Corrective Action Plans

Finding 565420 (2024-005)

Significant Deficiency 2024

MA

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-005 Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that BAM case investigations are completed timely in...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-005 Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that BAM case investigations are completed timely in accordance with the time limits established in the ET Handbook No. 395. Action taken in response to finding: Analysis showed that BAM Investigators spend a minimum of 20% of work hours devoted to clerical tasks necessary to develop an investigatory file. As part of MDUA’s modernized UI system, the new system features an electronic BAM casefile which should reduce clerical work 5% or below, and, in turn, allow additional time to investigate and complete case work. BAM has always relied on postal mail as a primary methodology to contact interested persons. By integrating the BAM casefile into the UI system, investigators can send questionnaires and notifications to interested persons through the system. In turn, interested persons may complete questionnaires and upload information into the system thereby reducing time between issuance of documents and response. Name(s) of the contact person(s) responsible for corrective action: Susan Saulnier, Director of UI Performs Planned completion date for corrective action plan: June 2026 This statistic is compiled for a year of data. Because BAM was not an on-line program, all cases prior to May 18, 2025 remain in the old format, and, therefore were not placed in the new system. As of May 19, 2025 and moving forward, all BAM cases will be held in the electronic case file. By June 2026, MDUA will have a year of data with improvements to BAM investigative methodology.

View Audit 359283

Finding 565416 (2024-008)

None 2024

Commonwealth of Massachusetts

MA

Matching / Level of Effort / Earmarking § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-008 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: We recommend the Department develop and document internal controls over reporting earmarking requirements to ensure that reports are accurate and that earma...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-008 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: We recommend the Department develop and document internal controls over reporting earmarking requirements to ensure that reports are accurate and that earmarking requirements are met. Action taken in response to finding: EOLWD Finance has developed a new Expenditure Detail Report (EDR) within their internal Finance Data Mart. This new report is designed to mirror the structure of federal quarter filings and improve the traceability between reported expenditures and source documentation. Beginning in FY26, phase codes associated with federal grant activity will be further disaggregated and mapped in MMARS screen BQ87 (Federal Grant Phase Budget Status). This enhancement will improve the accuracy and clarity of budget-to-actual comparisons by providing a clearer breakout of expenditures by phase. It will also strengthen internal controls and facilitate better alignment between MMARS, Finance Data Mart, and federal reporting requirements. Finance and DCS will continue to conduct joint reviews of the EDR each quarter to ensure data consistency across systems and compliance with federal reporting standards. Name(s) of the contact person(s) responsible for corrective action: Dave Manning and Ken Luke Planned completion date for corrective action plan: 12/31/2025

View Audit 359283

Finding 565414 (2024-007)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submi...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submitted to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance needs to update the Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and by establishing a more accurate subaward report. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565411 (2024-003)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Procurement, Suspension & Debarment Eligibility § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program require...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program requirements. Action taken in response to finding: Starting July 2025, the Accounting Director (or Deputy Accounting Director when hired) will sign and date the reconciliation documentation (and retain) when reviews are performed. The standard operating procedures will be clarified that preparer and reviewer typing their names and date within the reconciliation documentation is an acceptable form of sign-off upon completion of the reconciliations and reviews. Name(s) of the contact person(s) responsible for corrective action: Keivon Spencer, Director of Accounting | DTA Finance Planned completion date for corrective action plan: June 30, 2025 and forward – Sign and date reconciliation reviews October 30, 2025 – Standard operating procedures

View Audit 359283

Finding 565378 (2024-002)

Significant Deficiency 2024

George J. and Hilda Meyer Foundation, Inc.

MO

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

U.S. Department of Agriculture 2024-002 Communities Facilities Loans & Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Foundation design controls to ensure that the calculation is completed in accordance with the loan agreement and funded in full prior to the end of each fisc...

U.S. Department of Agriculture 2024-002 Communities Facilities Loans & Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Foundation design controls to ensure that the calculation is completed in accordance with the loan agreement and funded in full prior to the end of each fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The USDA has waived this requirement in past years. The community obtained a waiver for the current period. Name(s) of the contact person(s) responsible for corrective action: Tiffany Goetz Planned completion date for corrective action plan: June 2, 2025

View Audit 359225

Finding 565375 (2024-001)

None 2024

Umass Memorial Health Care, Inc.

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.318 § 200.324

2024-001 Procurement Cluster: Not applicable Grantor: Department of Health and Human Services (DHHS) Award Name: Congressionally Directed Spending Award Number: 6 CE1HS52894‐01‐04, 6 CE1HS52345‐01‐05 Award Year: FY2024 Assistance Listing Number: 93.493 Assistance Listing Title: Congressional Dire...

2024-001 Procurement Cluster: Not applicable Grantor: Department of Health and Human Services (DHHS) Award Name: Congressionally Directed Spending Award Number: 6 CE1HS52894‐01‐04, 6 CE1HS52345‐01‐05 Award Year: FY2024 Assistance Listing Number: 93.493 Assistance Listing Title: Congressional Directives Pass-through Entity: Not applicable In accordance with 2 CFR 200.318 the System must maintain procurement records of sufficient detail that include the rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. For two of two of the auditors’ selections sufficient documentation was not retained from the time of procurement during fiscal year 2023 to demonstrate sole source justification or the competitive bidding process for these samples. For one mammography technology asset, documentation of sole source vendor justification was not documented and retained by the System following Policy HA-50-42, Capital Equipment Requests. For the second selection, while competitive bids were obtained, management did not adequately retain documentation to support the vendor ultimately selected for the selected hardware component and the other bids obtained. Management has reviewed the Capital Equipment Request policy and the related capital request process and will reinforce the need to adhere to existing policies and the importance of retaining appropriate documentation during fiscal year 2025. Primary responsibility of implementing the Corrective Action Plan for this finding rests with Brian Huggins, Senior Vice President of Finance, Corporate Controller, (508) 334-0252.

View Audit 359222

Finding 565337 (2024-001)

Significant Deficiency 2024

Cook County, Illinios

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.208 § 200.305

To address the identified non-compliance with timely subrecipient payments, the Cook County State’s Attorney Ofﬁce has implemented an internal invoice submission form designed to streamline and formalize the invoice processing workflow. This form is now utilized by all business managers and program ...

To address the identified non-compliance with timely subrecipient payments, the Cook County State’s Attorney Ofﬁce has implemented an internal invoice submission form designed to streamline and formalize the invoice processing workflow. This form is now utilized by all business managers and program managers, who have been trained and granted functional access to ensure consistent and accurate usage. Additionally, a dedicated SharePoint site has been established to manage and monitor the invoice submission process. This platform allows for real-time tracking of invoice numbers, amounts, vendor names, and payment statuses, thereby enhancing transparency and accountability. These measures collectively aim to strengthen internal controls, improve communication among parties involved, and ensure compliance with federal cash management requirements moving forward. Party(ies) responsible for overseeing the corrective action plan for the grant programs: - Nader Abusumayah, Chief Accountant, nader.abusumayah2@cookcountysao.org, 312.603.1840 The department plans on completing the above corrective action on 6/1/2025.

View Audit 359160

Finding 565207 (2024-002)

Significant Deficiency 2024

American Academy McAllister Institute of Funeral Service, Inc.

NY

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

Finding 2024-002 - Special Tests and Provisions - Federal Direct Loan Program Student Notification – Significant Deficiency Name of Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Award Identification Number an...

Finding 2024-002 - Special Tests and Provisions - Federal Direct Loan Program Student Notification – Significant Deficiency Name of Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Award Identification Number and Year: P268K243382 2024 Name of Pass-through Entity: N/A Planned Corrective Action: The failure to timely send out the required notification of Federal Direct Student Loan Program proceeds credited to one student’s account, as noted in the auditor’s findings, was an administrative oversight. In May 2025, the Institute reviewed and revised its current procedures to ensure that all required notifications are made. Under the revised procedures, an employee independent from the student loan proceed crediting notification process is to review that notifications are sent out within prescribed time frames in accordance with U.S. Department of Education regulations to all students receiving and being credited with Federal Direct Loan Program amounts and that copies of the notifications are maintained in each applicable student’s file.

View Audit 359094

Finding 565206 (2024-001)

Significant Deficiency 2024

American Academy McAllister Institute of Funeral Service, Inc.

NY

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2024-001 – Special Tests and Provisions – Exit Counseling – Significant Deficiency Name of Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Award Identification Number and Year: P268K243382 2024 Name of ...

Finding 2024-001 – Special Tests and Provisions – Exit Counseling – Significant Deficiency Name of Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Award Identification Number and Year: P268K243382 2024 Name of Pass-through Entity: N/A Planned Corrective Action: The failure to document the exit conference of one student borrower in the Federal Direct Loans Program, as noted in the auditor’s findings, was an administrative oversight. In May 2025, the Institute reviewed and revised its current procedures to ensure that all exit conferences are documented. Under the revised procedures, an employee independent from the exit conference process is to review that any student that has not enrolled in a new semester or that is enrolled at less than half time status has received proper exit conferencing and that the exit conferencing has been properly documented.

View Audit 359094

Finding 565201 (2024-006)

Significant Deficiency 2024

University of Guam

GU

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding NO. 2024-0006 – Reporting View of the University of Guam and Correction Action Plan: An agreed upon timeline for generating data will be established for use in the annual FISAP. The Admissions and Records Office will generate the school enrollment for the relevant academic year. The data sn...

Finding NO. 2024-0006 – Reporting View of the University of Guam and Correction Action Plan: An agreed upon timeline for generating data will be established for use in the annual FISAP. The Admissions and Records Office will generate the school enrollment for the relevant academic year. The data snapshot will be taken immediately after the end of the summer semester. For the enrollment data for AY24-25, the snapshot will be taken during the first week of September 2025 with a similar timeline for subsequent years. Once that data snapshot is generated, the Office of Information Technology will generate a report of collected tuition and fees corresponding to the snapshot data from Admissions and Records. In testing, this was found to be the most accurate process in generating the required data for the FISAP. Name of Contact Person: Mark Duarte, Director, Financial Aid and Triton One Stop Office Proposed Completion date: Next Reporting Period

View Audit 359091

Finding 565196 (2024-005)

Significant Deficiency 2024

University of Guam

GU

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding NO. 2024-005 Special Tests and Provisions – Enrollment Reporting View of the University of Guam and Corrective Action Plan: The University of Guam has signed a service agreement with the National Student Clearinghouse (NSC) to assist the University with enrollment reporting. The Admissions...

Finding NO. 2024-005 Special Tests and Provisions – Enrollment Reporting View of the University of Guam and Corrective Action Plan: The University of Guam has signed a service agreement with the National Student Clearinghouse (NSC) to assist the University with enrollment reporting. The Admissions and Records Office (A&R) will submit an enrollment report to the NSC at least four times per semester. A first of term report, and three other subsequent reports within the semester. This report will be sent to the National Student Loan Database System (NSLDS) in fulfillment of the federal regulations requirement for enrollment reporting. Name of Contact Person: Mark Duarte, Director, Financial Aid and Triton One Stop Office Proposed Completion date: Next Reporting Period

View Audit 359091

Finding 565195 (2024-004)

Significant Deficiency 2024

University of Guam

GU

Special Tests & Provisions Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding NO. 2024-004 Special Tests and Provisions – Wage Rate Requirements View of the University of Guam and Corrective Action Plan: The Facilities Management and Services Office has begun reviewing weekly certified payrolls to ensure prevailing wage rates are enforced. Weekly payrolls have been...

Finding NO. 2024-004 Special Tests and Provisions – Wage Rate Requirements View of the University of Guam and Corrective Action Plan: The Facilities Management and Services Office has begun reviewing weekly certified payrolls to ensure prevailing wage rates are enforced. Weekly payrolls have been requested from current contractors as part of an ongoing process. Name of Contact Person: Zenon Belanger, Interim Facilities Management and Services Director Proposed Completion date: Ongoing

View Audit 359091

Finding 565190 (2024-003)

Significant Deficiency 2024

University of Guam

GU

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

Finding NO. 2024-003 Cash Management View of the University of Guam and Corrective Action Plan: The Financial Aid Office (FAO) will conduct both internal and external monthly reconciliations to ensure the accuracy of financial aid disbursements and compliance with federal regulations. Internally, ...

Finding NO. 2024-003 Cash Management View of the University of Guam and Corrective Action Plan: The Financial Aid Office (FAO) will conduct both internal and external monthly reconciliations to ensure the accuracy of financial aid disbursements and compliance with federal regulations. Internally, the FAO and the Business Office will reconcile actual disbursements and adjustments against drawdowns, drawdown adjustments, refunds of cash, and returns weekly or bi-weekly, following each transmittal to the Business Office. Any discrepancies will be documented and resolved promptly. Externally, the FAO will reconcile with the COD system by the 10th of each month, comparing all disbursements, adjustments, and refunds to the balances reported in COD. A copy of the completed monthly reconciliation will be forwarded to Accounts Receivable as official documentation. Name of Contact Person: Mark Duarte, Director, Financial Aid and Triton One Stop Office Proposed Completion date: Ongoing

View Audit 359091

Finding 565159 (2024-002)

Significant Deficiency 2024

Kaskaskia Community College District #501

IL

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

Action taken in response to finding: Admissions training manuals have been updated to ensure that the date the student first indicated a desire to withdraw from a course is used as the date of withdrawal rather than the date that the withdrawal was processed in Colleague. Admissions staff members ha...

Action taken in response to finding: Admissions training manuals have been updated to ensure that the date the student first indicated a desire to withdraw from a course is used as the date of withdrawal rather than the date that the withdrawal was processed in Colleague. Admissions staff members have been trained on the updated procedure for processing student course withdrawals. The Office of Institutional Research has reviewed and updated the procedures used to generate reports sent to National Student Clearinghouse. IR staff members will ensure that the last date of attendance is reported for student course withdrawals. The office of Institutional Research has contacted National Student Clearinghouse for guidance on the enrollment reports needed to ensure that student enrollment is reported to NSLDS accurately and timely. An additional enrollment report will now be sent to National Student Clearinghouse for reporting graduated students. This will ensure that students that have graduated are reported as no longer enrolled within the required reporting timeframe.

View Audit 359072

Finding 565155 (2024-001)

Significant Deficiency 2024

Kaskaskia Community College District #501

IL

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

Action taken in response to finding: As a result of the 2023 audit, which concluded in May of 2024, adjustments were made to reflect a five day fall break for Fall 2024. R2T4 calculations for Fall 2024 have been reviewed and the use of a five-day break for the term has been verified. The Fall 2025 t...

Action taken in response to finding: As a result of the 2023 audit, which concluded in May of 2024, adjustments were made to reflect a five day fall break for Fall 2024. R2T4 calculations for Fall 2024 have been reviewed and the use of a five-day break for the term has been verified. The Fall 2025 term has already been built in Colleague to reflect a five day fall break. The Fall 2023 term was built in Colleague by the previous Director of Financial Aid. The current Director of Financial Aid has recognized a five-day break when building the fall terms in Colleague and will continue this practice for future terms. In following our recently updated R2T4 process, all Financial Aid staff members have been trained and are able to perform R2T4 calculations. R2T4 calculations for the 2024-2025 academic year have been performed by Financial Aid staff and have been reviewed for accuracy and approved by the Director of Financial Aid.

View Audit 359072

Finding 565020 (2024-001)

Significant Deficiency 2024

Commonwealth Institute of Funeral Service

TX

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #...

Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #003556 and G03556, Contract years: 05/05/21 – 12/31/26. Recommendation: Emphasize the importance of accurately reporting enrollment status. Planned corrective action: Management agrees with audit finding #2024-001. The Financial Aid Coordinator is responsible for reporting enrollment status changes, certifying enrollment every 60 days, and responding to NSLDS Roster files within 15 days, all through the NSLDSFAP website. To enhance the accuracy of these enrollment reports, the Institute is implementing a new double-check process. Henceforth, the Financial Aid Coordinator will print all enrollment status changes or enrollment report rosters prior to making any online updates or certifications. These printed reports will then be given to the Director of Operations for verification. Only after this verification will the Financial Aid Coordinator proceed with the necessary changes or certifications on the NSLDSFAP website. All printed reports will be retained by the Financial Aid Coordinator for documentation. Responsible officer: Cody Lopasky, President. Estimated completion date: June 1, 2025.

View Audit 358905

Finding 565013 (2024-001)

Significant Deficiency 2024

City of Daytona Beach, Florida

FL

Cash Management Reporting Matching / Level of Effort / Earmarking § 200.303

2024-001 GRANT REPORTING U.S. Department of Treasury ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds Contract No. 23.saa.900.46 (2023) Passed through the Florida Department of State 2024 Funding Repeat Finding Criteria: 2 CFR 200.303 requires non-federal entities to establish and main...

2024-001 GRANT REPORTING U.S. Department of Treasury ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds Contract No. 23.saa.900.46 (2023) Passed through the Florida Department of State 2024 Funding Repeat Finding Criteria: 2 CFR 200.303 requires non-federal entities to establish and maintain effective internal controls. Reports and reimbursement requests should be subject to independent review for the full fiscal year to verify completeness, validity and timeliness of submission. The grant agreement requires quarterly progress reports to be filed with the pass through entity, Florida Department of State. Condition: Review of quarterly reports was not always documented by City officials before submittal by their third party consultant. Cause of condition: The department at the City that is responsible for managing the grant did not originally have a process in place to document their review of progress reports submitted to the Florida Department of State by their third party consultant. Potential effect of condition: Reports submitted to the Florida Department of State may be incomplete, include errors, or be submitted late. Perspective: After this condition was reported as a finding for the fiscal year ending September 30, 2023, the City’s department that is responsible for managing the grant implemented a review process, but it was not in place for the full fiscal year 2024. Questioned costs: None. Recommendation: The City’s department responsible for the grant should continue to perform the review process that was put in place late in fiscal year 2024. Management’s Response: The City updated its control process to ensure that reports prepared by thirdparty consultant are reviewed by City staff prior to being submitted to the grantor. Responsible Parties: Natalia Eckroth, CFO and Christine Aiken, Assistant Finance Director. Anticipated Completion: December 31, 2024.

View Audit 358881

Finding 565012 (2024-001)

Material Weakness 2024

Lapeer County

MI

Questioned Costs Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.317 § 200.318 § 200.327

May 27, 2025 Roslund, Prestage & Company, P.C. 525 W. Warwick Drive, Suite A Alma, MI 48801 Re: Corrective Action Plan Regarding Section III: Schedule of Findings and Questioned Costs for the Fiscal Year Ended September 30, 2024, in Reference to 2024-001 Procurement It was identified in the findings...

May 27, 2025 Roslund, Prestage & Company, P.C. 525 W. Warwick Drive, Suite A Alma, MI 48801 Re: Corrective Action Plan Regarding Section III: Schedule of Findings and Questioned Costs for the Fiscal Year Ended September 30, 2024, in Reference to 2024-001 Procurement It was identified in the findings of 2024-001 Procurement (repeat comment) that LCCMH had not followed proper procurement requirements and procedures regarding the agreement in reference to ALN 93.969 Certified Community Behavioral Health Clinics (CCBHC) expansion Grants. LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards Committee, which is responsible for regularly reviewing Policies and Procedures and approving or recommending changes, reviewed and approved the following policy revisions at its November 19, 2024 meeting to maintain compliance with federal regulation standards. 0.1.02.65 Provider Procurement and Best Value Purchasing 01.02.85 Procuring Employment Services Providers, Independent Contractors and Network Providers. The approved policies were also presented at the LCCMH Full Board meeting on November 21, 2024. All LCCMH Staff were advised on December 2, 2024, to review the revised policies and procedures. On April 22, 2025, SAMSHA provided LCCMH written notification identifying the 2023 citation for procurement as resolved. Thank you, Brooke Sankiewicz Chief Executive Officer Lapeer County Community Mental Health (810) 667-0500 bsankiewicz lapeercmh.org

View Audit 358880 Questioned Costs: $1

Finding 564659 (2024-003)

Material Weakness 2024

McIntosh Senior Living

MN

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

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing: #10.766 Finding Summary: The Organization did not have an adequate internal control policy in place to ensure the reserve account was separately trac...

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing: #10.766 Finding Summary: The Organization did not have an adequate internal control policy in place to ensure the reserve account was separately tracked and a documented review and approval over the reserve fund occurred. Responsible Individuals: Sharlene Knutson, Administrator Corrective Action Plan: We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2025

View Audit 358780

Finding 564651 (2024-004)

Material Weakness 2024

Teach.org Inc.

CA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

Auditor’s Recommendation: Internal control should be documented to ensure compliance with the reporting compliance requirement. Documentation should include a signed certification by the preparer and a reviewer that the requests for payment, written summaries of reporting-specific meetings with gran...

Auditor’s Recommendation: Internal control should be documented to ensure compliance with the reporting compliance requirement. Documentation should include a signed certification by the preparer and a reviewer that the requests for payment, written summaries of reporting-specific meetings with grantors, and any other reporting activities are complete, accurate, and agree to supporting records of expenditures or other accounting or database information. Written policies and procedures should be designed and implemented for documentation of internal controls performed for reporting. Corrective Action: TEACH.org will write a policy to address internal controls for reporting. TEACH staff will obtain training on documentation of internal controls performed for reporting related to Federal awards. After training, TEACH staff will review all documentation of internal controls and make changes to our policies as needed to properly document our internal controls. Responsible for Corrective Action: TEACH.org Deputy Chief of Staff will obtain training on internal controls documentation for Federal grants. Once training is completed, DCoS will review all fiscal policies and add or edit our policies as needed to address proper documentation of internal controls performed for reporting. Anticipated Completion Date: TEACH.org DCoS will obtain training by September 30, 2025 and conclude their review of TEACH fiscal policies by December 31, 2025.

View Audit 358749

Finding 564605 (2024-004)

Material Weakness 2024

Kipp Delta, Inc. D/b/a Kipp Delta Public Schools

AR

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.302

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place for the review and approval of expenditures and maintenance of supporting documentation surrounding federal awards. Action Plan:  See the “Conduct Training Sessions fo...

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place for the review and approval of expenditures and maintenance of supporting documentation surrounding federal awards. Action Plan:  See the “Conduct Training Sessions for Expenditures Personnel” and “Audit of all FY25 YTD Expenditures” sections of management’s action plan for finding 2024-001  Review and update the Allowable Funds document o Locate the latest Allowable Funds Guide created by KIPP Delta. o Review and update the guide as necessary. o Store the updated guide in a central cloud location for responsible personnel to access easily. o Process completed as of April 17, 2025.  Develop a Federal Funds Workflow in Avid for POs and invoices: o A designated finance team member must review all federally funded purchases to improve the federal funds purchasing process. Steps include:  Create a separate workflow in Avid for POs and invoices to track federal purchases.  Ensure a purchase order is created before an invoice is submitted and paid.  Attach all required documentation to the PO, as with all other expenditures.  Verify that the expenditure complies with the Allowable Funds guide o Anticipated completion date of May 30, 2025.

View Audit 358741 Questioned Costs: $1

Finding 564593 (2024-005)

Significant Deficiency 2024

Goshen Community Schools

IN

Cash Management Subrecipient Monitoring Significant Deficiency § 200.303

FINDING 2024-005 Finding Subject: Special Education Cluster (IDEA) - Internal Controls Contact Person Responsible for Corrective Action: Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Cash ...

FINDING 2024-005 Finding Subject: Special Education Cluster (IDEA) - Internal Controls Contact Person Responsible for Corrective Action: Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Cash Management Requests for reimbursement will not be submitted until the Treasurer has attached the supporting documentation from the financial software system (member schools will provide documentation). The documentation will be reviewed and approved by the Executive Director of ECSEC prior to submission to the Treasurer. The reimbursement request will require an approval signature from the Chief Financial Officer/Treasurer prior to submittal. Anticipated Completion Date: June 2025

View Audit 358719

Finding 564584 (2024-003)

Material Weakness 2024

Goshen Community Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2024-003 Finding Subject: Child Nutrition Cluster – Internal Controls Contact Person Responsible for Corrective Action: Heather Bontrager, Director of Nutrition and Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Descript...

FINDING 2024-003 Finding Subject: Child Nutrition Cluster – Internal Controls Contact Person Responsible for Corrective Action: Heather Bontrager, Director of Nutrition and Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Activities Allowed or Unallowed, Allowable Costs/Cost Principles This finding was limited to payroll claims and payroll vendor disbursements and did not involve accounts payable vendor disbursements. For payroll disbursements, once payroll is processed, a distribution report is sent to the Director of Nutrition to review all employees paid from the Federal Nutrition Program (Fund 0800). The Director communicates any necessary corrections to employee distributions, which are then adjusted by the payroll specialist, if needed. During the audit period, the school corporation experienced a vacancy in the payroll specialist position. As a result, the Treasurer processed payroll and the Deputy Treasurer conducted the reviews. However, the school corporation did not obtain signatures on the payroll reports during this time. The only signed documentation was the ACH report used for the bank upload. Going forward, the school will implement the use of digital signatures whenever possible to document payroll report reviews. For payroll vendor claims, vouchers are generated from the financial system and are signed by both the payroll specialist and the Chief Financial Officer. These signed vouchers are also included on the board docket. Although this process was in place during the audit period, the school corporation did not have a fully effective internal control system to ensure that all payroll reports were consistently signed following review by the Treasurer. Anticipated Completion Date: June 2025

View Audit 358719

Finding 564563 (2024-003)

Significant Deficiency 2024

New Hampshire College & University Council

NH

Matching / Level of Effort / Earmarking

Management acknowledges the recommendation and will track all expenses allocated by match funds by grant year in the same spreadsheet. Note - Auditors were provided with documentation showing salary allocations verifying that no salaries were used simultaneously across grants.

View Audit 358679

Finding 564558 (2024-004)

Significant Deficiency 2024

Campus Compact for New Hampshire

NH

Matching / Level of Effort / Earmarking

Management will track all expenses allocated by match funds by grant year in the same spreadsheet

View Audit 358678

Corrective Action Plans

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