Corrective Action Plans

Finding 1214366 (2022-002)

Material Weakness 2022

CA

Procurement, Suspension & Debarment Material Weakness

2022-002 Support for Expenditures Material Weakness Recommendation: Auditors recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Tribal Chairperson has been a designated check ...

2022-002 Support for Expenditures Material Weakness Recommendation: Auditors recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Tribal Chairperson has been a designated check signer as well as the St. Croix Tribal Council reviews revenue and expenditures on a monthly basis.

View Audit 401032

Finding 1214201 (2022-008)

Material Weakness 2022

Open Door Ministries of High Point, Inc.

NC

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.430

Department of Housing and Urban Development and Department of Veterans Affairs 2022-008 Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a sy...

Department of Housing and Urban Development and Department of Veterans Affairs 2022-008 Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

View Audit 400920

Finding 1214199 (2022-007)

Material Weakness 2022

Open Door Ministries of High Point, Inc.

NC

Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.334 § 200.337

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally re...

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

View Audit 400920

Finding 1211144 (2022-005)

Material Weakness 2022

Carestl Health

MO

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.328 § 200.329

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.

View Audit 400353

Finding 1211141 (2022-002)

Material Weakness 2022

Carestl Health

MO

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility § 200.302 § 200.303

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Per...

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations

View Audit 400353

Finding 1211140 (2022-001)

Material Weakness 2022

Carestl Health

MO

Internal Control / Segregation of Duties Cash Management Material Weakness

Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the...

Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the general ledger • Performing timely and accurate reconciliations of all key accounts, particularly cash • Establishing procedures to ensure all financial transactions are supported with adequate documentation • Implementing review and approval controls over financial records and reconciliations • Evaluating staffing and resources to ensure the accounting function can meet reporting requirements Strengthening these areas is critical to improving the accuracy, reliability, and auditability of the organization’s financial statements.

View Audit 400353

Finding 1210538 (2022-009)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Material Weakness School Nutrition Programs Equipment & Real Property Management

REFERENCE # 2022-009 SPECIAL TEST – ACCOUNTABILITY FOR USDA FOODS– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will ensure the documentation related to inventory counts are reviewed and maintained. Action Date: Ongoin...

REFERENCE # 2022-009 SPECIAL TEST – ACCOUNTABILITY FOR USDA FOODS– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will ensure the documentation related to inventory counts are reviewed and maintained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745

View Audit 399930

Finding 1210523 (2022-008)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Subrecipient Monitoring Eligibility Material Weakness

REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants t...

REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify that they meet the grant eligibility requirements. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745

View Audit 399930

Finding 1210508 (2022-007)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division wi...

REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division will ensure proper documentation of the weight of items distributed is retained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745

View Audit 399930

Finding 1210478 (2022-004)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Cash Management Subrecipient Monitoring Material Weakness § 200.3 § 200.305

REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US T...

REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US Treasury or pass-through entity and disbursement by the non-federal entity for direct program or project costs and the proportionate share of allowable indirect costs, whether the payment is made by electronic funds transfer, or issuance or redemption of checks, warrants, or payment by other means (2 CFR section 200.305(b)). What constitutes minimized elapsed time for funds transfer will depend on what payment system/method a non-federal entity uses. Under the advance payment method, federal awarding agency or pass-through entity payment is made to the non-federal entity before the non-federal entity disburses the funds for program purposes (2 CFR section 200.3). A non-federal entity must be paid in advance provided that it maintains, or demonstrates the willingness to maintain, both written procedures that minimize the time elapsing between the transfer of funds from the US Treasury and disbursement by the non-federal entity, as well as a financial management system that meets the specified standards for fund control and accountability (2 CFR section 200.305(b)(1)). Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division receives advance funds from the pass-through agency and incurred program expenditures. Of the Sixty (60) files selected for testing We noted that the Division: (1) Does not have written procedures that minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Questioned Costs: Cannot be determined Recommendation: We recommend Division minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Corrective Action Plan: The Division will strive to minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

View Audit 399930

Finding 1206310 (2022-006)

Material Weakness 2022

Island Health, Inc.

MA

Cash Management HUD Housing Programs Material Weakness § 200.302 § 200.303 § 200.305

Item 2022.006 - Cash Manaaement Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures ...

Item 2022.006 - Cash Manaaement Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval process, submission to the funding agency, and the recording of the drawdown in the accounting system immediately after submission • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices

View Audit 398372

Finding 1206309 (2022-007)

Material Weakness 2022

Island Health, Inc.

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.

View Audit 398372

Finding 1206172 (2022-007)

Material Weakness 2022

Native Village of Barrow

AK

Reporting Material Weakness § 200.512

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.

View Audit 398166

Finding 1206169 (2022-004)

Material Weakness 2022

Native Village of Barrow

AK

Reporting Procurement, Suspension & Debarment HUD Housing Programs

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.

View Audit 398166

Finding 1206162 (2022-005)

Material Weakness 2022

Native Village of Barrow

AK

Reporting Procurement, Suspension & Debarment Material Weakness

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.

View Audit 398166

Finding 1182846 (2022-001)

Material Weakness 2022

Prevent Child Abuse Utah

UT

Material Weakness Internal Control / Segregation of Duties

Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Ch...

Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Child Abuse Utah evaluate the ongoing benefits and expenses of including this element into its system of internal control.

View Audit 394245

Finding 1179321 (2022-011)

Material Weakness 2022

The Young Men's Christian Association of Metropolitan Denver

CO

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.309 § 200.77

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreem...

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCA has worked diligently to strengthen its accounting standards when it comes to Federal awards, including the centralization of reporting through its YESS shared services accounting systems and procedures. Operations personnel review the tenants of the grants up front in the process of executing each Federal grant. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: Complete

View Audit 391683

Finding 1179320 (2022-010)

Material Weakness 2022

The Young Men's Christian Association of Metropolitan Denver

CO

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

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that the Organization consider updating its cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximiz...

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that the Organization consider updating its cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations that are calculated in a consistent manner that ensure costs are applied uniformly to respective benefited activities, and that are reflective on employees’ time and effort records Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCAs overhead structure differs from department to department, which makes it difficult to develop a common framework. And quite often the Federal or State agency is prescriptive when it publishes its grant guidelines. Though these grants are developed and submitted more centrally than in the past; nonetheless we will endeavor to develop a common listing of approved cost allocations. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: December 2026

View Audit 391683

Finding 1179144 (2022-005)

Material Weakness 2022

VALLEY CITY PUBLIC SCHOOL DISTRICT

ND

Material Weakness School Nutrition Programs

Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2024

View Audit 391539

Finding 1175930 (2022-002)

Material Weakness 2022

Head Start of Lane County

OR

Allowable Costs / Cost Principles Material Weakness

Head Start of Lane County has created a paln with assitance of Wipfli to complete outstanding audits. See corrective action item 2022-004 for more details. The agency has implemented a yearly closeout starting in the year 2024-2025 going forward. This will allow for timely audit preparation, reconci...

Head Start of Lane County has created a paln with assitance of Wipfli to complete outstanding audits. See corrective action item 2022-004 for more details. The agency has implemented a yearly closeout starting in the year 2024-2025 going forward. This will allow for timely audit preparation, reconciliations and adjustments to occur

View Audit 389901

Finding 1174933 (2022-018)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Eligibility Internal Control / Segregation of Duties HUD Housing Programs § 200.303

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174931 (2022-016)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Allowable Costs / Cost Principles Material Weakness Significant Deficiency § 200.303

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174927 (2022-014)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Equipment & Real Property Management Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303

Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all ...

Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all required Head Start facilities documentation is obtained, accurately completed, retained, and readily accessible for review. Resources will be allocated to develop, implement, and monitor policies and procedures that support effective operations, timely reporting, and full compliance with Head Start facilities requirements. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174926 (2022-013)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.303

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174138 (2022-002)

Material Weakness 2022

THE BELLEVUE HOSPITAL AND SUBSIDIARIES

OH

Reporting Matching / Level of Effort / Earmarking Material Weakness § 200.403

Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action...

Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure expenditures submitted were not already reimbursed under a separate grant. Contact person responsible for corrective action: Kevin Riley Anticipated Completion Date: 12/31/2025

View Audit 387815

Corrective Action Plans

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