Corrective Action Plans

Finding 500255 (2023-001)

Significant Deficiency 2023

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

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

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pr...

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.

View Audit 323033 Questioned Costs: $1

Finding 500253 (2023-003)

Significant Deficiency 2023

Nationwide Children's Hospital

OH

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

Finding 2023-003 Grantor: Department of Health and Human Services Federal Program: Oral Diseases and Disorders Research Maternal and Child Health Federal Consolidated Programs Assistance Listing #: 93.121 93.110 Title: Effort Certification Award Year: Fiscal year 2023 1/1/2023 – 12/31/2...

Finding 2023-003 Grantor: Department of Health and Human Services Federal Program: Oral Diseases and Disorders Research Maternal and Child Health Federal Consolidated Programs Assistance Listing #: 93.121 93.110 Title: Effort Certification Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: 1R01DE031756-01A1 2 U03MC28844-09-00 Corrective Action Plan and Anticipate Completion Date • In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has been remediated. Management implemented a new procedure to ensure timely time and effort certification. Management implemented the process for first quarter 2024 to allow time for system updates and training. Responsible person: Aaron Ufferman, Director, Sponsored Projects Completion Date: February 1, 2024

View Audit 323032

Finding 500215 (2023-002)

Significant Deficiency 2023

Nationwide Children's Hospital

OH

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2023-002 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Fringe Rate Analysis – Formula Error Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: Various Management agrees with the recommendation. Ho...

Finding 2023-002 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Fringe Rate Analysis – Formula Error Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: Various Management agrees with the recommendation. However, while there was an error in the underlying data used to evaluate the annual fringe rate, the federal government was not overcharged for fringe benefits. Corrective Action Plan and Anticipate Completion Date Management’s corrective action plan includes: • Management will ensure a more robust review of the underlying formulas. Responsible Person: Natasha Collins, Director of Research Accounting Completion Date: December 31, 2024

View Audit 323032

Finding 500153 (2023-002)

Material Weakness 2023

Collaborative Solutions for Communities

DC

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.308 § 200.430

Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hir...

Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hiring will be the responsibility of the grantor. While the grantor placed the instructions for clearances in the scope of work for Safe Passage, it was not clearly outlined in the grant under personnel requirements. Proposed Completion Date August 31, 2024

View Audit 322995 Questioned Costs: $1

Finding 500135 (2023-003)

Significant Deficiency 2023

1890 Universities Foundation

DC

Allowable Costs / Cost Principles Period of Performance Significant Deficiency § 200.430

Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting Foundation employees’ time and effort reports are submitted monthly to t...

Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting Foundation employees’ time and effort reports are submitted monthly to the Director of Finance. The Director of Finance reviews time and effort reports and compiles the data to allocate personnel expenditures, however, the time stamp of approvals was not effectively documented during 2023. The Foundation has implemented procedures to effectively time stamp the review and approval process, each month. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024

View Audit 322978

Finding 500133 (2023-005)

Significant Deficiency 2023

County of Delaware

PA

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time fra...

This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/ petitions to case files and file documentation beginning in November 2023.

View Audit 322974

Finding 500118 (2023-002)

Material Weakness 2023

Centro Hispano, Inc.

WI

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.318

2023-002 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21.027 Recommendation: Procurements should follow the required methods per Uniform Guidance and document the full procurement history. Procurement procedures should be designed, implemented, and written consistent w...

2023-002 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21.027 Recommendation: Procurements should follow the required methods per Uniform Guidance and document the full procurement history. Procurement procedures should be designed, implemented, and written consistent with Uniform Guidance. Personnel responsible for procurement should be trained on Uniform Guidance requirements and Centro Hispano's written procurement procedures. Action Taken: Centro Hispano drafted and approved an Accounting Policies and Procedures manual in September 2024 which conforms with Uniform Guidance requirements.

View Audit 322967 Questioned Costs: $1

Finding 500117 (2023-003)

Material Weakness 2023

Charter Township of Commerce

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.302

Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allo...

Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allocated into the correct funds as approved by the Township Board. Contact person responsible for corrective action: Molly Phillips and Katelyn Massey Anticipated Completion Date: 12/31/2024

View Audit 322964

Finding 500114 (2023-001)

None 2023

South Shore Child Guidance Association, Inc.

NY

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.317 § 200.318 § 200.327

Corrective Action Planned: We will review the Uniform Guidance Standards and update the procedures needed to be in full accordance. Name(s) of Contact Person(s) Responsible for Corrective Action: Lynette Bacchus will make the changes and John Pinto and Lawrence Boord will approve. Anticipated Com...

Corrective Action Planned: We will review the Uniform Guidance Standards and update the procedures needed to be in full accordance. Name(s) of Contact Person(s) Responsible for Corrective Action: Lynette Bacchus will make the changes and John Pinto and Lawrence Boord will approve. Anticipated Completion Date: October 31, 2024.

View Audit 322959

Finding 500105 (2023-002)

Material Weakness 2023

Shiloh Manor, Inc.

CT

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid payroll expenses in the amount of $76 on behalf of an affiliate from the project cash without HUD approval. The amount due to the project as of December 31, 2023 is $76. b. Action(s) Taken or Plan...

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid payroll expenses in the amount of $76 on behalf of an affiliate from the project cash without HUD approval. The amount due to the project as of December 31, 2023 is $76. b. Action(s) Taken or Planned on the Finding 1 The finding for the $76 are items deducted from Shiloh Manor due an error with the setup of payroll processing with Paychex that resulted in a few items deducted from the bank account that should have been for First Housing Corp. It was eventually fixed with Paychex in 2024 and the amount was accounted for as Accounts Receivable - Other as a due from First Housing Corp. A transfer will be made in 2024 for the total of the balance due of $75.60 from First Housing Corp to Shiloh Manor to correct.

View Audit 322940 Questioned Costs: $1

Finding 500104 (2023-001)

None 2023

Shiloh Manor, Inc.

CT

HUD Housing Programs Matching / Level of Effort / Earmarking

a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In 2017, HUD had approved a loan to operations from the reserve for replacement to be repaid upon receipt of the past due subsidy. When the subsidy was received, the property was unable to repay the loan be...

a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In 2017, HUD had approved a loan to operations from the reserve for replacement to be repaid upon receipt of the past due subsidy. When the subsidy was received, the property was unable to repay the loan because of an unexpected increase in vacancies as a result of tenant turnover. The loan has not yet been repaid. During 2022, property transferred $9,000 of reserve for replacement funds to operations to fund payroll and operating payables; the funds have not been reimbursed as of December 31, 2023. b. Action(s) Taken or Planned on the Finding The 2022 transfer from reserve of $9,000 was not returned as of 2023. A conversation with HUD on May 29, 2024, lead to a decision being made with a payment plan of $1,500 per month to start on June 1, 2024. As of December 31, 2023, there was a meeting with HUD representatives on March 23, 2023, resulted in the decision for the waiver of the balance owed to the reserve of the $40,239. We are awaiting documentation from HUD on this decision.

View Audit 322940

Finding 500102 (2023-002)

Significant Deficiency 2023

City of Wausau

WI

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.214

Suspension and Debarment State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that ar...

Suspension and Debarment State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will take actual computer image snips of the search results. Name(s) of the contact person(s) responsible for corrective action: Maryanne Groat Planned completion date for corrective action plan: 9/30/2024

View Audit 322932

Finding 500059 (2023-003)

Material Weakness 2023

Northshore University Healthsystem

IL

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

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management...

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management will update the salary cap in the system in a timely manner and validate that the system is calculating correctly. Going forward, management will do a quarterly review of the effort distributions, and make adjustments when needed in a timely manner. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 322924 Questioned Costs: $1

Finding 499980 (2023-002)

Significant Deficiency 2023

Acupuncture and Integrative Medicine College, Berkeley

CA

Student Financial Aid Reporting Significant Deficiency

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. According to NSLDS Enrollment Reporting Guide, “At a minimum, schools are required to certify enrollment every 60 days, and respond within 15 days of the date that NSLDS sends a Roster file to the school or i...

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. According to NSLDS Enrollment Reporting Guide, “At a minimum, schools are required to certify enrollment every 60 days, and respond within 15 days of the date that NSLDS sends a Roster file to the school or it’s third-party servicer.” And “Rosters will be sent to schools no less frequently than every two months.” It seems RGM did not receive the rosters from NSLDS thus the Enrollment Reporting was not filed in a timely manner. The school will work closely with the third-party servicer and monitor the NSLDS Enrollment Reporting from now on, effective September 23, 2024.

View Audit 322916

Finding 499979 (2023-001)

Significant Deficiency 2023

Acupuncture and Integrative Medicine College, Berkeley

CA

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

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. A reminder will be posted in RGM and the school will review the monthly roster. The school will work closely with the third-party servicer to make sure correct student status information is reported to the N...

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. A reminder will be posted in RGM and the school will review the monthly roster. The school will work closely with the third-party servicer to make sure correct student status information is reported to the NSLDS from now on. Effective completion September 24, 2024

View Audit 322916

Finding 499967 (2023-001)

Material Weakness 2023

Bossier Office of Community Services, Inc.

LA

Matching / Level of Effort / Earmarking § 200.302

The Finance Director was responsible for ensuring that bank accounts are reconciled accurately and on a monthly basis. Due to performance, the finance director has been terminated and the agency has contracted with a CPA firm to review and make any corrections to account reconciliations.

View Audit 322911

Finding 499948 (2023-003)

Material Weakness 2023

Town of Whitestown

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report withou...

FINDING 2023-003 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The Town submitted one P&E report during the audit period timely; however, a single employee prepared and submitted the P&E report without a review or oversight process in place to prevent or detect and correct errors. Only one annual report was required to be submitted by the Town. For the report tested, all activity for the reporting period was not included, information submitted was not supported by the Town's records, and the reports were not fairly presented. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For applicable reports that are to be submitted for federal grants, we will implement a control/review and ensure the information being reported is correct prior to submission. Anticipated Completion Date: November 1, 2024

View Audit 322895

Finding 499945 (2023-003)

Significant Deficiency 2023

Community Development Corporation of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the pers...

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the person responsible for the plan.

View Audit 322891 Questioned Costs: $1

Finding 499932 (2023-001)

None 2023

Care Plus Bergen, Inc.

NJ

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking

Planned Corrective Action: Management is reviewing current policies and procedures. Management will make proper adjustments to the policies to ensure that awards are accounted for in the proper performance period. Further education will be done with staff and there will be mid mid-year internal au...

Planned Corrective Action: Management is reviewing current policies and procedures. Management will make proper adjustments to the policies to ensure that awards are accounted for in the proper performance period. Further education will be done with staff and there will be mid mid-year internal audits. Person(s) Responsible: Sandi Weiss, AVP Finance Expected Completion Date: November 15, 2024

View Audit 322865 Questioned Costs: $1

Finding 499927 (2023-002)

Material Weakness 2023

Chris Properties Graham Circle, Inc.

GA

Questioned Costs Reporting Matching / Level of Effort / Earmarking

To address the deficiencies identified in the audit regarding payroll allocations, the Organization will utilize the services of Attain Partners, a professional services firm specializing in grants management. Attain Partners will assist the Organization with implementing procedures including the fo...

To address the deficiencies identified in the audit regarding payroll allocations, the Organization will utilize the services of Attain Partners, a professional services firm specializing in grants management. Attain Partners will assist the Organization with implementing procedures including the following Time and Effort Recording • Work with the CFO, COO, and CCO to revise the current T&E policies and procedures. • Work with Finance and HR to revise the current payroll allocation form to include all information needed to correctly record the T&E information in the HRIS and accounting system. • Work with Finance and HR to ensure the payroll allocation journal entries in the accounting system are correctly labeled, easily identifiable, and allocated correctly. • Work with HR to determine the correct reports needed to track employee allocations are designed correctly in the HRIS. 2. Effort Reports/Certifications • Work with the program leadership on the Time and Effort Certification process including individual and project certifications. • Assist the program leadership in reviewing the time charged to the grants per pay period and certifying that actual time and effort was charged and not budgeted time and effort. • Work with Finance and HR in comparing labor reports to any journal entry with the retro reference, to ensure there was a change and an allocation form completed. This manual process is needed as the current HRIS does not record retro changes.

View Audit 322863 Questioned Costs: $1

Finding 499913 (2023-002)

Significant Deficiency 2023

Alabama Nursing Home Association Education Foundation

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.403 § 200.405

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Granto...

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Grantor no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

View Audit 322841 Questioned Costs: $1

Finding 499912 (2023-001)

Significant Deficiency 2023

Alabama Nursing Home Association Education Foundation

AL

Period of Performance Significant Deficiency Matching / Level of Effort / Earmarking § 200.203 § 200.303

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home a...

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home applicants that the applicant had or will have sufficient unmet needs related to qualifying purposes due to the COVID‐19 pandemic to support the receipt of the various allocations of the herein described COVID‐19 Funds. Under the terms of the certification, each applying nursing home further certified that for ten (10) years it would maintain auditable records supporting the unmet need and use of the COVID‐19 Funds. This manner of requiring only a certification for the distribution to health care providers is consistent with the requirements the federal government used when distributing an array of emergency funding (e.g., provider relief funds, rural funds, and infection control funds) to health care providers to meet the unmet needs caused by the COVID‐19 pandemic. The term “COVID‐19 Funds” means those funds the Foundation received from the Grantor with respect to (i) The CARES Act Corona Virus Relief Funds for the period from January 31, 2020, through December 31, 2021, and (ii) America Rescue Plan Act (ARPA) funds for unmet needs for qualifying purposes incurred or to be incurred during the period March 11, 2021, through December 31, 2024. To provide further assurance that the COVID‐19 Funds were properly applied by the nursing home beneficiaries receiving COVID‐19 Funds through the Foundation, the Foundation is working with its outside accountants and legal counsel to develop a look‐back review plan. The framework of the lookback review plan will be for each nursing home beneficiary that received COVID‐19 Funds to submit during the calendar year 2024, a worksheet similar to the period reporting worksheets that are required by the federal Health Resources & Services Administration (HRSA) to justify the COVID‐19 provider relief funds, rural funds, and infection control funds received by health care providers. In addition to these HRSA type worksheets, a more in‐depth examination of a sample of nursing homes will be made by randomly selecting 10 nursing homes from a pool of the 30 nursing homes that received the most COVID‐19 Funds through the Foundation, plus another 10 nursing homes from the remainder of the pool of beneficiary nursing homes. These randomly selected nursing homes will be required to supply actual documentation supporting the COVID‐19 Funds received. This documentation will include invoices, payroll records, revenue journals, and cost reports. Among the provisions of the certifications submitted by each applying nursing home, is an acknowledgement that (i) the nursing home is subject to audit by the applicable State and federal agencies, and the Foundation, (ii) any COVID‐19 Funds received through the Foundation and not properly applied must be refunded, and the nursing home will comply with the requirement that it must maintain for ten (10) years auditable records supporting its use of the COVID‐19 Funds it received through the Foundation. In the event that it is determined that one or more nursing homes were unable to properly apply the COVID‐19 Funds to an unmet need for a qualifying purpose, those COVID‐19 Funds will be recouped and either redistributed to any nursing homes that are able show an unmet need continues to exist using a distribution formula consistent with past distributions of refunded COVID‐19 Funds, or returned to the Grantor. This redistribution or return to the Grantor will occur no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

View Audit 322841

Finding 499911 (2023-001)

Material Weakness 2023

Metropolitan Learning Institute, Inc.

NY

Questioned Costs Matching / Level of Effort / Earmarking Cash Management

Management’s Corrective Action Plan Audit Firm: Andrew Pieri CPA, PC. Audit Period: January 1, 2023 through December 31, 2023 The finding from the December 31, 2023 schedule of findings and question costs is discussed below. The finding is numbered consistent with the number assigned in the schedu...

Management’s Corrective Action Plan Audit Firm: Andrew Pieri CPA, PC. Audit Period: January 1, 2023 through December 31, 2023 The finding from the December 31, 2023 schedule of findings and question costs is discussed below. The finding is numbered consistent with the number assigned in the schedule. FINDING: 2023-001 Earmarking Federal Agency / Federal Program: U.S. Department of Education / Education Stabilization Fund Subject: Earmarking (G) ALN Number: 84.425 Metropolitan Learning Institute, Inc. agrees with the finding. Planned Corrective Action Plan: The School has contacted DOE to request the HEERF III students funds in order to distribute the funds to its student. If the School is unable to receive those funds, we will contact DOE to resolve the potential liability. Responsible for corrective action: James Bruce . Anticipated completion date: December 31, 2024

View Audit 322838 Questioned Costs: $1

Finding 499899 (2023-001)

Significant Deficiency 2023

Sunny Glen Children's Home, Inc.

TX

Questioned Costs Procurement, Suspension & Debarment Equipment & Real Property Management

CORRECTIVE ACTION PLAN 2023-001 - Equipment and Other Capital Expenditure Type of Finding: Federal Award Finding and Questioned Cost Responsible for Implementation of Corrective Action Plan: Chase Palmer CEO & Cynthia Pinkerton CFO Estimated Date of Completion: December 2024 Actions to Address ...

CORRECTIVE ACTION PLAN 2023-001 - Equipment and Other Capital Expenditure Type of Finding: Federal Award Finding and Questioned Cost Responsible for Implementation of Corrective Action Plan: Chase Palmer CEO & Cynthia Pinkerton CFO Estimated Date of Completion: December 2024 Actions to Address the Finding: Sunny Glen will continue to pursue formal written clearance from the Administration for Children and Families (ACF) regarding the questioned vehicle lease expenditures. While prior email guidance and budget approvals have been received, Sunny Glen recognizes the importance of securing formal documentation from ACF to fully resolve this matter. We will: • Engage in direct communication with ACF to expedite the final determination process regarding the vehicle lease arrangements. • Submit any additional documentation, if requested by ACF, including lease agreements, budget approvals and prior communications. • Maintain a log of all communication and follow-up actions to ensure transparency and documentation of our efforts. Responsible Individual: The CFO, Cynthia Pinkerton, will be responsible for overseeing this corrective action plan and ensuring all steps are taken to resolve the finding. Timeline for Implementation: Sunny Glen will initiate this follow-up process immediately upon issuance of this report and will aim to secure formal written clearance within the next audit period, subject to response from ACF. Disagreement with Finding: Sunny Glen continues to disagree with the prior finding regarding the allowability of the vehicle lease expenditures. The lease terms were provided to the Office of Refugee Resettlement (ORR) as part of the budgeting process, and the amounts were approved as necessary and reasonable to facilitate the program. Email guidance was also received from ACF indicating the appropriateness of the lease arrangements. We believe the expenditures were appropriate and compliant with grant guidelines. Monitoring of Progress: The CFO will provide regular updates to management and the audit committee regarding the status of the corrective action and any responses from ACF. Sunny Glen will adjust its actions as necessary based on ACF's feedback to achieve full resolution.

View Audit 322828 Questioned Costs: $1

Finding 499893 (2023-003)

Significant Deficiency 2023

Lutheran Metropolitan Ministry

OH

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

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this...

LMM agrees that 4 out of 40 tested non-payroll costs did not have evidence of approval for payment. While the payments were for contracted services that were received by LMM the written approval for payment was not able to be located. LMM has recently adopted Concur for expense management. With this platform all approvals are required electronically and evidence of approval will be able to be submitted.

View Audit 322823

Corrective Action Plans

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