Corrective Action Plans

Finding 518431 (2023-001)

Material Weakness 2023

Richmond Henrico Public Health Foundation

VA

Subrecipient Monitoring Material Weakness

--RHPHF will establish policies for any qualifying federal funds detailing procedures for sub recipient risk evaluation and monitoring.

View Audit 336830

Finding 518327 (2023-003)

Material Weakness 2023

Community Action Team, Inc.

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

2023-003 Federal Award Special Reporting – Federal Funding Accountability and Transparency Act (FFATA) – Material Non-Compliance and Material Weakness in Internal Controls over Compliance Recommendation: The Organization should establish written policies and procedures regarding review of grant agre...

2023-003 Federal Award Special Reporting – Federal Funding Accountability and Transparency Act (FFATA) – Material Non-Compliance and Material Weakness in Internal Controls over Compliance Recommendation: The Organization should establish written policies and procedures regarding review of grant agreements for compliance requirements along with written policies and procedures for first-tier subawards including tracking and proper internal control procedures. Action Taken: Management concurs with the finding and has defined corrective action to address it. We have identified gaps in our reporting processes and worked to implement changes to ensure compliance with special reporting requirements. Policies and procedures will be updated regarding special reporting requirements. The Fiscal department will also be responsible for reviewing all contracts to identify all compliance requirements. Tracking procedures will be implemented to ensure reports are filed timely. The above identified corrective action was implemented in July 2024. Stacey Wilson, Fiscal Director, has implemented a tracking system for the FFATA.

View Audit 336686

Finding 518155 (2023-002)

Material Weakness 2023

Nebraska Children's Home Society

NE

Subrecipient Monitoring Material Weakness Reporting

NCHS has established a new structure, policy, and procedures. This new structure has the COO managing the accounting functions of Finance. We are currently fully staffed within our accounting department, with more SOP and a new software system that better supports the department. The COO and Account...

NCHS has established a new structure, policy, and procedures. This new structure has the COO managing the accounting functions of Finance. We are currently fully staffed within our accounting department, with more SOP and a new software system that better supports the department. The COO and Accounting team now adheres to protocols and timelines that ensure timely and accurate completion of accounting tasks. The COO will continue to work with our auditors to ensure NCHS meet the filing deadlines.

View Audit 336471

Finding 518154 (2023-001)

Material Weakness 2023

Nebraska Children's Home Society

NE

Subrecipient Monitoring Reporting Material Weakness

To increase controls and improve preparation of accounting records. NCHS has reorganized the finance department. The accounting functions are now a part of Operations. With accounting reporting to operations, the Chief Operations Officer (COO) now oversees and provides support and leadership to this...

To increase controls and improve preparation of accounting records. NCHS has reorganized the finance department. The accounting functions are now a part of Operations. With accounting reporting to operations, the Chief Operations Officer (COO) now oversees and provides support and leadership to this division of Finance. The COO has created and implemented new Standard Operation Processes (SOP). These new SOPs clearly define, documents, and support all accounting activities. The SOPs cover critical areas, including contract and grants management, reconciliation processes and month-end closings. The responsibilities of the accounting team are now clearly delineated, providing more transparency and accountability. A formal schedule for processing and reconciliation tasks has been established and maintained by the Senior Accountant. These schedules are reviewed monthly with the COO to ensure accuracy and timely completion of accounting tasks are occurring.

View Audit 336471

Finding 518135 (2023-003)

Material Weakness 2023

Contemporary Oriental Medicine Foundation

FL

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

Finding 2023-003: Failure to Meet the Standards for Safeguarding Customer Information Comments on Finding and Recommendations: The College agrees with this finding as determined in the audit and states that the College has complied with the requirement. Actions Taken or Planned: Dragon Rises Colleg...

Finding 2023-003: Failure to Meet the Standards for Safeguarding Customer Information Comments on Finding and Recommendations: The College agrees with this finding as determined in the audit and states that the College has complied with the requirement. Actions Taken or Planned: Dragon Rises College of Oriental Medicine has completed the requirements and published the Information Security Program Compliance with Gramm-Leach-Bliley Act (GLBA). The College is committed to the preservation and security of personal data and is dedicated to adhering to regulations pertaining to the safeguarding of personal, sensitive, and other protected data within its purview. Name: Dr. Dorian G. Kramer DACM Title: Director Telephone: (941)-289-2456 Email: dkramer@dragonrises.edu

View Audit 336438

Finding 517955 (2023-012)

Material Weakness 2023

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

U.S Department of Homeland Security Staffing for Adequate Fire and Emergency Response (SAFER) – 97.083 Management’s Response: During 2024, management worked with the Fire Department and Payroll to ensure only straight time was coded to this grant and no overtime was charged to this grant. This was a...

U.S Department of Homeland Security Staffing for Adequate Fire and Emergency Response (SAFER) – 97.083 Management’s Response: During 2024, management worked with the Fire Department and Payroll to ensure only straight time was coded to this grant and no overtime was charged to this grant. This was a finding in 2022 but we were not aware until the audit was completed in 2024 there was an issue the existing payroll system was not flagging. This has been corrected in in 2024 and should not be a recurring issue. Views of Responsible Officials and Corrective Action: The reason for recurrence is the finding was communicated late in the prior year. Management will work with stakeholders so that only the allowed costs are used as the basis of the reimbursement packet. We have also created fencing around allowed costs and period of performance in our new ERP system. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 336226

Finding 517823 (2023-002)

Material Weakness 2023

Zanesville-Muskingum County General Health District

OH

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.420 § 200.476

Finding Number: 2023-002 Planned Corrective Action: Allowable Costs/Cost Principles Re: Noncompliance / Material Weakness/ Questioned Cost • ZMCHD has developed a spreadsheet for management to review time and activity of their staff including time worked and effort documentation quarterly based on a...

Finding Number: 2023-002 Planned Corrective Action: Allowable Costs/Cost Principles Re: Noncompliance / Material Weakness/ Questioned Cost • ZMCHD has developed a spreadsheet for management to review time and activity of their staff including time worked and effort documentation quarterly based on actual time worked vs. budgeted time worked. Any necessary corrections will be shared with the fiscal officer to ensure corrections are made as necessary. • ZMCHD will ensure staff are educated on how to report time worked when they are doing activities for multiple programs and ensure that staff are disciplined when they are not reporting correctly. Anticipated Completion Date: 12/31/2024 Responsible Contact Person: Erin Wood, Chief Administrative Officer

View Audit 335989 Questioned Costs: $1

Finding 517750 (2023-001)

Material Weakness 2023

Community Action of East Central Indiana, Inc.

IN

Reporting Material Weakness

Community Action of East Central Indiana, Inc. ceased operations as of July 31, 2024 for any new business. Community Development Institute (CDI), as contracted by the Office of Head Start, has taken over the leadership and operations.

View Audit 335885

Finding 517735 (2023-002)

Material Weakness 2023

Bay St. Louis-Waveland School District

MS

Questioned Costs Cash Management Allowable Costs / Cost Principles

2023-002 Cash management excessive cash and fund balances. A. Name of contact person responsible for corrective action: Name: Thomas J. Burleson Title: Business Administrator B. Corrective action planned: It is recommended that the district implement policies or procedures to establish an internal c...

2023-002 Cash management excessive cash and fund balances. A. Name of contact person responsible for corrective action: Name: Thomas J. Burleson Title: Business Administrator B. Corrective action planned: It is recommended that the district implement policies or procedures to establish an internal control system that will ensure funds are expended for reimbursable grants before requested reimbursement. C. Anticipated completion date: June 30, 2024.

View Audit 335824 Questioned Costs: $1

Finding 517515 (2023-005)

Material Weakness 2023

Green Lake County

WI

Cash Management Material Weakness Reporting

Recommendation: CLA recommended that there is an appropriate reviewer of each claim, and expenditure reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: County will have someone other than the ...

Recommendation: CLA recommended that there is an appropriate reviewer of each claim, and expenditure reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: County will have someone other than the preparer review the report prior to submission going forward. Name(s) of the contact person(s) responsible for corrective action: Cate Wylie Planned completion date for corrective action plan: December 31, 2024

View Audit 335549

Finding 517041 (2023-004)

Material Weakness 2023

Methodist Services

PA

Reporting Procurement, Suspension & Debarment Subrecipient Monitoring

Finding #2023-004 – Material Weakness – Reporting 93.558 Temporary Assistance for Needy Families – Out of School Time Program 93.600 Head Start Untimely Submission of Required Reports Condition The Organization is required to submit quarterly financial and performance reports. The total population ...

Finding #2023-004 – Material Weakness – Reporting 93.558 Temporary Assistance for Needy Families – Out of School Time Program 93.600 Head Start Untimely Submission of Required Reports Condition The Organization is required to submit quarterly financial and performance reports. The total population was eight reports and of those four were selected for testing. These financial and performance reports were not submitted to the granting agencies within the deadlines established by the terms and conditions of the federal awards. Recommendation We recommend that the Organization strengthen its internal controls to ensure that all required reports are submitted to granting agencies on time. Management should implement a centralized system to track reporting deadlines and designate responsible personnel to monitor and ensure compliance with these deadlines. Additionally, periodic reviews of the reporting process should be conducted to identify any potential issues and address them proactively. Management’s Corrective Action Plan The Organization agrees with this finding and has begun implementing corrective actions to ensure timely submission of required reports. The organization is in the process of developing a reporting schedule and assigning dedicated personnel to monitor deadlines. Contact Person: Cynthia Benton, Chief Financial Officer Anticipated Completion Date: June 30, 2024

View Audit 334930

Finding 517037 (2023-002)

Material Weakness 2023

Methodist Services

PA

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

Finding #2023-002 – Material Weakness – Activities Allowed or Unallowed, Allowable Cost Principles 93.558 Temporary Assistance for Needy Families – Out of School Time Program 93.600 Head Start Payroll Approval Condition During our audit of the Organization for compliance with Uniform Guidance requ...

Finding #2023-002 – Material Weakness – Activities Allowed or Unallowed, Allowable Cost Principles 93.558 Temporary Assistance for Needy Families – Out of School Time Program 93.600 Head Start Payroll Approval Condition During our audit of the Organization for compliance with Uniform Guidance requirements, we noted that the client was unable to provide sufficient evidence of management review or approval of payroll transactions before disbursement. Payroll costs were verified through additional supporting documentation including payroll registers and time cards. In total sixty-five payroll samples were selected for testing and the lack of review occurred for all items tested. Recommendation We recommend that Organization establish and enforce formal procedures requiring documented management review and approval of all payroll transactions before they are processed. The review process should be supported by evidence, such as approval signatures, electronic audit trails, or other verifiable records. In addition, management should perform regular reconciliations of payroll to ensure compliance with federal and organizational policies. Management’s Corrective Action Plan The Organization concurs with the finding and has already begun implementing a revised payroll approval process. Management is developing a formal payroll review policy, including electronic approval workflows, to ensure proper documentation and oversight of payroll prior to disbursement is maintained. Contact Person: Cynthia Benton, Chief Financial Officer Anticipated Completion Date: June 30, 2024

View Audit 334930

Finding 517029 (2023-001)

Material Weakness 2023

Methodist Services

PA

Material Weakness § 200.512

Finding 2023-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended June 30, 2023, management was unable to provide timely year end trial balances in accordance with U.S. GAAP without significant adjusting journal entries required to accurately reflec...

Finding 2023-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended June 30, 2023, management was unable to provide timely year end trial balances in accordance with U.S. GAAP without significant adjusting journal entries required to accurately reflect the underlying accounting transactions. Recommendation We recommend that individuals overseeing the accounting and finance department continue to review the Organization’s current accounting policies and update existing policies or implement new policies, as needed, to ensure that the trial balances are accurately maintained throughout the year, reconciliations are completed and reviewed monthly or quarterly, as appropriate, and the trial balances and related supporting schedules are prepared and reviewed timely after year-end. Management’s Corrective Action Plan There was significant turnover in the finance department, including the CFO and the finance director. These turnovers affected the ability of the organization to produce the information on time for the auditors. The Organization is working with external consultants to improve the timeliness of reconciliations and audit preparation and recruiting vacant positions. We completed accounting policy changes which will correct the issues noted. Management is confident that the issues that have been noted will be rectified in the fiscal year ending June 30, 2024. Contact Person: Cynthia Benton, Chief Financial Officer Anticipated Completion Date: June 30, 2024

View Audit 334930

Finding 516970 (2023-003)

Material Weakness 2023

Spirit of Soccer, Inc.

PA

Subrecipient Monitoring Cash Management Material Weakness

Response - Management agrees with the recommendation and will implement the necessary components of the recommendation. Accounting policies and procedures have been developed which pertain to our subrecipient reporting and monitoring and are in the process of being implemented. Also, by adding the b...

Response - Management agrees with the recommendation and will implement the necessary components of the recommendation. Accounting policies and procedures have been developed which pertain to our subrecipient reporting and monitoring and are in the process of being implemented. Also, by adding the bookkeeper in March of 2021, receipt spot checking of subrecipients on a monthly basis has been implemented to help ensure compliance.

View Audit 334894

Finding 516969 (2023-002)

Material Weakness 2023

Spirit of Soccer, Inc.

PA

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management

Response - Management agrees with the recommendation and will continue to work at implementing the necessary components of the recommendation. New board members have come aboard and are working to implement changes. A finance committee has been established (independent of the CEO) and their role wil...

Response - Management agrees with the recommendation and will continue to work at implementing the necessary components of the recommendation. New board members have come aboard and are working to implement changes. A finance committee has been established (independent of the CEO) and their role will be to ensure the adoption and recommendations of the CAP to ensure transparency and accountability. A bookkeeper was added March 2021 as another tier of financial control, along with CEO handing over some financial duties to the financial advisor and bookkeeper. Regular meetings are held by bookkeeper, financial advisor, and finance committee member of the Board. Please note though, that the small size of our staff, precludes the total elimination of this weakness.

View Audit 334894

Finding 516940 (2023-005)

Material Weakness 2023

Oakland Livingston Human Service Agency

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this tas...

The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task to the Assistant Director for Financial Compliance to ensure that reporting is completed to the FFATA Reporting System FSRS.

View Audit 334839

Finding 516935 (2023-006)

Material Weakness 2023

Oakland Livingston Human Service Agency

MI

Subrecipient Monitoring Material Weakness Reporting § 200.501 § 200.512 § 200.514

We agree with this finding. The Chief Financial Officer in collaboration with the Assistant Director for Finance and the Assistant Director for Financial Compliance will set a calendar at the end of the fiscal year to ensure timely closeout of the books that will allow ample time to engage and comp...

We agree with this finding. The Chief Financial Officer in collaboration with the Assistant Director for Finance and the Assistant Director for Financial Compliance will set a calendar at the end of the fiscal year to ensure timely closeout of the books that will allow ample time to engage and complete the audit prior to the deadline for the FAC filing.

View Audit 334839

Finding 516934 (2023-004)

Material Weakness 2023

Oakland Livingston Human Service Agency

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this tas...

The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task to the Assistant Director for Financial Compliance to ensure that reporting is completed to the FFATA Reporting System FSRS.

View Audit 334839

Finding 516920 (2023-001)

Material Weakness 2023

City of Tacoma

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Material Weakness

The City is fully committed to establishing and maintaining robust internal controls to ensure compliance with federal requirements, particularly in the administration of federal grant programs. Reporting: To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will tak...

The City is fully committed to establishing and maintaining robust internal controls to ensure compliance with federal requirements, particularly in the administration of federal grant programs. Reporting: To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will take the following actions: Update training material and implement annual training for all Accounting staff and City departments managing federal grants. Update and distribute monthly email to departments to clarify the required information for FFATA filing and require responses with supporting documentation for review. Periodically review federal reporting requirements for any updates and make adjustments as needed, utilizing resources such as the State Auditor’s Office (SAO) Newsletter, conferences, and trainings. Wage Rate Requirement: To meet Davis Bacon Act reporting requirements, the City will incorporate the verbiage from 29 CFR 5.5(a) in full into specifications, as applicable, which will be incorporated into the resulting contracts.

View Audit 334833

Finding 516586 (2023-001)

Material Weakness 2023

Southwestern Wisconsin Community Action Program, Inc.

WI

Reporting Material Weakness

2023-001: Internal Control Over Financial Reporting Auditor's Recommendation: We recommend SWCAP implement procedures to ensure accounts are adjusted and that provided supplementary audit information is accurately prepared. Corrective Action: SWCAP experienced significant turnover in its accounting ...

2023-001: Internal Control Over Financial Reporting Auditor's Recommendation: We recommend SWCAP implement procedures to ensure accounts are adjusted and that provided supplementary audit information is accurately prepared. Corrective Action: SWCAP experienced significant turnover in its accounting and finance team during the year. Immediate action has been taken and as of December 2024, SWCAP has identified and implemented changes with its personnel, hired an outsourced accounting firm, and implemented additional internal controls to include secondary level of review. SWCAP will make any additional changes necessary to complete the closing process and provide accurate financial information. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director). Anticipated Completion Date: Completed as of December 2024.

View Audit 334558

Finding 516585 (2023-002)

Material Weakness 2023

Digital Harbor Foundation INC

MD

Procurement, Suspension & Debarment Material Weakness § 200.318 § 200.327

MATERIAL WEAKNESS 2023-002 Policies and Procedures Auditor’s Recommendation: We recommend that the Foundation adopt a formal written procurement policy in the format and with the elements required by 2 CFR Sections 200.318 to 200.327. Action Taken: • As a First Year Single Auditee, the management...

MATERIAL WEAKNESS 2023-002 Policies and Procedures Auditor’s Recommendation: We recommend that the Foundation adopt a formal written procurement policy in the format and with the elements required by 2 CFR Sections 200.318 to 200.327. Action Taken: • As a First Year Single Auditee, the management team will ensure that senior leadership team, finance and accounting team, as well as program manager/directors for federal awards receive some form of training and certify receipt of this training within six-months of these findings no later than December 31st, 2024. • As a First Year Single Auditee, the management team will ensure that specific policies are created to ensure a procurement process for goods and services expensed from federal funds is established and in alignment with UG (Uniform Guidance) standards for federal awards no later than December 31st, 2024. • As a First Year Single Auditee, the management team will have an independent audit firm review this policy to ensure they are in alignment and conformance with UG (Uniform Guidance) standards no later than December 31st, 2024.

View Audit 334550

Finding 516473 (2023-010)

Material Weakness 2023

Academy of America

MI

Matching / Level of Effort / Earmarking Subrecipient Monitoring Material Weakness § 200.501 § 200.512 § 200.514

View of Responsible Officials and Corrective Action Plan – The Academies will develop a reliable system that will lead to the timely processing of the financial records by reviewing existing procedures to identify bottlenecks and areas of improvement. Feedback will be gathered from team members invo...

View of Responsible Officials and Corrective Action Plan – The Academies will develop a reliable system that will lead to the timely processing of the financial records by reviewing existing procedures to identify bottlenecks and areas of improvement. Feedback will be gathered from team members involved in the financial record keeping process so that standard procedures can be development and implemented. Furthermore, opportunities to automate processes and use software to assist with data entry, record reconciliation, and reporting can be used. This will significantly decrease manual workload and improve accuracy and timeliness.

View Audit 334382

Finding 516472 (2023-009)

Material Weakness 2023

Academy of America

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

View of Responsible Officials and Corrective Action Plan – Management will monitor the review and approval procedures for reporting to ensure that reports are signed off to indicated and document that review and approval has been made.

View Audit 334382

Finding 516325 (2023-002)

Material Weakness 2023

All Nations Health Center, Inc.

MT

Subrecipient Monitoring Eligibility Material Weakness

All Nations Health Center has switched EHR systems that allows for intake coordinators to suspend/pause eligibility status until all proper documentation has been obtain from the client, scanned into the system, and filed appropriately.

View Audit 334164

Finding 516134 (2023-002)

Material Weakness 2023

Kalama School District

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kalama School District No. 402 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Fed...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kalama School District No. 402 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: James Capen Director of Business Services 360-673-5282 Corrective action the auditee plans to take in response to the finding: The Kalama School District has taken the following steps to ensure that we are currently in compliance, and will continue to stay in compliance, with the Davis-Bacon Act; 1. All new contractors and existing contractors covered by the Davis-Bacon Act will submit certification attesting to compliance of prevailing wage requirements. 2. District staff will review the State Labor and Industries prevailing wage and certification website on a weekly basis when work is performed or collect a certified payroll record from the contractor on a weekly basis. 3. All new staff that have purchasing or financial oversight will be trained on these procedures when hired and on an ongoing basis. Anticipated date to complete the corrective action: 7-26-24

View Audit 333974

Corrective Action Plans

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