Corrective Action Plans

Finding 565455 (2024-021)

Material Weakness 2024

MA

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

DEPARTMENT OF PUBLIC HEALTH 2024-021 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend that the Department review and enhance its procedures and internal co...

DEPARTMENT OF PUBLIC HEALTH 2024-021 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend that the Department review and enhance its procedures and internal controls to ensure that performance reports are submitted timely and that the review and approval process of financial and performance reports is documented prior to submission. Action taken in response to finding: Fiscal reporting will consist of email communication from the Director of Administration and Finance to the Project Director requesting the Project Director to review both the quarterly report in the ELC’s CAMP portal and the attached spreadsheet backup attached to the email communication that supports the financial data in ELC’s CAMP portal. The Project Director will review the spreadsheet and financial data in ELC CAMP. If the Project Director, approves, the PD will email the Director of Administration and Finance stating that she has reviewed and approved the data in the spreadsheet and in the ELC CAMP portal. If the PD does not approve, the PD will communicate this through email to the Director of Administration and Finance with what the issues are and ask the Director of Administration and Finance to correct and resubmit the information to PD. The same process as noted above will be followed until it is approved by the PD. Programmatic performance reporting with be entered into the ELC CAMP Portal by ELC multiple programmatic leads for various ELC sections. Once completed, the multiple programmatic leads will email the Project Director to review. The Project Director will review the programmatic data in the ELC CAMP portal. The Project Director will send multiple programmatic leads and email with her approval and ask them to submit his/her section in ELC CAMP. If the Project Director finds errors, she will email the programmatic lead(s) identifying the error and ask the programmatic lead(s) to correct. The same process noted above would continue until the Project Director approves the programmatic performance report. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS ; Natalie Morgenstern, Project Director, ELC leads for various ELC sections for performance reports (multiple staff) Planned completion date for corrective action plan: 8/31/2025

View Audit 359283

Finding 565453 (2024-020)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-020 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend the Department establish procedures and internal controls to ensure t...

DEPARTMENT OF PUBLIC HEALTH 2024-020 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend the Department establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Bureau of Infectious Disease and Laboratory Sciences (BIDLS) will put in place starting August 1, 2025 a process to review obligations for subawards under Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323, to identify subawards that fall under the rules set forth by Federal Funding Accountability and Transparency Act (FFATA) and report the appropriate obligations to FSRS according to the above-mentioned recommendations. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS Planned completion date for corrective action plan: 9/30/25

View Audit 359283

Finding 565451 (2024-019)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-019 Immunization Cooperative Agreements, COVID-19 - Immunization Cooperative Agreements - Assistance Listing No. 93.268 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit. It should establish procedu...

DEPARTMENT OF PUBLIC HEALTH 2024-019 Immunization Cooperative Agreements, COVID-19 - Immunization Cooperative Agreements - Assistance Listing No. 93.268 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit. It should establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to the FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Bureau of Infectious Disease and Laboratory Sciences (BIDLS) will put in place starting August 1, 2025 a process to review obligations for subawards under Immunization, Assistance Listing No. 93.268 to identify subawards that fall under the rules set forth by Federal Funding Accountability and Transparency Act (FFATA) and report the appropriate obligations to FSRS according to the above-mentioned recommendations. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS Planned completion date for corrective action plan: 9/30/25

View Audit 359283

Finding 565442 (2024-016)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-016 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the...

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-016 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: AGE has developed a form to attach to all relevant contracts to capture required reporting requirements and will implement a calendar of reporting deadlines to the AGE internal control plan, specifically the section regarding federal grants management. Name(s) of the contact person(s) responsible for corrective action: Sheila Tunney, CFO Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565427 (2024-011)

Material Weakness 2024

Commonwealth of Massachusetts

MA

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

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-011 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that intern...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-011 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are reviewed for accuracy prior to submission. Action taken in response to finding: This issue occurred during a period when the preparation and submission of the ETA 9130 reports were handled by a single staff member without peer review. The lack of internal checks and collaborative review contributed to the inaccuracies. With new management and restructured team now in place, we have implemented and strengthened review processes. Moving forward, ETA 9130 reports will be jointly reviewed by Finance and program staff before submission and certification. Supporting documentation will be cross-checked for accuracy and completeness, and all relevant files will be maintained in a centralized, shared folder to ensure transparency and accountability. This multi-layered review and documentation process will be incorporated into standard quarterly reporting procedures to prevent future discrepancies and ensure federal reporting integrity. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke, Vina Yung Planned completion date for corrective action plan: 8/30/2025

View Audit 359283

Finding 565424 (2024-010)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely to ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely 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 has finalized a 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 efficiently. 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 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 565357 (2024-001)

Material Weakness 2024

The Crest at Lakeshore, Llc. Dba: the Crest at Lakeshore

MN

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

Material Weakness in Internal Control over Compliance Recommendation: We recommend management ensure they are properly calculating surplus cash and distributing in accordance with the calculation. Action taken in response to finding: Management will review and establish procedures to properly calcul...

Material Weakness in Internal Control over Compliance Recommendation: We recommend management ensure they are properly calculating surplus cash and distributing in accordance with the calculation. Action taken in response to finding: Management will review and establish procedures to properly calculate surplus cash and distribute these funds timely after year end audit. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: December 31, 2024

View Audit 359185

Finding 565168 (2024-001)

Material Weakness 2024

Calumet Public School District 132

IL

Material Weakness Reporting Internal Control / Segregation of Duties

Condition: During audit fieldwork, w enoted the District's management has not received a bank reconciliation from the Calumet Township Treasurer for pooled cash and investments. This represents a material weakness in the internal control over financial reporting. Plan: The superintendent, along with...

Condition: During audit fieldwork, w enoted the District's management has not received a bank reconciliation from the Calumet Township Treasurer for pooled cash and investments. This represents a material weakness in the internal control over financial reporting. Plan: The superintendent, along with staff, will work with the Calumet Township Treasurer to ensure that monthly bank reconciliations and support documents are performed and received prior to or during audit fieldwork. Anticipated Date of Completion: June 30, 2025 Name of Contact Person: Armand Gasbaro - Chief School Board Official. Management Response: The CSBO and Superintendent will work with the new Calumet Township Treasurer to establish a process to receive a montly bank reconciliation for pooled cash and investments.

View Audit 359076

Finding 565127 (2024-004)

Material Weakness 2024

West Virginia School of Osteopathic Medicine Clinic, Inc. D/b/a Robert C. Byrd Clinic

WV

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.303

Finding 2024-004 Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allow...

Finding 2024-004 Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Period of Performance Finding Summary: Some expenditures were not fully supported by underlying documentation. In addition, some of the expenditures tested did not have documentation of the review and approval of the allocation of the expenditure to the federal program. The Clinic also calculated their indirect cost rate based on the total grant budget and claimed an equal amount of indirect costs per month instead of calculating the indirect cost rate per direct expenditures for each month. Responsible Individuals: Kayla Trent, Finance Director Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we have implemented procedures to retain expenditure listings and other support for federal awards as well as the related review. The Clinic began retaining expense reconciliations for all Grants. Anticipated Completion Date: July 1, 2024

View Audit 359059

Finding 565126 (2024-003)

Material Weakness 2024

West Virginia School of Osteopathic Medicine Clinic, Inc. D/b/a Robert C. Byrd Clinic

WV

Cash Management Material Weakness Internal Control / Segregation of Duties § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Cash Management Finding Summary: ...

Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Cash Management Finding Summary: The cash draw requests were done on a prospective basis despite the program requiring that cash draw requests must be for expenditures already incurred or that would be paid within three days. Responsible Individuals: Kayla Trent, Finance Director Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we have implemented procedures to understand program requirements related to cash draws. The Clinic began requesting funds only for expenditures already incurred or that would be paid within three days. Anticipated Completion Date: Ongoing

View Audit 359059

Finding 565092 (2024-003)

Material Weakness 2024

Ark-Tex Council of Governments

TX

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

Planned Corrective Action: We have provided communication and training to caseworkers, inspectors, and property managers regarding the program requirements. ATCOG has updated its administrative processes for HUD programs, which has included a strengthened review process over admissions to ensure tha...

Planned Corrective Action: We have provided communication and training to caseworkers, inspectors, and property managers regarding the program requirements. ATCOG has updated its administrative processes for HUD programs, which has included a strengthened review process over admissions to ensure that all required elements, including a passed inspection, are present before Housing Assistance Payments are made. Contact Person Responsible for Corrective Action: Mary Beth Rudel, Executive Director Completion Date: March 31, 2025

View Audit 359044

Finding 565091 (2024-002)

Material Weakness 2024

Ark-Tex Council of Governments

TX

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs

Planned Corrective Action: When this condition was discovered, ATCOG was already in the process of updating and amending its administrative policies for HUD programs. These updates were begun in Fall 2024 and included clarifying procedures over the waiting list process. Moreover, ATCOG has implement...

Planned Corrective Action: When this condition was discovered, ATCOG was already in the process of updating and amending its administrative policies for HUD programs. These updates were begun in Fall 2024 and included clarifying procedures over the waiting list process. Moreover, ATCOG has implemented a review process for its waiting list process so that the errors that led to the improper selection method will not be repeated. Contact Person Responsible for Corrective Action: Mary Beth Rudel, Executive Director Completion Date: March 31, 2025

View Audit 359044

Finding 565081 (2024-003)

Material Weakness 2024

Osceola Electric Cooperative, Inc.

IA

Reporting Material Weakness

Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Iowa Homeland Security & Emergency Management Federal Financial Assistance Listing #97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Cooperative does not have an internal control system desig...

Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Iowa Homeland Security & Emergency Management Federal Financial Assistance Listing #97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Cooperative does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards (the schedule) being audited. We requested our auditors to assist with the preparation of the schedule and the accompanying notes to the schedule. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the schedule of federal expenditures of federal awards and the accompanying notes to the schedule. We requested that our auditors, Eide Bailly, LLP, prepare the schedule and accompanying notes. We have designated a member of management to review the drafted schedule and accompanying notes to the schedule. Responsible Individuals: Mark Vander Pol, Office Manager and Jeff TenNapel, General Manager Anticipated Completion Date: Ongoing

View Audit 359017

Finding 565054 (2024-003)

Material Weakness 2024

Community Bridges, Inc.

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

Item: 2024-003 Assistance Listing Number: 16.812 Program: Second Chance Act Reentry Initiative Federal Agency: U.S. Department of Justice Pass-Through Agencies: Pima County Contract Numbers: CT-BH-21-378 Award Year: 10/01/2023 – 9/30/2024 Compliance Requirement: Reporting Criteria: In accordance wi...

Item: 2024-003 Assistance Listing Number: 16.812 Program: Second Chance Act Reentry Initiative Federal Agency: U.S. Department of Justice Pass-Through Agencies: Pima County Contract Numbers: CT-BH-21-378 Award Year: 10/01/2023 – 9/30/2024 Compliance Requirement: Reporting Criteria: In accordance with the grant agreement, the Organization is required to submit monthly reports to the grantor within 10 days following the end of each month. Condition: For all 4 of the monthly reports tested, the reports were submitted subsequent to the 10th day following the end of each respective month. Name of Contact Person: Ramon Dominguez, CFO Phone Number (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2025 Views of Responsible Officials and Corrective Actions: The Organization will ensure that monthly reporting for the grant is reviewed and approved in a timely manner in order to meet grant deadlines.

View Audit 358970

Finding 565049 (2024-002)

Material Weakness 2024

Community Bridges, Inc.

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

Item: 2024-002 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Relief Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: Maricopa County, City of Phoenix Contract Numbers: C-22-20-029-3-12, 220141; 157666-005, 159341-0 , 160315-0 Award Ye...

Item: 2024-002 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Relief Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: Maricopa County, City of Phoenix Contract Numbers: C-22-20-029-3-12, 220141; 157666-005, 159341-0 , 160315-0 Award Year: 10/01/2023 – 9/30/2024 Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit monthly program reports for each contract within certain prescribed timeframes. Documentation should be maintained to support that the required reports were submitted to the granting agencies and that the submissions were timely. Condition: For seven reports tested, there was no documentation supporting that the reports were submitted to the granting agencies. Name of Contact Person: Ramon Dominguez, CFO Phone Number (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2025 Views of Responsible Officials and Corrective Actions: The Organization will ensure that documentation of submission of monthly program reporting to granting agencies is maintained.

View Audit 358970

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 565002 (2024-002)

Material Weakness 2024

Holland Home

MI

Material Weakness Reporting Internal Control / Segregation of Duties

Condition: The Organization is required to submit a quarterly narrative report within 30 days following the end of the calendar quarter to the granting agency. The Organization submitted the four required reports for the year, however, 3 of the 4 reports were submitted after the required deadline. P...

Condition: The Organization is required to submit a quarterly narrative report within 30 days following the end of the calendar quarter to the granting agency. The Organization submitted the four required reports for the year, however, 3 of the 4 reports were submitted after the required deadline. Planned Corrective Action: Management will update its review process to ensure all required reporting is completed timely. Management has noted that the nature through which the grant was issued resulted in some confusion regarding time periods and critical reporting requirements related to the grant program. Contact person responsible for corrective action: Adam Kinder, CFO Anticipated Completion Date: December 2024 – January 2025

View Audit 358874

Finding 565001 (2024-001)

Material Weakness 2024

Holland Home

MI

Subrecipient Monitoring Material Weakness Reporting

Condition: The Organization has engaged a subrecipient as part of this grant program, which was subsequently determined, but did not have an executed agreement with the subrecipient until October 2024. As a result, the Organization did not meet the requirements of performing formal risk assessment p...

Condition: The Organization has engaged a subrecipient as part of this grant program, which was subsequently determined, but did not have an executed agreement with the subrecipient until October 2024. As a result, the Organization did not meet the requirements of performing formal risk assessment procedures prior to engaging with the subrecipient. Planned Corrective Action: Management has executed an agreement with the identified subrecipient and implement formalized policies and procedures to ensure no risk factors for non-compliance exist and to properly monitor the subrecipient activity. The identified subrecipient has met all documentation and submission requirements to support reporting and appropriate usage of grant funds related to the grant program. Contact person responsible for corrective action: Adam Kinder, CFO Anticipated Completion Date: October 2024

View Audit 358874

Finding 564768 (2024-004)

Material Weakness 2024

Unified School District No. 431 Hoisington, Kansas

KS

Cash Management Material Weakness Reporting

MATERIAL WEAKNESS 2024-004 – Education Stabilization Fund - Reporting Condition The quarterly reports had incorrect expenditures reported for the ESSER III award. Recommendation Reporting methods required by the awarding agency should be well understood, and an individual other than the preparer ...

MATERIAL WEAKNESS 2024-004 – Education Stabilization Fund - Reporting Condition The quarterly reports had incorrect expenditures reported for the ESSER III award. Recommendation Reporting methods required by the awarding agency should be well understood, and an individual other than the preparer should review all reports prior to their submission. Comments on the Finding The District is aware of the oversight and has implemented procedures to prevent this in the future. Actions Taken As of the date of this notice, an individual other than the one preparing the ESSER reporting will be asked to review it, prior to submission.

View Audit 358831

Finding 564705 (2024-001)

Material Weakness 2024

Heber-Overgaard Unified School District No. 6

AZ

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.512

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Forest Service Schools and Roads Cluster, Education Stabilization Fund Assistance Listing Number: 10.665, 84.425 Contact Person: Andrea Despain, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The ...

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Forest Service Schools and Roads Cluster, Education Stabilization Fund Assistance Listing Number: 10.665, 84.425 Contact Person: Andrea Despain, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The District will collaborate with all grant stakeholders to strengthen internal controls by clearly defining responsibilities, tracking submission deadlines, and ensuring strict adherence to policies. Oversight will be reinforced through regular grant management meetings and reviews conducted by the Business Manager. To enhance reporting accuracy and documentation practices, staff will receive targeted training on compliance requirements. Additionally, recordkeeping processes will be standardized, with periodic reviews to verify adherence and improve efficiency. These corrective actions will be implemented promptly and continuously supported through ongoing monitoring, ensuring more timely and accurate audits while maintaining compliance with federal regulations.

View Audit 358807

Finding 564663 (2024-003)

Material Weakness 2024

Pioneer Resources, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding 2024-003: MATERIAL WEAKNESS—Transit Services Programs Cluster Payroll Procedures U.S. Department of Transportation Pass-through Entity: Michigan Department of Transportation Assistance Listing Numbers: 20.516 and 20.521 Award Numbers: 215509NI, 215541NI, 220776NI and 221303NI Award Year ...

Finding 2024-003: MATERIAL WEAKNESS—Transit Services Programs Cluster Payroll Procedures U.S. Department of Transportation Pass-through Entity: Michigan Department of Transportation Assistance Listing Numbers: 20.516 and 20.521 Award Numbers: 215509NI, 215541NI, 220776NI and 221303NI Award Year End: September 30, 2024 Recommendation: The Organization should follow its established procedures to ensure that payroll records, including manual and electronic, are properly and timely filed and maintained in accordance with the Organization’s written record retention policy so that they can be readily located when needed. Action Taken: Staff responsible for these tasks will be educated on the importance of following the Organization’s policy. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2025.

View Audit 358795 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 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

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