Corrective Action Plans

Finding 526853 (2023-005)

Significant Deficiency 2023

IN

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

In January 2024, we partnered with G&A, which provided services that automated time tracking allocations in the accounting system based on Time and Attendance records placed in the payroll system. This information applies time ratios spent on grants times actual cost from payroll and automatically c...

In January 2024, we partnered with G&A, which provided services that automated time tracking allocations in the accounting system based on Time and Attendance records placed in the payroll system. This information applies time ratios spent on grants times actual cost from payroll and automatically comes in the accounting system based on project costing (time concerning all time spent on projects). The purchase of the grant management system will pull accounting data from the accounting software, and the data will be mapped to the budgetary lines of the grant. Monthly, the financial grant coordinator will work with senior directors and directors to go over the financial information and ensure compliance with the allowable cost to respective grants. Correctively, budget vs actual reviews with senior directors take place in which directors identify permissible costs or costs that are not, and those costs are adjusted to programs that allow such cost or to admin.

View Audit 345960 Questioned Costs: $1

Finding 526852 (2023-004)

Significant Deficiency 2023

Edna Martin Christian Center, Inc.

IN

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

The purchase of the grant management system will pull accounting data from the accounting software, and the data will be mapped to the budgetary lines of the grant. Monthly, the financial grant coordinator will work with senior directors and directors to go over the financial information and ensure ...

The purchase of the grant management system will pull accounting data from the accounting software, and the data will be mapped to the budgetary lines of the grant. Monthly, the financial grant coordinator will work with senior directors and directors to go over the financial information and ensure compliance with the allowable cost to respective grants Correctively, budget vs actual reviews with senior directors take place in which directors identify permissible costs or costs that are not, and those costs are adjusted to programs that allow such cost or to admin

View Audit 345960

Finding 526851 (2023-003)

Significant Deficiency 2023

Edna Martin Christian Center, Inc.

IN

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

The purchase of the grant management system will pull accounting data from the accounting software and the data will be mapped to the budgetary lines of the grant. Monthly, the financial grant coordinator will work with senior directors and directors to go over the financial information and ensure c...

The purchase of the grant management system will pull accounting data from the accounting software and the data will be mapped to the budgetary lines of the grant. Monthly, the financial grant coordinator will work with senior directors and directors to go over the financial information and ensure compliance with allowable cost to respective grants Correctively, budget vs actual reviews with senior directors take place in which directors identify permissible costs or costs that are not, and those costs are adjusted to programs that allow such cost or to admin

View Audit 345960 Questioned Costs: $1

Finding 526850 (2023-002)

Material Weakness 2023

Edna Martin Christian Center, Inc.

IN

Subrecipient Monitoring Reporting Material Weakness § 200.305 § 200.502 § 200.510

A grant manager and grant-financial coordinator have been hired to work with the finance team to communicate the whole gamut of applicable elements of ASC 606. Also, we are purchasing a grant management system—not a manual Excel sheet- that can scan grants and identify conditions and restrictions.

View Audit 345960

Finding 526564 (2023-004)

Material Weakness 2023

Doral Academy of Northern Nevada

NV

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking

Corrective Action Plan: Due to unexpected turnover, a secondary review was not performed to verify the preparation of the ESSER reporting. To strengthen the oversight of financial management of the School, Academica Nevada, the School’s management company, filled all open positions and realigned sta...

Corrective Action Plan: Due to unexpected turnover, a secondary review was not performed to verify the preparation of the ESSER reporting. To strengthen the oversight of financial management of the School, Academica Nevada, the School’s management company, filled all open positions and realigned staff responsibilities to reduce individual workloads and provide additional oversight and review. In addition, a financial controller has been added to ensure that secondary reviews occur on all required filings and reconciliations. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024

View Audit 345521

Finding 526551 (2023-006)

Material Weakness 2023

Dunseith Public School District No. 1

ND

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

Contact Person Evan Peltier Planned Corrective Action Dunseith Public School Dist. #1 will implement the recommendation from Brady Martz. Planned Completion Date The planned completion date is June 30, 2025.

View Audit 345466

Finding 526512 (2023-003)

Material Weakness 2023

Boulder City Hospital, Inc.

NV

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Finding 2023-003 Federal Agency Name: U.S. Department of Agriculture Federal Financial Assistance Listing: #10.766 Program Name: Community Facilities Loans and Grants Cluster, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did...

Finding 2023-003 Federal Agency Name: U.S. Department of Agriculture Federal Financial Assistance Listing: #10.766 Program Name: Community Facilities Loans and Grants Cluster, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2023, the Hospital should have USDA debt reserves at least equal to $389,998. Responsible Individuals: Doug B. Lewis, Chief Financial Officer Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.

View Audit 345428

Finding 526462 (2023-001)

Significant Deficiency 2023

Okanogan County Child Development Association

WA

Internal Control / Segregation of Duties Significant Deficiency Matching / Level of Effort / Earmarking

Recommendation: We recommend that Association staff familiarize themselves with the terms of the loan agreement and put controls in place to ensure funds are properly transferred to the reserve account at least annually. Explanation of disagreement with audit finding: There is no disagreement with t...

Recommendation: We recommend that Association staff familiarize themselves with the terms of the loan agreement and put controls in place to ensure funds are properly transferred to the reserve account at least annually. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment: Fiscal Manager has reviewed the loan requirements. Root Cause Due to large turnover in the fiscal team and the lack of knowledge of loan requirements. Action Taken Fiscal Manager has reviewed loan documents and requirements making ourselves familiar with the reserve account requirements. Moving forward the transfer to the reserve account will happen on a monthly basis in conjunction with the mortgage payment. OCCDA now has a recurring entry for this transaction and the funds are transferred monthly. Also we updated our procedures to ensure that all transfers are completed and are documented for cross training.

View Audit 345386

Finding 526452 (2023-002)

Material Weakness 2023

City of Wyandotte, Michigan

MI

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.502 § 200.508 § 200.510

Condition: The schedule of expenditures of federal awards (SEFA) was not accurate. Planned Corrective Action: The City will review its process for identifying and communicating Federal Grant expenditures to its auditors. Contact person responsible for corrective action: Robert McMahon, City Administ...

Condition: The schedule of expenditures of federal awards (SEFA) was not accurate. Planned Corrective Action: The City will review its process for identifying and communicating Federal Grant expenditures to its auditors. Contact person responsible for corrective action: Robert McMahon, City Administrator Anticipated Completion Date: 09/30/2025

View Audit 345380

Finding 525947 (2023-007)

Significant Deficiency 2023

Glacierland Resource Conservation and Development Council, Inc.

WI

Cash Management Reporting Matching / Level of Effort / Earmarking

Finding: 2023-007 • Condition: We identified differences in the amounts of costs reported to grantors compared to actual costs incurred during those periods. • Planned Corrective Action: Financial policies created will identify a double check system in which the bookkeeper and the Executive Directo...

Finding: 2023-007 • Condition: We identified differences in the amounts of costs reported to grantors compared to actual costs incurred during those periods. • Planned Corrective Action: Financial policies created will identify a double check system in which the bookkeeper and the Executive Director must both review the documentation for a given period to ensure accuracy. Contact Person: Katherine Jaeger Anticipated Date of Completion: 2/21/2025

View Audit 345115

Finding 525876 (2023-005)

Material Weakness 2023

County of Solano

CA

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Epidemiology and Laboratory Capacity for Infectious Diseases Federal Assistance Listing Number: 93.323 Pass‐through: California Department of Public Health Award No. and Year: COVID-19ELC48, COVID-19ELC106, 2021/2022 Compl...

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Epidemiology and Laboratory Capacity for Infectious Diseases Federal Assistance Listing Number: 93.323 Pass‐through: California Department of Public Health Award No. and Year: COVID-19ELC48, COVID-19ELC106, 2021/2022 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Corrective action was implemented in April 2023. Responsible Individual(s): Nina Delmendo, Director of Administrative Services Anticipated Completion Date: April 2023

View Audit 345033

Finding 525285 (2023-002)

Material Weakness 2023

African American Child Wellness Institute

MN

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Emplo...

Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Employee time sheets do not identify the hours charged to each federal grant, and do not identify hours worked by employees on non-federal grants. Actions Planned in Response to the Finding: The timeline for hiring an in-house accountant is very compressed. The in-house accountant will undergo various training on Uniform Guidance and federal grant management. These training programs will help the organization to create a system of time and effort reporting that will meet the Standards for Documentation of Personnel Expenses included in OMB Uniform Guidance. Specifically, time sheets will be redesigned to ensure that employees record hours charged to each federal grant, any other projects, and administrative time. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: June 30, 2025

View Audit 344524 Questioned Costs: $1

Finding 525281 (2023-001)

Material Weakness 2023

African American Child Wellness Institute

MN

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minn...

To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minneapolis, MN 55415 African American Child Wellness Institute submits the following corrective action plan for the year ended December 31, 2023. Please contact Akinyele Akinsanya at 763-522-0100. Finding 2023-001 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Expenses charged to the federal grant cannot be traced into the Organization’s general ledger. Invoices submitted to the pass-through agency for reimbursement also cannot be traced into the general ledger. Actions Planned in Response to the Finding: It is clear to management that the Organization needs to boost its accounting team to fulfil effective reporting that could easily be traced into the organization’s general ledger. As a result, the organization will recruit and hire a full-time accountant to work with the current team. Further steps may be required including replacing the organization’s current accounting software that will identify and record expenditure specific to each cost centers for each federal grant. The in-house accountant will also be required to obtain additional training in Uniform Guidance and federal grant management and create a system of financial reporting to record expenditure directly to each federal grant award. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: March 15, 2025

View Audit 344524 Questioned Costs: $1

Finding 525118 (2023-007)

Significant Deficiency 2023

Mary's Center for Maternal and Child Care, Inc.

DC

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

Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, caused personnel to s...

Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, caused personnel to store information in different locations. In May 2023, the organization made the transition to the new accounting system where data can easily be centralized/shared. Management has also implemented policies and procedures that require review of documents within the accounting system prior to approval, thus creating internal controls to prevent a lack of supporting documentation for future reporting periods. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller

View Audit 344384

Finding 525115 (2023-006)

Significant Deficiency 2023

Mary's Center for Maternal and Child Care, Inc.

DC

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.414

Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis...

Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis including computing actual indirect cost rates at the conclusion of each audit. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller

View Audit 344384

Finding 525109 (2023-004)

Significant Deficiency 2023

Mary's Center for Maternal and Child Care, Inc.

DC

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

Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, it caused personnel t...

Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, it caused personnel to store information in different locations. In May 2023, the organization made the transition to the new accounting system where data can easily be centralized/shared. Management has also implemented policies and procedures that require review of documents within the accounting system prior to approval, thus creating internal controls to prevent a lack of supporting documentation for future reporting periods. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller

View Audit 344384 Questioned Costs: $1

Finding 524860 (2023-002)

Material Weakness 2023

A+ Arts Academy

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management

Construction projects for A+ Arts were facilitated by the management company with approval from the Board of Directors. Although the likelihood of additional construction projects being done in the future using Federal dollars since ESSER funds are no longer available is very remote, the management ...

Construction projects for A+ Arts were facilitated by the management company with approval from the Board of Directors. Although the likelihood of additional construction projects being done in the future using Federal dollars since ESSER funds are no longer available is very remote, the management company is aware of the prevailing wage and certified payroll requirement and will make sure any future projects adhere to these requirements.

View Audit 344218

Finding 524734 (2023-002)

Material Weakness 2023

Aiken/barnwell Counties Community Action Agency INC

SC

Matching / Level of Effort / Earmarking Special Tests & Provisions

We agree with the finding. Management is proceeding with a process for accommodating timely and accurate financial reporting. Members of the financial team will be updated and trained in policies and procedures to ensure proper operations are being performed. The hiring and training of additional ac...

We agree with the finding. Management is proceeding with a process for accommodating timely and accurate financial reporting. Members of the financial team will be updated and trained in policies and procedures to ensure proper operations are being performed. The hiring and training of additional accounting staff will be implemented. We plan to complete these processes by May 31, 2025.

View Audit 344155

Finding 524466 (2023-003)

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 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

Corrective Action Plans

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