Weakness 2024

Edna Martin Christian Center, Inc.

IN

Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking § 200.303

The purchase of the grant management system will interface directly with the organization’s accounting software, allowing for the automated extraction of financial data. This data will be systematically mapped to the corresponding budgetary lines of each grant to ensure accurate tracking and reporti...

The purchase of the grant management system will interface directly with the organization’s accounting software, allowing for the automated extraction of financial data. This data will be systematically mapped to the corresponding budgetary lines of each grant to ensure accurate tracking and reporting. On a monthly basis, the Financial Grant Coordinator will collaborate with Senior Directors and Program Directors to review financial activity. These reviews aim to verify that expenditure aligns with the allowable costs defined by each grant, ensuring full compliance with funding requirements. Corrective: Budget vs. actual reviews are conducted with senior directors to evaluate financial performance and ensure alignment with programmatic, administrative guidelines, and funding guidelines. During these reviews, directors assess which costs are permissible and identify any expenditure that falls outside allowable parameters. Non-compliant costs are reallocated to appropriate programs that permit such expenses or to administrative accounts as necessary.

View Audit 369464 Questioned Costs: $1

Finding 1157131 (2024-002)

Material Weakness 2024

Ashtabula Metropolitan Housing Authority

OH

Questioned Costs HUD Housing Programs Allowable Costs / Cost Principles § 200.403

All five (5) properties were SOLD

View Audit 369463 Questioned Costs: $1

Finding 1157118 (2024-001)

Material Weakness 2024

American College of Occupational and Environmental Medicine

IL

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

To ensure compliance with grant requirements and address the issue with employee timecards and vouchers submitted, the following steps will be implemented: 1. Time Tracking: Employees will continue to be required to record their time every two weeks (through HourTimeSheet), ensuring that the hours w...

To ensure compliance with grant requirements and address the issue with employee timecards and vouchers submitted, the following steps will be implemented: 1. Time Tracking: Employees will continue to be required to record their time every two weeks (through HourTimeSheet), ensuring that the hours worked align with the percentage of time allocated to the grant for those two weeks. 2. Clear Communication: The Project Director will clarify the importance of matching monthly hours with the percentage allocated to all staff participating in the grant. This will help prevent misunderstandings regarding time reporting. 3. Reviews: The Project Director will continue to conduct monthly reviews of timecards to verify that reported hours correspond with the grant’s allocation requirements before submitting vouchers. By implementing these measures, we aim to ensure that timecards accurately reflect the allocation of employee-related costs on a monthly basis, promoting compliance with grant requirements moving forward.

View Audit 369421

Finding 1157101 (2024-001)

Material Weakness 2024

Maryland Mep, Inc.

MD

Allowable Costs / Cost Principles

2024-001 Allowability Manufacturing Extension Partnership – Assistance Listing No. 11.611 Recommendation: We recommend that the Organization update the cost allocation plan for shared administrative expenses. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...

2024-001 Allowability Manufacturing Extension Partnership – Assistance Listing No. 11.611 Recommendation: We recommend that the Organization update the cost allocation plan for shared administrative expenses. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. CORRECTIVE ACTION PLAN Action taken in response to finding: Maryland MEP will update the cost allocation process to include a review of the allocation of all costs, including payroll processing fees. Through this update, Maryland MEP will ensure all costs are allowable and that all shared administrative expenses are allocated and attributed to all of Maryland MEP’s programs in a manner consistent with the organizational policy. In addition to updating the cost allocation process, Maryland MEP will ensure effective controls are in place to review the allocation performed on a regular basis. Name of the contact person responsible for corrective action: Michael Kelleher Planned completion date for corrective action plan: 10/31/2025

View Audit 369415

Finding 1157098 (2024-002)

Material Weakness 2024

Boys & Girls Clubs of Central Nh INC

NH

Allowable Costs / Cost Principles

View of Responsible Officials and Planned Corrective Action: The Club has reviewed the findings and acknowledges the importance of documented controls over federal expenditures. The expenses noted were submitted for payment by the appropriate approver via Email, however, the emails were not maintain...

View of Responsible Officials and Planned Corrective Action: The Club has reviewed the findings and acknowledges the importance of documented controls over federal expenditures. The expenses noted were submitted for payment by the appropriate approver via Email, however, the emails were not maintained due to staff turnover. To address this finding, all grant expenditures are documented with approval and scanned prior payment.

View Audit 369401

Finding 1157077 (2024-005)

Material Weakness 2024

Unity Health Care, Inc.

MD

Allowable Costs / Cost Principles § 200.303

Management Response #2024-005: Due to staff turnover the Corporation did not have adequate personnel or infrastructure in place to monitor costs in order to calculate and determine an updated indirect cost rate. Also, the current indirect cost rate allocations is based on historical assumptions. Cor...

Management Response #2024-005: Due to staff turnover the Corporation did not have adequate personnel or infrastructure in place to monitor costs in order to calculate and determine an updated indirect cost rate. Also, the current indirect cost rate allocations is based on historical assumptions. Corrective Action Plan: The Finance Team will develop overall operational costs reports to calculate and support a new rate. The proposed rate will be submitted to HRSA for approval. This will allow us to ensure the calculation for indirect costs and documentation supporting the indirect cost pool conform to the current regulations. Management expects to be completed by December 31, 2026. Responsible Party: Tamara Barnes, CFO

View Audit 369390

Finding 1157075 (2024-002)

Material Weakness 2024

Unity Health Care, Inc.

MD

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.431

Management Response #2024-002: Due to the financial system and time keeping infrastructure, the Corporation did not maintain evidence of fringe benefit cost objectives calculations. Also, the current fringe cost rate and allocations is based on historical assumptions. Corrective Action Plan: • The f...

Management Response #2024-002: Due to the financial system and time keeping infrastructure, the Corporation did not maintain evidence of fringe benefit cost objectives calculations. Also, the current fringe cost rate and allocations is based on historical assumptions. Corrective Action Plan: • The finance team will work to ensure fringe costs are entered into the financial system based on actual costs paid by the Corporation for each employee. • The grants finance department will also create actual to budget reports in accordance with HRSA guidelines for fringe costs • The Finance Team will develop fringe costs reports to calculate, monitor and support the current rate. This will allow us to ensure the fringe cost allocation conform to the current regulations. Management expects to be completed by December 31, 2026. Responsible Party: Tamara Barnes, CFO

View Audit 369390

Finding 1157074 (2024-001)

Material Weakness 2024

Unity Health Care, Inc.

MD

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

Management Response #2024-001: The time keeping system and process does not currently allow tracking of time based on funded resources. The past practice had been for the finance department manually calculated salary allocations. Due to the influx of grants and staffing resources the Corporation was...

Management Response #2024-001: The time keeping system and process does not currently allow tracking of time based on funded resources. The past practice had been for the finance department manually calculated salary allocations. Due to the influx of grants and staffing resources the Corporation was unable to maintain this process. Corrective Action Plan: Finance Management, Human Resources, and Payroll will collaborate to integrate time-tracking functionality into the current timekeeping system, enabling real-time tracking of time worked on grants for FY25. The rollout of this new process is expected to begin in Q4 of FY25. Responsible Party: Tamara Barnes, CFO

View Audit 369390

Finding 1157057 (2024-001)

Material Weakness 2024

Daughters of Miriam Center for the Aged

NJ

HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles

We have hired an outside independent company, Infinity File Compliance, LLC to work with us on updating and maintaining all HUD documentation requirements. We are working on applying all the new policies and procedures and will be implementing trainings to ensure future compliance.

View Audit 369375

Finding 1157055 (2024-001)

Material Weakness 2024

West End Neighborhood House, Inc.

DE

Reporting Allowable Costs / Cost Principles HUD Housing Programs § 200.303

Management has updated its compliance responsibility procedures to clarify roles and responsibilities and to ensure accountabilities for all federal reporting requirements. Specifically: • A compliance calendar will be established to track all non-standard reporting deadlines (other than monthly or ...

Management has updated its compliance responsibility procedures to clarify roles and responsibilities and to ensure accountabilities for all federal reporting requirements. Specifically: • A compliance calendar will be established to track all non-standard reporting deadlines (other than monthly or quarterly cost reimbursement grant request). • Responsibility for preparing and submitting DRGR reports has been formally assigned to Finance Department. • Verification procedures have been implemented to confirm that all reports are filed timely. • Periodic internal reviews will be conducted to ensure compliance with reporting requirements.

View Audit 369363

Finding 1157035 (2024-003)

Material Weakness 2024

Our Katahdin and Subsidiary

ME

Period of Performance Questioned Costs Allowable Costs / Cost Principles

The Organization will continue efforts to obtain written confirmation from the Department of Commerce, compile all available email correspondence and notes from verbal conversations, and prepare a detailed timeline of authorization requests and responses. Further, the Organization will submit a form...

The Organization will continue efforts to obtain written confirmation from the Department of Commerce, compile all available email correspondence and notes from verbal conversations, and prepare a detailed timeline of authorization requests and responses. Further, the Organization will submit a formal response to the Department of Commerce regarding questioned costs, provide documentation supporting the allowability of expenses, and request a formal resolution of questioned costs. Person Responsible: Steve Sanders, Grant Manager, Tel: 207-249-8578 Estimated completion: December 2025

View Audit 369350 Questioned Costs: $1

Finding 1157034 (2024-002)

Material Weakness 2024

Our Katahdin and Subsidiary

ME

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment

The Organization will verify all current active vendors against the SAM.gov exclusions database, document verification results, and remediate any issues identified. Going forward, the Organization will modify its policy to establish quarterly vendor verification review by the management team. The Or...

The Organization will verify all current active vendors against the SAM.gov exclusions database, document verification results, and remediate any issues identified. Going forward, the Organization will modify its policy to establish quarterly vendor verification review by the management team. The Organization will conduct a quarterly review of vendor verification documentation by reviewing the accounting system vendor list against the SAM.gov exclusion search documentation to help ensure no vendors were omitted, verifying that the date of each SAM.gov search is properly documented, and documenting the management team’s review findings and any corrective actions taken. Person Responsible: Stephanie Walsh, Treasurer, Tel: 207-249-8578 Estimated completion: December 2025

View Audit 369350

Finding 1157025 (2024-003)

Material Weakness 2024

Women's Center for Advancement

NE

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

Condition: Certain underlying support related to the VOCA Victim Assistance Formula Grant did not agree to amounts charged to the grant. Supporting information and records indicated more funds were spent by the Organization than were charged to the grant. Planned Corrective Action: Management will r...

Condition: Certain underlying support related to the VOCA Victim Assistance Formula Grant did not agree to amounts charged to the grant. Supporting information and records indicated more funds were spent by the Organization than were charged to the grant. Planned Corrective Action: Management will review its processes, procedures and controls to ensure that reconciliation and review of grant reimbursement requests and supporting underlying documentation occurs in future periods. Planned Completion Date: Ongoing Person Responsible: Kim Reed, VP of Finance

View Audit 369341

Finding 1157016 (2024-004)

Material Weakness 2024

Crosspurpose

CO

Allowable Costs / Cost Principles Eligibility Subrecipient Monitoring § 200.334 § 200.344 § 200.403

Management has reinforced the effective execution of existing controls around proper documentation of all expenditures and record retention for these expenditures. Monthly and year-end procedures have been updated to ensure compliance with these procedures. Anticipated completion date: June 30, 2025...

Management has reinforced the effective execution of existing controls around proper documentation of all expenditures and record retention for these expenditures. Monthly and year-end procedures have been updated to ensure compliance with these procedures. Anticipated completion date: June 30, 2025.

View Audit 369319

Finding 1157007 (2024-001)

Material Weakness 2024

Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky

WA

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

Managements Corrective Action Plan Year Ending – December 31, 2024 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2024. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2024-001 – Reporting Contact: Jennifer Moore...

Managements Corrective Action Plan Year Ending – December 31, 2024 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2024. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2024-001 – Reporting Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2025 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Indiana, Kentucky has implemented a process improvement plan in 2024 that addresses each of the findings: • In 2024, a new team has taken over the reporting and filing process for our grant awards, including federal. This team is responsible for submitting the reporting and draws by the designated timeline, and it is confirmed as part of the month-end close process. • During this time, we have established a grant tracking document that notates – o The reporting month o Dollar amount expected o Date submitted ▪ This date should always be within the month following the required filing o Date the funding was received o An area to document any information or changes worth noting • In 2025, the following items have been added to the tracking document to allow for greater oversight – o Review approval o Reporting requirements o Due Dates (monthly, quarterly, etc.) o Proof of submission

View Audit 369310

Finding 1156983 (2024-001)

Material Weakness 2024

Springboard Collaborative

PA

Allowable Costs / Cost Principles Significant Deficiency

DEPARTMENT OF THE TREASURY 2024-001 During our testing of payroll transactions for the major federal program, we were unable review the internal control of approved timesheets for any part time employees and seasonal employees with payroll periods selected for testing through September 2024. The Org...

DEPARTMENT OF THE TREASURY 2024-001 During our testing of payroll transactions for the major federal program, we were unable review the internal control of approved timesheets for any part time employees and seasonal employees with payroll periods selected for testing through September 2024. The Organization changed payroll service providers in September 2024 and could no longer access the timesheets requested. Recommendation: The Organization should ensure when there are changes in the Organizations service providers, there are procedures in place to ensure all necessary documentation is retained to support the controls in place for federal spending. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate Action Completed: We have communicated to our People Operations team the requirement to maintain access to all payroll documentation, including approved timesheets for part-time and seasonal employees, to support federal spending controls. Policy Implementation: We have established procedures requiring that before any payroll service provider changes are finalized, the Finance and People Operations teams must verify that all necessary historical documentation will remain accessible for audit and compliance purposes, including but not limited to approved timesheets, payroll registers, and supporting documentation for all employee categories. Training and Communication: All relevant staff members have been trained on the new procedures and understand their responsibilities for maintaining documentation access during service provider transitions. Name(s) of the contact person(s) responsible for corrective action: Amy Chen, VP, Finance Planned completion date for corrective action plan: 9/10/2025 The planned corrective action will be completed by 9/10/2025.

View Audit 369298

Finding 1156982 (2024-002)

Material Weakness 2024

Shalom Health Care Center, Inc.

IN

Allowable Costs / Cost Principles § 200.430

Material Weakness, Allowable Costs- The following steps have been taken or will be taken to address Finding 2024-002: • Shalom Health Care Center, Inc. has been working on updating federal grant draws within the timeframe of payroll and not monthly. • Shalom Health Care Center, Inc. will also prepar...

Material Weakness, Allowable Costs- The following steps have been taken or will be taken to address Finding 2024-002: • Shalom Health Care Center, Inc. has been working on updating federal grant draws within the timeframe of payroll and not monthly. • Shalom Health Care Center, Inc. will also prepare semiannual attestation for management to review staff allocations. Contact Michael A. Nino, Chief Financial Officer anino@shalomhealthcenter.org 317-269-7198

View Audit 369288

Finding 1156976 (2024-001)

Material Weakness 2024

Public Hospital District No. 1 of Skagit County

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Management’s Corrective Action Plan Year Ending – December 31, 2024 Schedule of Findings and Questioned Costs: Section III – Federal Award Finding: 2024-001 – Allowable Cost ALN #97.036 Contact: Matthew Vaughn Title: Regional Director of Financial Planning & Analysis Completion Date: Present Correct...

Management’s Corrective Action Plan Year Ending – December 31, 2024 Schedule of Findings and Questioned Costs: Section III – Federal Award Finding: 2024-001 – Allowable Cost ALN #97.036 Contact: Matthew Vaughn Title: Regional Director of Financial Planning & Analysis Completion Date: Present Corrective Action: January of 2022 saw a massive uptick in daily Covid-19 cases across the country. As a result of this crisis, the incident command (IC) structure established a labor pool that deployed volunteers into unfilled shifts at the hospital for a myriad of critical positions. These shifts were tracked and coordinated via the incident command structure on separate worksheets and as a result worked shifts were not coded directly on employee timecards as had been done previously over the course of the pandemic. All other payroll submissions of the county will refer to timecard-coded worked hours and expenses, which allow the user to generate standard payroll cost reports directly out of source financial systems rather than manually matching multiple data sources to calculate relevant costs

View Audit 369262

Finding 1156910 (2024-002)

Material Weakness 2024

Future Harvest, Inc.

MD

Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.334 § 200.403

Name of Contact Person: Grace Leatherman – Executive Director Contact Information: 410-440-9066 Corrective Action Plan: Finding 2024 – 002 Management is in agreement with the findings and will remind staff to include supporting calculations when submitting for reimbursement per Organization policies...

Name of Contact Person: Grace Leatherman – Executive Director Contact Information: 410-440-9066 Corrective Action Plan: Finding 2024 – 002 Management is in agreement with the findings and will remind staff to include supporting calculations when submitting for reimbursement per Organization policies. Senior staff will review payroll data to ensure calculations are being made and reported. Expected Completion Date: The Organization expects all findings to be resolved by December 31, 2025

View Audit 369250 Questioned Costs: $1

Finding 1156886 (2024-004)

Material Weakness 2024

Hearts for the Invisible Charlotte Coalition

NC

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management § 200.303 § 200.328 § 200.430

Each employee will have a payroll file that includes: • Date of hire • Title • Grant(s) they are assigned to if applicable • Pay amount • Any changes to the above and the date of the change Each employee will complete a timesheet weekly that includes the number of hours worked and if applicable brok...

Each employee will have a payroll file that includes: • Date of hire • Title • Grant(s) they are assigned to if applicable • Pay amount • Any changes to the above and the date of the change Each employee will complete a timesheet weekly that includes the number of hours worked and if applicable broken out by what grant(s) they worked on. The bookkeeper provides a budget:actual report when invoices for federal contracts are prepared. The ED notes signs off that they have been approved for draw. That report is stored on the server. The Treasurer reviews the cost-reimbursement requests prepared by the ED, along with the detailed back up.

View Audit 369236

Corrective Action Plans

Filters