Corrective Action Plans

1.       Updated drawdown procedures have been incorporated into SCMRC’s financial policies and will be re-reviewed annually.

2.       Refresher training on 2 CFR § 200.305 and internal drawdown requirements will be conducted by Q4 2025.

3.       Results of monthly drawdown audits will be included in the Finance Committee compliance dashboard starting in September 2025.

4.       SCMRC will continue to require documented CEO approval on all federal drawdown submissions to ensure sustained internal control.

Corrective Actions Taken:

1. Implemented a 15-month rolling cash flow forecast in Q4 2024, updated weekly by the CEO and Controller in partnership with the contract accountant.

2. Finance staff monitor cash balances and disbursements at least twice per week to anticipate timing issues and support grant drawdown coordination.

3. Established internal minimum balance thresholds and enabled low balance alerts to prevent overdrafts.

4. Consolidated underutilized accounts in 2025 and formalized contingency planning with SCMRC’s banking institution.

5. Conducted nonprofit cash flow management training for the CEO, Controller, and Board in Q2 FY25.

6. Included cash flow forecasting and liquidity discussions in monthly Finance Committee updates.

7. These improvements were reviewed during the 2025 HRSA Verification Site Visit and contributed to clearance of relevant conditions under Chapter 21 of the HRSA Health Center Compliance Manual.

Corrective Action Plan:

1. Continue weekly updates of the 12-month rolling cash flow forecast.

2. Maintain twice-weekly internal cash reviews to align disbursements with available cash and grant timing.

3. Monitor operating accounts against internal minimum thresholds and refine automated alerts as needed.

4. Reassess account structure annually and maintain contingency agreements with the bank.

5. Require refresher training in cash flow management for new financial staff and Finance Committee members at least once annually.

6. Maintain Finance Committee oversight of liquidity metrics, with trends tracked in monthly dashboards.

7. Review internal controls annually to ensure continued alignment with 45 CFR § 75.302(b)(4) and evolving HRSA guidance.

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of disbursements in its job‐costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job‐costing system. Auditee Response: UICSL has limited access to its accounting system and removed access by outsourced financial management personnel. In addition to better invoicing structure, UICSL also revised its job-costing system to better comply with these requirements. Together, these systems will be used to request only the amount of attributable ot the programs for reimbursement-based grant funding. Corrective Action Plan: All transactions are logged into the accounting system with appropriate respective grant codes and departments. Invoices and transactions will not be processed without approval and proper coding. UICSL has also implemented a new credit card tracking system along with a purchase order system that is active and maintained by Finance and Accounting. Monthly and quarterly invoices will be prepared for grants in compliance with 2 CFR section 200.305(b). Person Responsible: Matt Poss, Executive Director and Mary Louise Santacaterina, Grants Manager Timeline: Already removed accounting system access by prior outsourced financial managemnet personnel. Monthly check-ins and expenditure reports have been implemented with department leads in 2024. Grants Manager tasked along with Director of Finance of reviewing monthly invoices and ensuring each meets grant and expenditure requirements. All invoices reviewed with grant/project leads and logged appropriately. Staff acountant hired in 2024 to help provide oversight.

Management Response and Planned Corrective Action: We concur with the Federal Award Findings outlined above of the auditors and have implemented a corrective action plan, including updating internal control policies and procedures. Views of Responsible Officials and Corrective Actions: The management team of the Council of Western State Foresters believe in the values of transparency, justification, and documentation for transactions made in the course of conducting job related duties. As a small organization with limited staff, suggested reasonable improvements to processes are always welcome. It is in this spirit that the below corrective actions for the compliance issues noted in the findings from the 2023 audit are put forward. 2023-004 Corrective Action Plan: Management acknowledges the need to strengthen procedures related to the preparation and review of SF-270 forms. The review and approval processes for SF-270 submissions have been evaluated and revised to ensure that requests for advances and reimbursements are accurately classified and properly documented. In alignment with 2 CFR § 200.305, all advance requests will be reviewed to ensure they are based on reasonable estimates of direct program costs that are immediately necessary for the applicable period. As part of this process, management will implement a cross-referencing procedure to verify that requests designated as reimbursements or advances are supported by appropriate documentation and accurately reflect the nature of the request. Anticipated Completion: Process revisions and controls have been completed

The Organization initially had difficulty identifying a qualified firm to carry out the Single Audit for the year ended December 31, 2023. During the first half of 2024, the Organization contacted a total of 17 firms to request quotes, in a process that proved especially difficult given that many did not have experience auditing Non-Profit entities or did not respond. The Organization also consulted with peer Non-Profits entities with similar budgets to obtain recommendations, and from all these efforts only one proposal was received. This prolonged search process significantly delayed the start of the audit. Nevertheless, the Organization entered into a formal agreement with a certified public accounting (CPA) firm to perform the Single Audit. In addition, as this was the Organization’s first audit, additional time was required to compile the requested documents. With a clear understanding now of the documentation requirements, the process is expected to be significantly quicker in future audits. Furthermore, the Organization has already agreed with the same firm to perform the Single Audit for subsequent years going forward.

As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final agreement, the budgeted requested salaries were not updated. We will attempt to have the sponsoring office of the federal program to retroactively amend the Assistance Agreement to remove the compensation limitation. The Assistance Agreement has been modified to remove any such limitation prospectively beginning with Modification 0015 April 2024.

FINDING 2023-002 Finding Subject: COVID‐19 ‐ Coronavirus State and Local Fiscal Recovery Funds ‐ Reporting Summary of Finding: The Elkhart County Health Department (Health Department) was awarded the Health Issues and Challenges Grant through the Indiana Department of Health (IDOH) financed through the Coronavirus State and Local Fiscal Recovery Funds The grant was funded through the American Rescue Plan Act that focused on the improvement of chronic disease, and more specifically, elevated blood lead level reduction. The Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS) each month. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels (EBLLs). A Case Manager managed all aspects of an individual patient's care. A home visit and two assessments were completed by the Case Manager and input into the NBS. Once these steps were marked as complete in the NBS, the Clinical Manager reviewed each case and compiled data along with the cost reimbursement amount into a spreadsheet. The Clinical Manager provided the spreadsheet to the Manager of Administration who then completed and submitted the reimbursement invoice to the IDOH. The reimbursement invoice was submitted without a documented oversight, review, or approval process to ensure the accuracy of the data prior to submission. Beginning in October 2022, the Health Department was required to submit program specific metrics and work plan data through RedCap software on a quarterly basis. The Case Manager was responsible for tracking and compiling the necessary information for the quarterly reports. Of the four reports tested, two reports were submitted late. In addition, the quarterly reports were submitted by the Case Manager via the RedCap software without a documented oversight, review, or approval process to ensure timely submission. Recommendation: We recommend the Health Department implement a formal oversight and review process for all data submissions to ensure accuracy and completeness before they are submitted to Indiana Department of Health (IDOH). This would involve a secondary review by a designated individual or team to verify the data. Additionally, improving workflow coordination through clearly defined roles and responsibilities for each team member would help streamline the process and prevent delays. To further improve timeliness, the Health Department should implement a tracking and reminder system for report due dates and reimbursement deadlines to ensure timely submissions. Providing staff with thorough training on reporting protocols and maintaining detailed documentation will help ensure consistent adherence to procedures. Finally, establishing accountability measures through clear roles, deadlines, and regular audits would enhance the efficiency and effectiveness of the reporting process. These steps will help ensure the Health Department meets grant requirements, maintains data accuracy, and avoids potential delays or issues in future submissions. INDIANA STATE BOARD OF ACCOUNTS 29 Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: During the prior audit we were informed of the deficiencies in our controls over the reimbursement requests submitted to the Department of Health. Unfortunately, due to the timing of the finding being brought to our attention near the end of its lifecycle we were unable to implement controls. With only one month remaining between the audit finding results and the grant’s end date, implementing the stated corrective action plan was deemed impractical. The Elkhart County Health Department has internal controls and policies for the grants that are received. This grant was very different from the other grants we have received in the past. Since the Elevated Blood Lead Level Reduction grant differed significantly from previous grants received by the Elkhart County Health Department, moving forward, if the department chooses to pursue and secure another grant with a similar scope, enhanced controls and policies will be implemented to strengthen accuracy and accountability. Specifically, the Health Department will establish a formal data review process. All data submissions will undergo an initial review, followed by a secondary verification conducted by a designated staff member. This dual review procedure will apply to all future grants of a similar nature to ensure the integrity and reliability of submitted information. The goal is to ensure there is an appropriate system of checks and balances, as well as a remediation/correction step, in place for all tasks and documentation related to grant-funded duties and invoicing. Anticipated Completion Date: Effective June 30, 2025 the Elkhart County Department of Health will implement this practice for all newly accepted grants similar in scope to the Elevated Blood Lead Level Reduction.