Corrective Action Plans

Finding 1157225 (2024-003)

Material Weakness 2024

OH

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Management will enforce a standardized reimbursement packet review checklist, requiring documented approval prior to submission. All reimbursement packets will be stored electronically in a central repository. Training will be provided to all accounting staff on documentation standards. Periodic sup...

Management will enforce a standardized reimbursement packet review checklist, requiring documented approval prior to submission. All reimbursement packets will be stored electronically in a central repository. Training will be provided to all accounting staff on documentation standards. Periodic supervisory reviews will be performed to confirm compliance.

View Audit 369522

Finding 1157216 (2024-001)

Material Weakness 2024

Npower Inc.

NY

Cash Management Reporting

Corrective Action Planned: The organization has been using the Microsoft Approvals app to capture approvals of expenditure reports and requests for drawdowns, in addition to the frequent weekly review meetings and approvals process to satisfy Uniform Guidance 2 CFR 200.511c and for Single Audit evid...

Corrective Action Planned: The organization has been using the Microsoft Approvals app to capture approvals of expenditure reports and requests for drawdowns, in addition to the frequent weekly review meetings and approvals process to satisfy Uniform Guidance 2 CFR 200.511c and for Single Audit evidence. Name(s) of Contact Person(s) Responsible for Corrective Action: Stefanie Boles, Chief Administrative Officer; Patrick Ma, Vice President for Finance and Business Operations Anticipated Completion Date: This change has already taken place as of September 2025.

View Audit 369500

Finding 1157171 (2024-003)

Material Weakness 2024

Transition Resource Action Center

TX

Allowable Costs / Cost Principles Cash Management Material Weakness § 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 1157035 (2024-003)

Material Weakness 2024

Our Katahdin and Subsidiary

ME

Questioned Costs Period of Performance 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 1157025 (2024-003)

Material Weakness 2024

Women's Center for Advancement

NE

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

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 1157024 (2024-002)

Material Weakness 2024

County of York, Pennsylvania

PA

Student Financial Aid Cash Management Matching / Level of Effort / Earmarking

We concur with this finding. The County of York has hired a Human Services Director of Finance to assist with improving systems and financial processes within the Human Services (HS) divisions. The HS Executive Director and Director of Finance are recommending engaging an expert Consultant to assist...

We concur with this finding. The County of York has hired a Human Services Director of Finance to assist with improving systems and financial processes within the Human Services (HS) divisions. The HS Executive Director and Director of Finance are recommending engaging an expert Consultant to assist the County’s Children & Youth Fiscal team in getting caught up on internal system timelines, as well as delayed reporting. The Consulting company will also be working to adequately train the Children & Youth Fiscal team for development purposes.

View Audit 369325

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 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 1156911 (2024-001)

Material Weakness 2024

The Maggie Walker Community Land Trust

VA

Cash Management Reporting

1. We have filed the missing December 31, 2024 report with the pass-through grantor (Chesterfield County). 2. The COO and CEO have reviewed and verified that all subsequent reporting submissions have been correctly filed with relevant pass-through grantors. 3. Moving forward, Director of Operations ...

1. We have filed the missing December 31, 2024 report with the pass-through grantor (Chesterfield County). 2. The COO and CEO have reviewed and verified that all subsequent reporting submissions have been correctly filed with relevant pass-through grantors. 3. Moving forward, Director of Operations and Real Estate and CEO will be carbon copied on all reporting submissions for federal grants. 4. We are committed to achieving full compliance by December 31, 2025, with the CEO overseeing the process.

View Audit 369253

Finding 1156910 (2024-002)

Material Weakness 2024

Future Harvest, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles 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

Finding 1156872 (2024-004)

Material Weakness 2024

State of Missouri

MO

Cash Management Material Weakness Reporting

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services – MO HealthNet Division Audit Finding Number: 2024-004 - Medicaid and CHIP Receipt Controls Name of the contact person responsible for corrective action: Andrea Smith Anticipate...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Social Services – MO HealthNet Division Audit Finding Number: 2024-004 - Medicaid and CHIP Receipt Controls Name of the contact person responsible for corrective action: Andrea Smith Anticipated completion date for corrective action: June 30, 2025 Recommendation: The DSS through the MHD continue to review, strengthen, and enforce internal controls over Medicaid and CHIP receipts. The MHD should restrict user access within the MMIS for FORU accounting personnel and adequately segregate asset custody and receipt recording duties from accounts receivable duties, or perform documented supervisory reviews of MMIS entries and changes made by employees whose duties are not segregated. In addition, the MHD should establish procedures to account for all cash control numbers to ensure all receipts are deposited or returned to senders. DSS Response: DSS agrees with the auditor’s recommendation. The Corrective Action Plan includes the department’s planned actions to address the finding. Corrective action planned is as follows: MHD has implemented a process to document supervisory reviews of the Finance Manual Checks Quarterly report to ensure segregation of duties in HealthTrack/AHS. This process began in August 2024. As a result of clarification on the finding during the FY24 audit, additional information has been added to the Finance Manual Check Quarterly report to include transactions the FORU Manager performed in the AHS system. This change was requested beginning in March 2025 and will be in use as soon as the report is available for review. MHD will continue to perform the audit of clerk ID ad hoc reports to review any segregation of duties within the MMIS. MHD implemented a process to ensure all cash control numbers in HealthTrack/AHS are accounted for by establishing a new cash control number (CCN) sequence, exclusive to manual checks logged within the FORU. This resolved the issue of cash control numbers for participant checks occurring out of sequence due to AHS running files in the background at the same time checks are being logged. This portion of the implementation occurred in August 2024. During the FY24 audit, MHD received further clarification and is implementing a review of a monthly report containing missing and unused cash control numbers for provider checks in eMMIS. This will be compared to a file updated by the Accounts Assistant with the daily cash control numbers used. FORU will use the monthly report to document reasons for any unused or skipped CCNs. This process is being completed monthly beginning March 2025.

View Audit 369219

Finding 1156812 (2024-003)

Material Weakness 2024

Florence County

WI

Allowable Costs / Cost Principles Cash Management Significant Deficiency

DEPARTMENT OF TREASURY 2024-003 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: We recommend that there is an appropriate reviewer of journal entry. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actio...

DEPARTMENT OF TREASURY 2024-003 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: We recommend that there is an appropriate reviewer of journal entry. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The amounts reported were accurate and in compliance. The department will continue to train employees in respective positions to ensure responsibilities align with program requirements. Immediately upon discovery of the omission of the review step, management reiterated to department financial staff the importance of the review process. Name(s) of the contact person(s) responsible for corrective action: Kim Merrill, Finance Manager Planned completion date for corrective action plan: December 31, 2025

View Audit 369191

Finding 1156788 (2024-002)

Material Weakness 2024

Mississippi Public Health Institute

MS

Questioned Costs Allowable Costs / Cost Principles Cash Management

AUDITEE’S CORRECTIVE ACTION PLAN As required by 2CFR Section 200.511 of the Uniform Guidance, Mississippi Public Health Institute has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questions Costs for the year ended December...

AUDITEE’S CORRECTIVE ACTION PLAN As required by 2CFR Section 200.511 of the Uniform Guidance, Mississippi Public Health Institute has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questions Costs for the year ended December 31, 2024: Federal Award Findings and Questioned Costs 2024-002 Unallowable Costs Criteria - The Uniform Guidance states that any federal share of allowable costs must be refunded to the government. During our audit, we noticed an instance of duplicate expenditures being recorded. Reimbursement was requested and received for these costs from the Racial and Ethnic Approaches to Community Health program under ALN 93.304. This occurred through a single vendor, for which it was noted that the vendor had sent duplicate invoices, and MSPHI recorded both invoices. Recommendation - We recommend the implementation of IT controls to prevent duplicate invoice numbers to be recorded. Corrective Action Plan - Mississippi Public Health Institute will increase oversight of grant expenditures and drawdowns to improve reconciliation accuracy. Position of Responsible Official – John Davis, Chief Financial Officer Anticipated Completion Date – Completed after brought to client’s attention. August 31st, 2025.

View Audit 369168 Questioned Costs: $1

Finding 1156777 (2024-003)

Material Weakness 2024

Special Children's Charities

IL

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302

The audit noted that federal awards and expenditures were not adequately tracked by grant in the general ledger. Corrective action has already been taken: the general ledger has been updated to ensure that federal awards are now tracked by the grant program. This enhancement allows for improved acco...

The audit noted that federal awards and expenditures were not adequately tracked by grant in the general ledger. Corrective action has already been taken: the general ledger has been updated to ensure that federal awards are now tracked by the grant program. This enhancement allows for improved accountability, accurate reporting, and compliance with federal requirements.

View Audit 369106

Finding 1156685 (2024-002)

Material Weakness 2024

Madonna Center, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management agrees and will develop review procedures to respond to the findings.

View Audit 369054 Questioned Costs: $1

Finding 1156684 (2024-001)

Material Weakness 2024

Madonna Center, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430

Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.

View Audit 369054 Questioned Costs: $1

Finding 1156668 (2024-003)

Material Weakness 2024

Belmont County

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.405

Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interp...

Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interpretation. As a result of this finding, BCDJFS will reassign the FCFC Coordinator to the shared cost pool and reimburse the shared cost pool from the applicable FCFC allocations through a MOU signed between the council and BCDJFS

View Audit 369030 Questioned Costs: $1

Finding 1156646 (2024-002)

Material Weakness 2024

Boys & Girls Clubs of Central Mississippi, Inc.

MS

Cash Management Material Weakness

The Organization's management has determined that they received additional funding that was not requested by them. The Organization has discussed this with the granting agency and will pay the excess funds back.

View Audit 369003

Finding 1156590 (2024-004)

Material Weakness 2024

Meeker County

MN

Allowable Costs / Cost Principles Cash Management Significant Deficiency

ALLOWABLE COSTS Recommendation: The County should review the listing of employees working on certain programs on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response t...

ALLOWABLE COSTS Recommendation: The County should review the listing of employees working on certain programs on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will review procedures and implement changes as needed to ensure reports are formally reviewed, submitted timely, and proper documentation is retained. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2025

View Audit 368940

Finding 1156586 (2024-002)

Material Weakness 2024

Saint Charles County, Missouri

MO

Subrecipient Monitoring Cash Management § 200.332

Action taken in response to finding: The County will review the subrecipient monitoring requirements and work with the County Auditor to develop a formal policy that includes internal controls, monitoring procedures, and documentation requirements.

View Audit 368939

Finding 1156551 (2024-004)

Material Weakness 2024

Andrew County Health Department

MO

Cash Management Reporting Significant Deficiency

Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and perf...

Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and performance reports.

View Audit 368888

Finding 1156544 (2024-002)

Material Weakness 2024

County of Mifflin

PA

Cash Management

Finding 2024-002: Cash Management / Matching / Interest Earned. Contact Person: Duane K. McMullen Jr., Director of Fiscal Affairs. Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding a...

Finding 2024-002: Cash Management / Matching / Interest Earned. Contact Person: Duane K. McMullen Jr., Director of Fiscal Affairs. Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding and created a new fund – Fund 07 – in the County’s accounting software and will begin creating corresponding revenue and expense accounts to match the existing structure within the new fund. This has been a work in process and has been slow to implement. Due to the turnover of the Director of Fiscal Affairs. The new Director of Fiscal Affairs is currently working to correct missing months transfers, and hopes to have the process stream lined once all past entries are posted. The County also opened a separate checking account at The Juniata Valley Bank for the Children and Youth Fund for all revenue and expenses beginning January 1, 2025. The County continues to engage an external third-party contractor provider familiar with Children and Youth Agency financial matters to assist in the transition. The County also made the affirmative decision to capitalize that fund with the prior year’s County-match at the start of the calendar year and continue to fund, as needed, throughout the year to ensure the necessary County match is attained. The Children and Youth Agency will continue to ensure compatibility and proper recording in MUNIS, the County accounting system, of all financial transactions to match with the internal accounting system maintained by the Children and Youth Agency. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will continue to engage with the external service provider and the Children and Youth Finance Director and overall Child and Youth Agency Director to monitor proper posting of financial transactions in the appropriate fund to match all transactions posted in the internal accounting system maintained by the Children and Youth Agency. Date for Completion: December 31, 2025.

View Audit 368886

Finding 1156525 (2024-001)

Material Weakness 2024

Sustainable Fisheries Partnership Foundation

HI

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could includ...

USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could include: signatures on reports, emails indicating review and approval from appropriate individuals, retention of meeting agendas and minutes to corroborate that review occurred during the meetings, etc. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective immediately, the COO (or the Director of Finance, once hired) will conduct a documented review and written approval of all federal draw requests prior to submission to USAID. This review will be evidenced by either1. A signed and dated approval on the draw request form, or 2. A saved electronic record (e.g., email approval) in the grant’s shared compliance folder. SFP will also retain relevant meeting minutes or other supporting documentation demonstrating review in accordance with 2 CFR §200.303(a) requirements for internal controls. Name(s) of the contact person(s) responsible for corrective action: Anna Gabis Planned completion date for corrective action plan: October 31, 2025

View Audit 368873

Corrective Action Plans

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