Corrective Action Plans

Finding 480387 (2023-003)

Material Weakness 2023

NC

Eligibility Material Weakness Equipment & Real Property Management

Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training st...

Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2024

View Audit 316617

Finding 480321 (2023-001)

Material Weakness 2023

Baptist Health Deaconess Madisonville, Inc.

KY

Reporting Material Weakness

Finding 2023-001 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: Management ...

Finding 2023-001 Federal Agency Name: Department of the Treasury Program Name: COVID-19 Claims Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing #21.027 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: Management prepared the Schedule for the year ended August 31, 2023. During the audit process, changes were proposed to include the COVID‐19 Claims Coronavirus State and Local Fiscal Recovery Funds, which were not originally included on the Schedule. Responsible Individuals: Kim Ashby, Vice President of Finance Corrective Action Plan: When funds for this grant were initially awarded in fiscal year 2021, the grant was state funded and not subject to A-133 audit. During fiscal year 2022, a portion of the grant became federally funded and subject to A-133 audit, but this was not discovered until the current fiscal year 2023 audit. Management has implemented a procedure to check the funding status of grants at the beginning of each fiscal year. Anticipated Completion Date: August 1, 2024

View Audit 316547

Finding 480308 (2023-004)

Material Weakness 2023

Blue Rivers Area Agency on Aging

NE

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

View of Responsible Officials and Planned Corrective Actions: Management will implement procedures to reconcile expenditures of federal awards to ensure expenditures can be accurately tracked and reported.

View Audit 316523

Finding 480284 (2023-003)

Material Weakness 2023

Sherburne County

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Federal Agency: U.S. Department of Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: SLFRP1643 - 2021 Award Period: March 3, 2021 through December 31, 2024 Type of Finding: • Material Weakn...

Federal Agency: U.S. Department of Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: SLFRP1643 - 2021 Award Period: March 3, 2021 through December 31, 2024 Type of Finding: • Material Weakness in Internal Control over Compliance Recommendation: We recommend that County management reviews the controls around payroll journal entries that are reclassifying payroll to federal grants to ensure the payroll that is being reclassified is supported and accurate and that such review continues to be formally documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement the recommendation immediately. Name of the contact person responsible for corrective action plan: Loraine Rupp, Sherburne County Auditor-Treasurer Planned completion date for corrective action plan: Already corrected

View Audit 316496

Finding 480262 (2023-003)

Material Weakness 2023

Human Relations Area Files, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Management intends to be more meticulous when inputting expenses into the reporting system as well as submissions to granting agencies. Additionally, management intends to maintain supporting documentation for all grant expenses going forward.

View Audit 316492 Questioned Costs: $1

Finding 480243 (2023-002)

Material Weakness 2023

Brother Bill's Helping Hand

TX

Allowable Costs / Cost Principles Material Weakness Reporting

Explanation: The audit conducted by SFC of Brother Bill’s Helping Hand identified noncompliance with Section 200 of the Code of Federal Regulations, which mandates recipients to establish robust internal controls ensuring adherence to cost principles for all grantrelated transactions. Among the samp...

Explanation: The audit conducted by SFC of Brother Bill’s Helping Hand identified noncompliance with Section 200 of the Code of Federal Regulations, which mandates recipients to establish robust internal controls ensuring adherence to cost principles for all grantrelated transactions. Among the sampled invoices for allowable costs under federal grants, 6 out of 24 lacked documented approval from management. Furthermore, the organization lacked a standardized procedure for documenting management approval of credit card transactions prior to payment. Analysis: Brother Bill’s Helping Hand acknowledges the non-compliance with Section 200 as identified by SFC. However, we maintain that the assertion implying absence of controls or standardized procedures for credit card expenditures is inaccurate. Each reimbursement submission to Dallas County undergoes meticulous scrutiny and personal vetting by CEO Wes Keyes. Mr. Keyes reviews every receipt before reimbursement and, if necessary, consults with the respective staff members regarding any discrepancies. Each reimbursement bears Mr. Keyes’ signature of approval. Nonetheless, SFC has recommended that CEO Keyes review and approve the credit card statement prior to payment, a practice not previously adhered to by BBHH. Actions Taken: Effective June 17, 2024, Mr. Keyes will review and sign each credit card statement prior to payment. These signed statements will be securely stored for potential future documentation needs. Responsibility: CEO Wes Keyes and Operations Manager Sarah Cienfuegos are responsible for implementing the change requiring CEO approval on credit card transactions prior to payment. Timeline: The corrective action has been implemented as of June 17, 2024. Monitoring: No ongoing monitoring is deemed necessary as the corrective measures have already been executed.

View Audit 316476

Finding 480043 (2023-003)

Material Weakness 2023

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Material Weakness Internal Control / Segregation of Duties § 200.303 § 200.334

Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by...

Management agrees with the recommendation and will implement stronger processes to ensure that all records are organized and maintained for ease of timely and complete review and consultation when needed. The processes to organize and secure files will be executed by program staff, with oversight by the Vice President of Community Building and Neighborhood Resources, Executive Vice President of Housing and Community Programs, Vice President of Family Empowerment and Self Sufficiency, Chief Financial & Operating Officer, and Sr. Director of Finance. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

View Audit 316337

Finding 480040 (2023-004)

Material Weakness 2023

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Eligibility Material Weakness Internal Control / Segregation of Duties

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on h...

Cornerstones acknowledges that our files were incomplete. It is our position that the COVID-19 pandemic created immense need to which Cornerstones responded by expanding rapidly and mobilizing funding and program requests that did not receive the benefit of comprehensive planning; the focus was on health prevention, isolation and quarantine activities, and temporary shelter for homeless and other low-income, vulnerable seniors and disabled persons. We served those in need and our intake processes and recordkeeping processes did not keep pace. Additionally, given the time that has passed since the services in question, it is possible that records that did exist were misplaced. Staff turnover, resulting from the pandemic burden, made it challenging to go back to the work that had been done. Due to the timing of receiving this finding we were not able to make necessary adjustments to FY23 practices, but Cornerstones has since further emphasized the compliance and documentation needs of the case management process, and we have filled turned-over positions with experienced staff that also understand intake and documentation requirements. We have also hired a Senior Director, Finance with over 20 years of federal contracts experience that is an integral part of increased program compliance and operational oversight responsibilities within the Finance/Operations function. This Senior Director and Cornerstones’ Chief Financial & Operating Officer, Executive Vice President of Housing and Community Programs, and other program leaders and staff, will all work together to ensure that the file construction process is complete and timely for all participants. Due to timing of receiving this finding, remediation processes began in fiscal year 2024 and will be applied fully to the fiscal year 2025, beginning 7/1/2024, files.

View Audit 316337

Finding 479996 (2023-006)

Material Weakness 2023

Idaho State University

ID

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

2023-006: Eligibility Federal Program Title: Student Financial Assistance Cluster Assistance Listing Number: Various Type of Finding: Material Weakness Other Matters Recommendation: ISU should evaluate its procedure...

2023-006: Eligibility Federal Program Title: Student Financial Assistance Cluster Assistance Listing Number: Various Type of Finding: Material Weakness Other Matters Recommendation: ISU should evaluate its procedures around disbursement of loans and ensure that notifications of disbursements are sent and contain all of the required elements outline in the FSA handbook. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To meet requirements outlined in 34 CFR 668.165, ISU includes information in a student’s award notification email and in their MyISU portal of pertinent Direct Loan information including their “Award Payment Schedule” and what steps to take to accept, decline or modify their award offers. Additionally, in July 2023, ISU implemented an automated email notification in our daily job scheduler, AppWorx, that is sent on each date of disbursement to student Direct Loan borrowers and parent borrowers of Direct Parent PLUS (added Feb 2024) notifying them of the disbursement and reminding them what they need to do to revise or cancel the loan disbursement. Name(s) of the contact person(s) responsible for corrective action: James Martin, Director of Financial Aid Planned completion date for corrective action plan: Implemented in December 2023.

View Audit 316332

Finding 479800 (2023-004)

Material Weakness 2023

Miami County

IN

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

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the P&E report by April 30, 2023, as required; however, there were no internal controls in place that would likely be effective in preventing, or detect...

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the P&E report by April 30, 2023, as required; however, there were no internal controls in place that would likely be effective in preventing, or detecting and correcting, noncompliance related to the P&E report. The County Auditor prepared and submitted the report without an oversight or review process. We recommended that management of the County design and implement a proper system of internal controls, including policies and procedures to ensure that the County provides the Treasury with complete and accurate information for the P&E report. Contact Person Responsible for Corrective Action: Mary Brown Contact Phone Number and Email Address: 765-472-3901 Ext. 1240 and mbrown@miamicountyin.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Due to an oversight, the reporting for ARPA funding was not reviewed by another person after entering the data for reporting. It was my understanding, based on data entered when initial reporting began, a copy of the information also went to the Chairman of Board of Commissioners, however, it was later determined a copy was not sent. For future reporting, we will ensure someone else reviews the information prior to final submission. Anticipated Completion Date: January 2025

View Audit 316317

Finding 479716 (2023-003)

Material Weakness 2023

City of Kearney, Nebraska

NE

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness

The Finance Office will implement a process to annually verify that vendors being paid with federal funds do not appear on the SAM.gov Suspended and Debarred list.

View Audit 316282

Finding 479710 (2023-002)

Material Weakness 2023

Harvest Regional Food Bank, Inc.

AR

Special Tests & Provisions Material Weakness Reporting

All federal food commodities received will be entered into the SMF QuickBooks system and reported to the Arkansas Department of Education (ADE) within 48 hours of delivery by the Operations Manager or his assistant. All federal food receipts will be verified by a secondary employee monthly to ensure...

All federal food commodities received will be entered into the SMF QuickBooks system and reported to the Arkansas Department of Education (ADE) within 48 hours of delivery by the Operations Manager or his assistant. All federal food receipts will be verified by a secondary employee monthly to ensure ADE has received and properly processed the submission into their system. Any discrepancies will be discussed and corrected as necessary. Harvest will perform an inventory count quarterly and adjust inventory amounts as needed in the SMF QuickBooks system.

View Audit 316274

Finding 479602 (2023-001)

Material Weakness 2023

Royalton Fire District #1

VT

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness § 200.318 § 200.327

CORRECTIVE ACTION PLAN {Concerning Finding 2023-001-RF3-407-3.0) Contact Person Responsible for Corrective Action: Judy L. Hayward Corrective Action: The Royalton Fire District 1 will take the following actions to address finding 2023-01. We will prepare and adopt a Federal Procurement Policy. Antic...

CORRECTIVE ACTION PLAN {Concerning Finding 2023-001-RF3-407-3.0) Contact Person Responsible for Corrective Action: Judy L. Hayward Corrective Action: The Royalton Fire District 1 will take the following actions to address finding 2023-01. We will prepare and adopt a Federal Procurement Policy. Anticipated Completion Date: June 30, 2024.

View Audit 316182

Finding 479582 (2023-001)

Material Weakness 2023

Care Alliance Health Center

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 202...

To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients' needs and complies with all federal guidelines. Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will overseE3 the training. 3. The Revenue Cycle Manager_will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results. Timeline: 1. Procedure draft completion: Completed 2. Review and approval by senior management: July 24, 2024 3. Initial staff training session: July 25, 2024 4. Follow-up training sessions: As needed 5. Monthly compliance audits: Starting September 1, 2024

View Audit 316128

Finding 479546 (2023-001)

Material Weakness 2023

Dayton's Bluff Neighborhood Housing Service, Inc.

MN

Reporting Subrecipient Monitoring Material Weakness

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1,...

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 2023 – December 31, 2023 The findings from the December 31, 2023 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2023-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Jim Erchul, Executive Director, 651-774-6995 Anticipated Completion Date: Ongoing

View Audit 316095

Finding 479530 (2023-002)

Material Weakness 2023

Worker Education & Resource Center INC

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to creat...

The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to create and implement as many internal controls that were needed, that were not implemented, and/or recommended by our current CPA firm who had been previously auditing prior years. Additionally, our Director of Finance has engaged the Board of Directors in taking a more active role in the financial statement overview that was not previously recommended to them by our CPA firm.

View Audit 316070

Finding 479513 (2023-003)

Material Weakness 2023

Christian Community Health Center

IL

Material Weakness Internal Control / Segregation of Duties

Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR...

Finding Number: 2023-003 Sliding Scale Assessment Planned Corrective Action: CCHC has created a workflow for staff as a guide in processing the sliding fee scale. This workflow is approved by the Head Nurse Supervisor and signed. Please see attached workflow sheet. CCHC will verify with Athena EHR system to make sure that the most up to date poverty guidelines are in the system that is being used to calculate sliding fee discounts. Person Responsible for Corrective Action Plan: Pasue Mahan, Chief Clinic Officer Anticipated Date of Completion: 07/01/2024

View Audit 316037

Finding 479440 (2023-001)

Material Weakness 2023

County of Accomack, Virginia

VA

Subrecipient Monitoring Material Weakness Reporting

Corrective Action Plan for Finding FA-2023-001: Lack of Timely Reporting, Reporting, Education Stabilization Funds (ESF) #84.425C, 84.425D, and 84.425U (Material Weakness and Nonmaterial Compliance) A master calendar is now being kept of required reports and their due date to ensure timely reportin...

Corrective Action Plan for Finding FA-2023-001: Lack of Timely Reporting, Reporting, Education Stabilization Funds (ESF) #84.425C, 84.425D, and 84.425U (Material Weakness and Nonmaterial Compliance) A master calendar is now being kept of required reports and their due date to ensure timely reporting. Responsible Official: Dr. Rhonda Hall, Accomack County Public Schools Superintendent, rhonda.hall@ accomack.k12.va.us (757-787-5759); Estimated completion date is not later than the June 30, 2024.

View Audit 315971

Finding 479373 (2023-001)

Material Weakness 2023

Spyglass Ridge

OR

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

Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper trainin...

Views of Responsible Officials and Planned Corrective Actions We agree with this finding. NWCH was successful in adding needed staff in 2023, but was unable to hire a degreed accountant or controller, or to contract with an accounting firm for oversight of the accounting function. Bookkeeper training was provided from Shelter Resources Financial Manager in February 2023. NWCH is researching CPA firms in order to contract a qualified controller with expertise in real estate holdings relevant to NWCH. NWCH has been actively searching for a qualified CPA to hire or contract with since 2021, however, due to capacity constraints and overwhelmed CPA firms, NWCH has been unsuccessful. Efforts to hire experienced accounting personnel continues.

View Audit 315878

Finding 479347 (2023-002)

Material Weakness 2023

Brazos Valley Community Action Programs

TX

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

CORRECTIVE ACTION PLANNED: We agree with the finding and have begun the process of enacting additional internal controls over the documentation of approval for pay rates. Beginning in August 2023, the Head Start program was administered with management, accounting, and payroll functions independent ...

CORRECTIVE ACTION PLANNED: We agree with the finding and have begun the process of enacting additional internal controls over the documentation of approval for pay rates. Beginning in August 2023, the Head Start program was administered with management, accounting, and payroll functions independent of other Agency programs. These key personnel report directly to the Board of Directors, which will direct staff to thoroughly document the approval of current pay rates for all active employees. The Agency will also enact additional controls to regularly review these records to ensure that, in the future, all required approvals and reviews are evidenced with written documentation. PERSON RESPONSIBLE FOR CORRECTION ACTION: James McCullough, Board President ANTICIPATED COMPLETION DATE: September 30, 2024

View Audit 315839

Finding 479327 (2023-009)

Material Weakness 2023

Colorado Legal Services, INC

CO

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.403

COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review ...

COIVD-19: Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit 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 based on employees’ time and effort records, effective compensation during work periods, and that are calculated in a consistent manner. We also recommend that the Organization maintain contemporaneous documentation supporting all cost allocations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization is updating the segregation of duties in order to improve the preparation, review and sign steps of the process. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826 Questioned Costs: $1

Finding 479314 (2023-008)

Material Weakness 2023

Colorado Legal Services, INC

CO

Matching / Level of Effort / Earmarking Material Weakness Reporting

Aging Cluster – Special Programs for the Aging, Title III, Part B – Assistance Listing No. 93.004 Recommendation: We recommend that the Organization implement a control process to ensure that it meets its matching requirements within the grant period. Explanation of disagreement with audit finding...

Aging Cluster – Special Programs for the Aging, Title III, Part B – Assistance Listing No. 93.004 Recommendation: We recommend that the Organization implement a control process to ensure that it meets its matching requirements within the grant period. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization is updating the segregation of duties in order to improve the preparation, review and sign steps of the process. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826

Finding 479298 (2023-007)

Material Weakness 2023

Colorado Legal Services, INC

CO

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

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: ...

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization update its derivative income allocation method, policy and procedures to reflect the method described in the federal regulations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will reach out to LSC to understand if our current method is acceptable. If not, the Organization will implement corrections to comply with applicable standards. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826

Finding 479297 (2023-006)

Material Weakness 2023

Colorado Legal Services, INC

CO

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual tim...

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries, wages, and employee benefit 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 based on employees’ time and effort records, effective compensation during work periods, and that are calculated in a consistent manner. We also recommend that the Organization maintain contemporaneous documentation supporting all cost allocations. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826 Questioned Costs: $1

Finding 479294 (2023-003)

Material Weakness 2023

Colorado Legal Services, INC

CO

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.430

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries and wages cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expen...

Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization consider updating its salaries and wages 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 based on employees’ time and effort records. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Organization will review this finding and current methodology and propose corrections as part of a broader review of its technologies. Name of the contact person responsible for corrective action: Silvia Zelaya, Finance Director Planned completion date for corrective action plan: January 2025

View Audit 315826 Questioned Costs: $1

Corrective Action Plans

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