Corrective Action Plans

Finding 524465 (2023-002)

Significant Deficiency 2023

Town of Eagle

CO

Reporting Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the...

Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the Town of Eagle, Colorado, to follow to ensure that the Town’s books and records are completed and provided to the Town’s independent auditors within 4 ½ months after the Town’s calendar year-end.

View Audit 343809

Finding 524464 (2023-001)

Significant Deficiency 2023

Town of Eagle

CO

Reporting Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the...

Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the Town of Eagle, Colorado, to follow to ensure that the Town’s books and records are completed and provided to the Town’s independent auditors within 4 ½ months after the Town’s calendar year-end.

View Audit 343809

Finding 524378 (2023-002)

Significant Deficiency 2023

The International Centre for Missing & Exploited Children and Affiliates

VA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Views of Responsible Officials and Planned Corrective Actions: Monthly reconciliations were not being done throughout 2023. The 2022 Audit that identified the need for such a process was not completed until February 2024. ICMEC does not prepare a consolidated financial statement or reconcile interco...

Views of Responsible Officials and Planned Corrective Actions: Monthly reconciliations were not being done throughout 2023. The 2022 Audit that identified the need for such a process was not completed until February 2024. ICMEC does not prepare a consolidated financial statement or reconcile intercompany accounts. Essentially the issue is that balance sheet schedules were not maintained from month to month during the year. However, we did provide the auditors with reconciled schedules at year end. Additionally, ICMEC did not historically keep a consolidated (including the Australian affiliate) financial statement via its accounting system, so all Australia affiliate activity was added manually during the audit. Action plan: we began maintaining regular monthly balance sheet schedules for all accounts in June 2024. Furthermore, the Australian affiliate was deconsolidated as of July 6, 2023 so ICMEC no longer needs to maintain the activity of the Australian affiliate in the consolidated financial statements.

View Audit 343616

Finding 524335 (2023-003)

None 2023

Friendship Home Association

IA

Matching / Level of Effort / Earmarking

FINDINGS — FEDERAL AWARD PROGRAMS AUDIT: INSTANCES OF NON-COMPLIANCE: 2023-003 Reserve Requirement Criteria: The Organization is required to maintain a calculated debt reserve fund based on annual debt payments each year as stated in the Letter of Conditions. Condition: During the audit, we identifi...

FINDINGS — FEDERAL AWARD PROGRAMS AUDIT: INSTANCES OF NON-COMPLIANCE: 2023-003 Reserve Requirement Criteria: The Organization is required to maintain a calculated debt reserve fund based on annual debt payments each year as stated in the Letter of Conditions. Condition: During the audit, we identified the Organization did not maintain sufficient funds in the debt reserve account. Cause: The required monthly transfers did not occur during the fiscal year Effect: As a result of the absent transfers, the debt reserve fund was not funded to the required amount as of December 31, 2023. Recommendation: The Organization should create a plan to bring the balance into the required amount and have procedures in place to make the monthly transfers. Client Response: We have discused our plan to bring the debt reserve fund back to current with the governing authority and have established a process to have the monthly transfers completed. Conclusion: Response accepted.

View Audit 343531

Finding 524268 (2023-003)

None 2023

Town of Ripley

NY

Matching / Level of Effort / Earmarking

Reserve requirement Auditor recommendation: The Town should make the required deposit into the reserve fund as soon as reasonably possible and develop a plan to ensure the reserve requirement is met on an annual basis. Town’s Response: The Town understands the requirement to make the annual reser...

Reserve requirement Auditor recommendation: The Town should make the required deposit into the reserve fund as soon as reasonably possible and develop a plan to ensure the reserve requirement is met on an annual basis. Town’s Response: The Town understands the requirement to make the annual reserve deposit and will make the required deposit for the year ended December 31, 2023.

View Audit 343450

Finding 524173 (2023-001)

Material Weakness 2023

South Scioto Academy

OH

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.414 § 200.501 § 200.502 § 200.510 § 200.512

All future federal expenditures will be reconciled to the disbursement ledger.

View Audit 343356

Finding 524133 (2023-002)

Significant Deficiency 2023

Phipps Neighborhoods, Inc.

NY

Subrecipient Monitoring Matching / Level of Effort / Earmarking Reporting

To resolve this issue and prevent recurrence, we are taking the following corrective actions: To ensure that all reports are submitted within the required time frame, we will implement a tracking system using calendar reminders that will provide alerts for upcoming deadlines, ensuring no reports are...

To resolve this issue and prevent recurrence, we are taking the following corrective actions: To ensure that all reports are submitted within the required time frame, we will implement a tracking system using calendar reminders that will provide alerts for upcoming deadlines, ensuring no reports are late. We will streamline our internal processes to ensure there is a clear and defined workflow for report preparation and submission. This will include setting internal submission deadlines well in advance of the official due dates to allow for any necessary review or corrections.

View Audit 343326

Finding 523547 (2023-001)

Significant Deficiency 2023

Pennsylvania Housing Finance Agency

PA

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

U.S. Department of Housing and Urban Development Home Investment Partnerships Program – Assistance Listing No. 14.239 Recommendation: CLA recommended that PHFA review their procedures surrounding the division sign-off form utilized in the pre-commitment meeting. Explanation of disagreement with a...

U.S. Department of Housing and Urban Development Home Investment Partnerships Program – Assistance Listing No. 14.239 Recommendation: CLA recommended that PHFA review their procedures surrounding the division sign-off form utilized in the pre-commitment meeting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHFA implemented a new process to ensure the required divisional signoffs are received after the completion of the pre-commitment meeting. The Lending Officer prepares an electronic approval listing in Microsoft Teams to capture the approvals after the pre-commitment meeting. The Lending Officer follows up with the requested signors to ensure that all outstanding questions have been answered and the signer can mark the Microsoft Teams’ listing approved. Name of the contact person responsible for corrective action: Jessica Perry, Director of Development The new Microsoft Teams approval system was implemented in August 2023. To date, approximately 20 developments have been approved via the new system.

View Audit 342838

Finding 523391 (2023-005)

Material Weakness 2023

Hope Community Services, Inc.

OK

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principle...

Department of Health and Human Services, Passed Through Oklahoma Department of Mental Health and Substance Abuse Services, Block Grants for Community Mental Health Services Listing 93.958, 4529063664/4529063519, 711/2022- 6/30/2023 Allowable Activities or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024

View Audit 342657 Questioned Costs: $1

Finding 523390 (2023-004)

Material Weakness 2023

Hope Community Services, Inc.

OK

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Cash Management § 200.303 § 200.403

Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost ...

Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022- 8/30/2023 Allowable Activities or Unallowed, Allowable Costs/Cost Principles, Cash Management, and Matching, Level of Effort, and Earmarking Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the process for allocating payroll or time worked to respective federal programs was insufficient and did not substantiate allowability under the federal award guidelines. Responsible Individuals: Chief Financial Officer and Chief Human Resources Officer Corrective Action Plan: In December 2024, changes were made to the payroll system to improve tracking of time worked and appropriate allocations to respective federal grant programs. Completion Date: December 2024

View Audit 342657

Finding 523371 (2023-029)

Significant Deficiency 2023

Government of Guam

GU

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.

View Audit 342645 Questioned Costs: $1

Finding 523368 (2023-028)

Significant Deficiency 2023

Government of Guam

GU

Questioned Costs Matching / Level of Effort / Earmarking

Finding No.: 2023-028 Matching, Level of Effort, Earmarking Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward. Howev...

Finding No.: 2023-028 Matching, Level of Effort, Earmarking Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward. However, the Matching Level of Effort (MOE) earmarking is not a requirement in accordance with the Supplemental Terms and Conditions for the Child Care Mandatory and Matching Funds of the Child Care & Development Fund's Cost Sharing or Matching (Non-Federal Share) of Program Funding, page 2. Item 6 identifies that a state match is not required while Item 8 identifies that the MOE threshold applies to states only.

View Audit 342645 Questioned Costs: $1

Finding 523366 (2023-024)

Material Weakness 2023

Government of Guam

GU

Matching / Level of Effort / Earmarking

Finding No.: 2023-024 Matching, Level of Effort, Earmarking Responding Agency: Guam State Clearing House (GSC) Responsible Personnel: Stephanie Flores, Director (GSC) Agency agrees with the finding and will apply the recommendations moving forward.

View Audit 342645

Finding 523316 (2023-001)

Material Weakness 2023

Cascadia Behavioral Healthcare, Inc.

OR

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502

Corrective action planned – The Organization will reinforce and expand its policy of reviewing contracts for federal awards to include development properties and other forms of non-standard expenditures including non-cash assistance and loans. These policies and procedures will be added to the year-...

Corrective action planned – The Organization will reinforce and expand its policy of reviewing contracts for federal awards to include development properties and other forms of non-standard expenditures including non-cash assistance and loans. These policies and procedures will be added to the year-end financial statement reporting checklist which is reviewed and monitored by the Controller. During this process, the staff member assigned to completing the schedule of federal expenditures (currently the senior fiscal program analyst), will communicate with risk management to review incoming contracts during the year, as well as at year end to ensure that federal monies are accounted for, and that significant unusual transactions will be accounted for. The staff member assigned to completing this report will also communicate it to the Controller for review. Name(s) of contact person(s) responsible for corrective action – Richard Sroka, Senior Fiscal Program Analyst in charge of grant reporting Anticipated completion date – Implemented.

View Audit 342585

Finding 523138 (2023-004)

Material Weakness 2023

Central Minnesota Jobs and Training Services

MN

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking

MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the calculation of indirect cost allocations. This policy should ensure that all r...

MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the calculation of indirect cost allocations. This policy should ensure that all relevant documentation is retained for the required period and is easily accessible for audit purposes. Additionally, the Organization should ensure the formal review process for indirect cost allocations is completed to verify their accuracy and compliance with applicable regulations. Staff responsible for financial record-keeping and review should receive training on the importance of documentation retention, review procedures, and the specific requirements under the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To strengthen our financial recordkeeping, CMJTS will update our Document Retention Policy. This updated policy will introduce detailed guidelines for the management, maintenance, and secure storage of records that support indirect cost allocations, ensuring they are retained for the required period and easily accessible for audits. Additionally, we will establish a structured review process, including quarterly reviews by the accounting team and an annual reconciliation, to verify accuracy and compliance with applicable regulations. Any necessary adjustments will be documented and reviewed by the finance manager. The CMJTS Executive meets monthly to review and calculate indirect cost allocations for all active grants. The established process is to determine total indirect costs (like rent, utilities, administrative salaries) for the agency by location and department and then allocate them across different grants using a calculated "indirect cost rate," which is usually a percentage of the direct costs associated with each program, based on factors like staff time, caseload size, or other relevant allocation bases; this ensures that each program bears a proportional share of the shared overhead expenses. Name(s) of the contact person(s) responsible for corrective action: Jake Humphrey Planned completion date for corrective action plan: Policy updates – 12 months; Indirect Cost Rates process – implemented

View Audit 342459

Finding 522981 (2023-003)

Material Weakness 2023

Wright County Community Action, Inc.

MN

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Head Start - ALN #93.600 Recommendation: We recommend that the assigned individual to review, formally documents their review and approval of the SF-425 and SF-429/A reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of...

Head Start - ALN #93.600 Recommendation: We recommend that the assigned individual to review, formally documents their review and approval of the SF-425 and SF-429/A reports with a signature before the required date to be submitted. We recommend implementing a process to ensure timely submission of all reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCCA will implement a control policy for a documented review and approval of reports prior to submission as well as ensuring reports are filed timely. Name(s) of the contact person(s) responsible for corrective action: Carrie Tripp, Executive Director Planned completion date for corrective action plan: September 30, 2025

View Audit 342228

Finding 522901 (2023-004)

Significant Deficiency 2023

Clarkson University

NY

Questioned Costs Cash Management Internal Control / Segregation of Duties § 200.303

Management accepts this finding and notes that the University’s policy regarding drawdowns was updated in August 2023 to clarify our procedures to include a secondary review by someone other than the preparer of the drawdown request. “Awards from federal agencies are not paid in full or in advance a...

Management accepts this finding and notes that the University’s policy regarding drawdowns was updated in August 2023 to clarify our procedures to include a secondary review by someone other than the preparer of the drawdown request. “Awards from federal agencies are not paid in full or in advance at the time they are awarded to the University. Instead, the University is required to draw funds down from the federal agencies payment systems periodically to reimburse the University for its expenses on all of our federal grants. The Research Accountant accesses the federal payment systems periodically to prepare cash drawdowns for reimbursement of expenditures on federal grants at the University. The Research Accountant receives a report on all sponsored projects. That list of grants can be used to run an expense detail report for the period of time that the reimbursement request is covering on a monthly schedule throughout the year. That list of grants can also be used to check that our records are up to date and accurate as far as award amounts and budgets are concerned. The payment request amount is calculated as the difference between the Cumulative Expenses as of the end date of the month you are doing the drawdown for and the Cumulative Expenses as of the last day of the period the last drawdown was requested. This calculation is done on each active award and the sum of all of the calculated payment requests is the total amount of the drawdown to be requested. The payment calculations are reviewed and approved by either the Sr. Research Accountant, Associate Controller or Controller. In the event the Sr. Research Accountant prepares the drawdown, the Associate Controller or the Controller must review and approve prior to submission. After receiving approval, whoever initiated the drawdown will submit and certify the drawdown. In no circumstance, shall the preparer submit and certify without first obtaining approval from the Associate Controller or Controller.” It has also been the practice in the Controller’s Office that drawdowns are posted to the General Ledger by the AR Specialist/Cashier as they appear in the M&T bank account which the bank reconciliation process is then separate from and performed by someone other than the person preparing the drawdown. The Controller’s Office also documented Drawdown Procedures in order to clarify the process. In July 2023, the Controller’s Office added an additional Research Accountant bringing the staff from one to two employees to better share and segregate job duties.

View Audit 342222 Questioned Costs: $1

Finding 522899 (2023-002)

Significant Deficiency 2023

Clarkson University

NY

Matching / Level of Effort / Earmarking Student Financial Aid Significant Deficiency § 200.303

Management accepts this finding and notes that loan disbursement notifications are automatically sent to students (we mail notifications to parents and have copies of those saved). There was a glitch in the system that was discovered while going through the audit that occurred on 2 dates in 2023 (Ma...

Management accepts this finding and notes that loan disbursement notifications are automatically sent to students (we mail notifications to parents and have copies of those saved). There was a glitch in the system that was discovered while going through the audit that occurred on 2 dates in 2023 (May 31, 2023 and September 3, 2023) which has since been fixed. Financial Aid worked with the Office of Information Technology to develop a daily report that will notify the Director of Financial Aid of anyone that did not receive a notification.

View Audit 342222

Finding 522820 (2023-004)

Material Weakness 2023

Belmont County

OH

Reporting Allowable Costs / Cost Principles Period of Performance § 200.302 § 200.328 § 200.329

This was an oversight and has been corrected.

View Audit 342216

Finding 522817 (2023-002)

None 2023

Congregation Masores Hachinuch INC

NY

Matching / Level of Effort / Earmarking

Recommendation: The Organization will develop a written code of conduct that provides disciplinary actions for violations by officers, employees, or agents. Action Taken: The SFA has updated the written code of conduct to include disciplinary actions, in the area of acceptance of gratuities, for vio...

Recommendation: The Organization will develop a written code of conduct that provides disciplinary actions for violations by officers, employees, or agents. Action Taken: The SFA has updated the written code of conduct to include disciplinary actions, in the area of acceptance of gratuities, for violations by officers, employees, or agents. The SFA will ensure that the written code of conduct is followed. We have designated Rabbi Shaul Rosengarten, administrator, to implement and monitor the plan of corrective action for this finding. Completion Date: 08/31/2022

View Audit 342215

Finding 522620 (2023-003)

Significant Deficiency 2023

Elder Care Services, Inc.

FL

Matching / Level of Effort / Earmarking Reporting § 200.303

Auditor’s Recommendation: The Auditor recommends the Organization develop and implement adequate internal controls to ensure reporting is reviewed for accuracy and approval is documented prior to submission. ...

Auditor’s Recommendation: The Auditor recommends the Organization develop and implement adequate internal controls to ensure reporting is reviewed for accuracy and approval is documented prior to submission. Views of Responsible Officials and Planned Corrective Action: Semi-annual program reports will be completed by SVP Director, April Kirk, in draft form in eGrants and printed for review by the CEO, Jocelyne Fliger. CEO will review, make any necessary corrections, and approve final report effective immediately.

View Audit 341857

Finding 522618 (2023-002)

Significant Deficiency 2023

Elder Care Services, Inc.

FL

Eligibility Matching / Level of Effort / Earmarking § 200.303

Auditor’s Recommendation: The Auditor recommends the Organization provide training for all program staff for eligibility review procedures and the requirements of document retention and documentation of review and approval. ...

Auditor’s Recommendation: The Auditor recommends the Organization provide training for all program staff for eligibility review procedures and the requirements of document retention and documentation of review and approval. Views of Responsible Officials and Planned Corrective Action: Annual review of income eligibility requirements and compliance with the AmeriCorps standards. All income eligibility will be reviewed in accordance with standards by Program Managers (Tiffane McMillon and Roshanda Dorsey) and then brought to SVP Director, April Kirk, for final approval effective immediately.

View Audit 341857

Finding 522590 (2023-001)

Material Weakness 2023

Center for Mental Health

MT

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring

Finding #2023-001 Allowable Costs and Cost Principles: Douglas Wilson was unable to determine if the Center complied with the 15% requirement or the $25,000 technical assistance limit for the CCBHC grant. Douglas Wilson was also unable to test a sample of direct costs charged to the program because...

Finding #2023-001 Allowable Costs and Cost Principles: Douglas Wilson was unable to determine if the Center complied with the 15% requirement or the $25,000 technical assistance limit for the CCBHC grant. Douglas Wilson was also unable to test a sample of direct costs charged to the program because transaction details were not provided. Per the recommendation of Douglas Wilson, we have updated the Center’s existing financial policy and procedures to include language specifically related to how the Center will retain documentation to support costs that are charged to the CCBHC grant, and also track and monitor compliance with the 15% and $25,000 maximum requirements for the grant (see Financial Policies and Procedures Policy A-14). Responsible official: Sydney Blair, Chief Executive Officer, 406.791.9603 Expected completion date: June 30, 2025

View Audit 341818

Finding 522506 (2023-006)

Material Weakness 2023

Barbour County Board of Education

AL

Questioned Costs Matching / Level of Effort / Earmarking Special Tests & Provisions

The Board will comply with Title 29, U. S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the "Davis-Bacon Act") when using COVID- 19 Education Stabilization Funds for construction.

View Audit 341776 Questioned Costs: $1

Finding 522498 (2023-003)

Significant Deficiency 2023

The Behavioral Wellness Center at Girard

PA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Corrective Action: Management agrees with the finding and has subsequently supported other eligible expenses that were not included in the original submission. These amounts exceeded the funding received. Anticipated Completion Date: November 15, 2024 Contact Person: Marco Giordano, Vice President ...

Corrective Action: Management agrees with the finding and has subsequently supported other eligible expenses that were not included in the original submission. These amounts exceeded the funding received. Anticipated Completion Date: November 15, 2024 Contact Person: Marco Giordano, Vice President and Chief Financial Officer

View Audit 341753

Corrective Action Plans

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