Corrective Action Plans

Finding 569029 (2024-002)

Significant Deficiency 2024

IN

HUD Housing Programs Questioned Costs Eligibility

The Management of the Authority agrees with the findings; we will implement improved internal controls to ensure that all annual recertifications are performed in a timely manner and that all required documents are kept in an organized manner. The Authority hired a Compliance Specialist in May 2025...

The Management of the Authority agrees with the findings; we will implement improved internal controls to ensure that all annual recertifications are performed in a timely manner and that all required documents are kept in an organized manner. The Authority hired a Compliance Specialist in May 2025 to perform quality control checks on the files to eliminate errors. The Public Housing Director is the responsible party, and controls will be in place by the end of the September 30, 2025 fiscal year.

View Audit 360680

Finding 569026 (2024-001)

Significant Deficiency 2024

Gardner Housing Authority

MA

HUD Housing Programs Questioned Costs Eligibility

Planned Implementation Date of Corrective Action: July 2025 Person Responsible for Correctove Action: Krishonna Murray, Executive Director I. 2024-001 Eligibility Rent Calculation Other Matter/Significant Deficiency The Authority had instances of missing income verifcation. Gardner Housing Au...

Planned Implementation Date of Corrective Action: July 2025 Person Responsible for Correctove Action: Krishonna Murray, Executive Director I. 2024-001 Eligibility Rent Calculation Other Matter/Significant Deficiency The Authority had instances of missing income verifcation. Gardner Housing Authority has establised a system of internal control over the participant recertification process that meets HUD's requirements. Seven (7) to ten (10) files will be reviewed fiscally for quality assurance.

View Audit 360667

Finding 569025 (2024-001)

None 2024

Integrated Justice Information Systems Institute, Inc.

VA

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.512

Action taken: Management has updated the process to verify that the reporting package, including the Single Audit report, is submitted to the FAC successfully. While management previously certified the reporting package properly, the final step of submission was not properly monitored and verified. ...

Action taken: Management has updated the process to verify that the reporting package, including the Single Audit report, is submitted to the FAC successfully. While management previously certified the reporting package properly, the final step of submission was not properly monitored and verified. Effective immediately, management has implemented a new step requiring the inclusion of a physical screenshot for the final submission to the FAC. This adjustment ensures proper documentation and alignment with compliance requirements. Person responsible: Maria Cardiellos, Executive Director Date completed: March 13, 2025

View Audit 360666

Finding 569021 (2024-004)

Material Weakness 2024

Fairview Health Services

MN

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding 2024-004 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Management will improve internal controls to include the documentation and retention of approval on all supply expenditures and the annual fringe benefit analysis. Responsible Offici...

Finding 2024-004 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Management will improve internal controls to include the documentation and retention of approval on all supply expenditures and the annual fringe benefit analysis. Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date –August 2025 Management agrees with the finding. Remediation: The accounting manager reviewed and approved the updated 2025 fringe benefit analysis with 2024 actuals on February 28, 2025. Upon finalization of the 2025 budget, the analysis will be revised and reviewed again. Accounting will collect evidence of review and approval of supply expenditure throughout the year to ensure proper retention of the documentation.

View Audit 360649

Finding 569016 (2024-001)

None 2024

Metropolitan Transit Authority of Harris County, Texas

TX

Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.303 § 200.516

The METRO Vanpool Department, in collaboration with the Grant Programs Administration Division, has initiated actions to strengthen internal controls and improve compliance with federal cost principles. These actions include: • Updating existing policies and procedures related to grant-funded expens...

The METRO Vanpool Department, in collaboration with the Grant Programs Administration Division, has initiated actions to strengthen internal controls and improve compliance with federal cost principles. These actions include: • Updating existing policies and procedures related to grant-funded expense transactions; • Developing guidance to ensure transactions are appropriately reviewed for allowability, allocability, and reasonableness; • Enhancing training for relevant personnel to reinforce understanding and application of award-specific terms and conditions; • Ensuring compliance with 2 CFR § 200.403 and § 200.303. These process improvements and control enhancements will be finalized and implemented no later than December 31, 2025, under the direction of the Director, Commuter Services. METRO believes these steps will ensure compliance and mitigate recurrence of similar findings in future audit periods.

View Audit 360643 Questioned Costs: $1

Finding 568950 (2024-002)

Significant Deficiency 2024

Universities Space Research Association

MD

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties § 200.308

The Company acknowledges the importance of accurately documenting key personnel requirements in support of federal contract compliance. The audit noted one contract with two projects where the individual listed as key personnel did not match the most current contract documentation. However, internal...

The Company acknowledges the importance of accurately documenting key personnel requirements in support of federal contract compliance. The audit noted one contract with two projects where the individual listed as key personnel did not match the most current contract documentation. However, internal “load sheets” and program communications consistently reflected the correct personnel assignments, and there was no impact on contract performance or deliverables. Given the isolated nature of these discrepancies and their lack of effect on program execution or financial reporting, the Company does not consider this matter to be material. Nonetheless, to strengthen internal controls, the Contracts Department now records and maintains all key personnel data directly in Costpoint. Additionally, the Controller performs a quarterly internal review of these records to verify accuracy and completeness. These measures provide added assurance that the Company remains fully compliant with federal award requirements. Director of Contracts/Elena Einstein now oversees this control which was put into place as of April 2025.Notwithstanding these findings, management is confident that the accompanying financial statements present fairly, in all material respects, the Company’s financial position for the fiscal year ended September 30, 2024.

View Audit 360636

Finding 568861 (2024-003)

Significant Deficiency 2024

Town of Cleveland

AL

Questioned Costs Subrecipient Monitoring Cash Management

The Mayor's Office is fully committed to addressing the audit finding and the requirement per the grant agreement to develop and implement a fiscal sustainability plan as of 06/10/2025 on any futhter awarded funds. The corrective actions outlined in this plan reflect the importance of prudent financ...

The Mayor's Office is fully committed to addressing the audit finding and the requirement per the grant agreement to develop and implement a fiscal sustainability plan as of 06/10/2025 on any futhter awarded funds. The corrective actions outlined in this plan reflect the importance of prudent financial management and forward-thinking strategies to safeguard the financial future of our community. Anticipated Completion Date: 6/10/2025 James A. Sullivan, Mayor.

View Audit 360598

Finding 568855 (2024-006)

Material Weakness 2024

Springfield Metropolitan Housing Authority

OH

Questioned Costs

Accounts will be reconciled and agreed to detail ledger monthly. At YE balance will be agreed to FDS prior submission. Training will be implemented to ensure completed.

View Audit 360596

Finding 568852 (2024-002)

Material Weakness 2024

King's Daughters Medical Center

MS

Questioned Costs Allowable Costs / Cost Principles Cash Management

Corrective Action Plan Details Finding Number: 2024-002 Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number 97.036 Federal Emergency Management Agency Passed through Mississippi Emergency Management Agency Responsible Official: Adam Moor...

Corrective Action Plan Details Finding Number: 2024-002 Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Assistance Listing Number 97.036 Federal Emergency Management Agency Passed through Mississippi Emergency Management Agency Responsible Official: Adam Moore, CFO Finding Detail: Expenses reimbursed from other sources and unsupported expenses were not identified. Appropriate calculations of cost formulas were not utilized for medication reimbursement amounts claimed. Corrective Action Planned: Management concurs with the finding and will implement additional internal controls over the identification of eligible expenditures for the Disaster Grants program. Expenditures identified as potential grant program expenditures will be reviewed by the controller, and final approval of each expense by the chief financial officer to ensure they are eligible expenses and have not been reimbursed by any other sources. We anticipate these additional controls to be in place by September 30. 2025. The Chief Development Officer will oversee the corrective action. Anticipated Completion Date: September 2025

View Audit 360576 Questioned Costs: $1

Finding 568847 (2024-006)

Significant Deficiency 2024

County of Berrien

MI

Questioned Costs Allowable Costs / Cost Principles

Finding: 2024-006 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the County's reporting process for CSLFRF grants received through pass-through entities, we noted that none of the financial reports selected for te...

Finding: 2024-006 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the County's reporting process for CSLFRF grants received through pass-through entities, we noted that none of the financial reports selected for testing included documentation that the reports were subjected to an independent review and approval prior to submission in order to detect and correct potential errors or omissions. As a result of this condition, the County was exposed to an increased risk that the reports filed could contain errors and not be detected and corrected on a timely basis. Auditor Recommendation: We recommend that the County establish procedures to ensure that all reports are subject to review and approval by an independent employee prior to submission, and that the review and approval is adequately documented. Corrective Action: County grant policies and procedures outline requirements of review and approval of grant reporting. Management recognizes the importance of establishing controls as noted, however policies and procedures stop short of requiring the signature and dating of approvals by independent reviewers. Policies and procedures will be modified to include verbiage requiring documentation of review and approval, along with reconciliations to the general ledger prior to submission. Contact Person: Brian Dissette, County Administrator/Controller Estimated Completion Date: December 31, 2025

View Audit 360575

Finding 568846 (2024-007)

Significant Deficiency 2024

County of Berrien

MI

Procurement, Suspension & Debarment Questioned Costs Allowable Costs / Cost Principles

Finding: 2024-007 – Suspension and Debarment Auditor Description of Condition and Effect: For three of the four vendors selected for testing, the County was unable to provide evidence that the vendors were not suspended, debarred, or otherwise excluded at the time they were engaged to provide goods...

Finding: 2024-007 – Suspension and Debarment Auditor Description of Condition and Effect: For three of the four vendors selected for testing, the County was unable to provide evidence that the vendors were not suspended, debarred, or otherwise excluded at the time they were engaged to provide goods or services. As a result of this condition, the County was exposed to an increased risk that disbursements of federal awards could be made to vendors or subrecipients suspended or debarred by the federal government. Auditor Recommendation: We recommend that the County review its written policies and procedures over federal awards with employees responsible for grant compliance to ensure that they are being followed consistently. Corrective Action: Vendors are reviewed based on specific criteria upon addition to the accounts payable system for the County. This review process includes review for suspension, debarment, and excluded parties. The County will review grant compliance requirements with employees responsible for federal awards and request retention of documents verifying compliance. Contact Person: Brian Dissette, County Administrator/Controller Estimated Completion Date: December 31, 2025

View Audit 360575

Finding 568845 (2024-005)

Significant Deficiency 2024

County of Berrien

MI

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding: 2024-005 – Reporting Auditor Description of Condition and Effect: The County has not performed all of the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting. Specifically, the Project and Expenditure report for the second quarter of 2024 was not filed. However...

Finding: 2024-005 – Reporting Auditor Description of Condition and Effect: The County has not performed all of the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting. Specifically, the Project and Expenditure report for the second quarter of 2024 was not filed. However, these reports were filed for the first, third and fourth quarters of 2024. As a result of this condition, the County did not comply completely with the reporting requirements of the Coronavirus State and Local Fiscal Recovery Funds grant. Auditor Recommendation: We recommend that the County review the reporting requirements for each grant and complete all reporting as required under the terms of the grant agreement. Corrective Action: Management acknowledges the oversight regarding the 2nd quarter reporting and agrees with the condition as noted. The County will provide a reminder to all grant administrators of the policy. An additional confirmation step is under consideration for verification of completion, at the discretion of County Administration, which would require notification to Financial Services personnel that filing activities have occurred. This oversight process change would require additional resources to complete. Contact Person: Brian Dissette, County Administrator/Controller Estimated Completion Date: December 31, 2025

View Audit 360575

Finding 568841 (2024-003)

Material Weakness 2024

Community Health & Social Services Center, Inc.

MI

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

CHASS management concurs with the audit findings and will put the following corrective action plan in place to mitigate this finding in the future: During the fiscal year, the organization submitted requests for reimbursement of federal grant funds before incurring allowable expenses under the terms...

CHASS management concurs with the audit findings and will put the following corrective action plan in place to mitigate this finding in the future: During the fiscal year, the organization submitted requests for reimbursement of federal grant funds before incurring allowable expenses under the terms of the grant agreement. Moving forward, the new CFO will implement and enforce policies and procedures to ensure that all federal fund requests are supported by documented and allowable expenditures. Staff responsible for grant management will receive training to ensure the organization maintains compliance with all federal funding. All reimbursement requests should be reviewed and approved by the program manager/COO and the new CFO.

View Audit 360573

Finding 568831 (2024-003)

Material Weakness 2024

Rolette Community Care Center

ND

Questioned Costs Material Weakness Reporting § 200.303

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Applicable Federal Award Number and Year - Period 6 TIN #205330283 Reporting Material Weakness in Internal Control Over Complia...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Applicable Federal Award Number and Year - Period 6 TIN #205330283 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: Rolette Community Care Center does not have an internal control system to ensure the amounts reported in the HHS Period 6 Special Report agreed to supporting documentation for each of the quarters included. In addition, there was no evidence of review of either the supporting documentation or the HHS Period 6 Special Report by someone other than the preparer. Responsible Individuals: Kathy Morrow, Business Office Manager Corrective Action Plan: Management will ensure that the information contained in the reports agrees to the supporting documentation and both documentation and the reports submitted are reviewed by someone other than the preparer. Anticipated Completion Date: December 31, 2025

View Audit 360565

Finding 568820 (2024-001)

Material Weakness 2024

Greater Erie Community Action Committee

PA

Questioned Costs Reporting Internal Control / Segregation of Duties

Corrective Action Plan: GECAC Finance Department has a Financial and Data Processing System that is followed in regards to posting transactions. GECAC’s Finance department has been challenged due to a shortage of staff since COVID in 2020. As a result, GECAC has experienced a tremendous amount of ...

Corrective Action Plan: GECAC Finance Department has a Financial and Data Processing System that is followed in regards to posting transactions. GECAC’s Finance department has been challenged due to a shortage of staff since COVID in 2020. As a result, GECAC has experienced a tremendous amount of turnover making it extremely difficult to stay on task with all duties. Controls have been implemented to ensure timely record keeping of all fiscal transactions: The Finance department is now fully staffed. When reconciling monthly bank statements, any transactions that are listed as an outstanding item will be researched and the necessary entries will be done to fix the problem so that the item is reconciled before the next month’s statement is issued. When running the monthly balance sheet and revenue/expense statement, any transactions that are incorrect and/or not posted, staff will make the adjusting entry(s) to correct the issue immediately. We currently have a full time Payroll/Fiscal Assistant in place. That staff has implemented a check list to ensure that all payroll transactions are recorded during the correct period. We are currently looking into upgrading our Payroll/HR software system to ensure more efficient processes which will help with time management. We will continue to evaluate and improve the financial processes and procedures as well as work on enhancing and streamlining training for new and existing accounting personnel. Contact Person: Antoinette Nicholson, Vice President of Finance Anticipated Completion Date: September 30, 2025

View Audit 360550

Finding 568798 (2024-001)

None 2024

Channahon School District No. 17

IL

Questioned Costs Reporting

The District will implement a process to track the submission time of the data collection form and audit package.

View Audit 360513

Finding 568514 (2024-003)

Significant Deficiency 2024

Bmc Health System, Inc.

MA

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

Audit Report Reference: 2024-003 Program name: Research and Development Completion Date: September 30, 2025 Finding 2024-003 is a repeat finding (2023-001) from fiscal year end September 30, 2023. The Health System implemented change controls and audit of employee permissions per the corrective act...

Audit Report Reference: 2024-003 Program name: Research and Development Completion Date: September 30, 2025 Finding 2024-003 is a repeat finding (2023-001) from fiscal year end September 30, 2023. The Health System implemented change controls and audit of employee permissions per the corrective action plan for 2023-001.The corrective actions for repeat finding 2024-003 addresses documentation of performed controls and training for employees involved in the control activities. Workday Change Review: The HRIS team will continue with a change review audit as they have done in the previous year with a few enhancements to increase auditability. The Sr. HRIS Manager will send official communication to the HRIS team to initiate the end-of-year change review. This email will provide a clear timeline for the audit period with a hard deadline. Once complete, the HR Compliance Manager and/or the Sr. HRIS Manager will issue a written communication to document the completion of the review summary of findings (if any), and corrective actions taken (if applicable). This will remedy the issue of missing approval documentation. The team will also be reeducated around the need to document written approval and testing for changes throughout the year. Workday Security Review: The HRIS team will continue to conduct an audit of security roles and users within Workday to ensure that permissions are updated appropriately. The HRIS Analyst will generate reports for the Sr. HRIS Manager's review, identifying any required changes. The analyst will then make these updates in Workday, followed by a new report for verification. Upon successful verification, the Sr. HRIS Manager will send a formal written communication of the approved changes. Workday Terminations: To address the access provisioning deficiency as it relates to terminating employees, the management team will be re-trained in the importance of adhering to timely terminations of employees in Workday. Person Responsible: Ashley Cesarano - HR Compliance and Workplace Accommodations Manager; Karen Alvarado – Senior Manager HRIS E-mail address: Ashley.Cesarano@bmc.org; Karen.Alvarado@bmc.org

View Audit 360505

Finding 568228 (2024-001)

None 2024

Research Triangle Institute

NC

Questioned Costs Subrecipient Monitoring Reporting

Audit Finding: Item 2024-001: Error in Federal Funding Accountability and Transparency Act (FFATA) Reporting Contact Person Responsible for Corrective Action Plan: Justin Johnson, Director, Government Compliance and Internal Controls Email: jbjohnson@rti.org Phone Number: 919-541-6127 Corrective Act...

Audit Finding: Item 2024-001: Error in Federal Funding Accountability and Transparency Act (FFATA) Reporting Contact Person Responsible for Corrective Action Plan: Justin Johnson, Director, Government Compliance and Internal Controls Email: jbjohnson@rti.org Phone Number: 919-541-6127 Corrective Action Plan: Summary of Finding: FFATA requires non-federal entities to report each first-tier subaward action that obligates $30,000 or more to the FFATA Subaward Reporting System (FSRS). Our independent auditor found that a sampled subaward transaction was not reported timely to the FSRS. Corrective Action Implementation: RTI’s Government Compliance and Internal Controls department has taken the following actions to ensure the complete, accurate, and timely FFATA subaward reporting to FSRS: 1. On the automatically generated report of subaward actions to be reported to FSRS, correct the defective date parameters that prevented the subaward action from being reported timely. Completion Date: April 21, 2025. 2. On a semi-annual basis (fiscal year midpoint and fiscal year-end), manually generate the report of subaward actions to be reported to FSRS for the preceding six-month period and perform a secondary check for any actions that have not been reported timely. Completion Date: April 1, 2025.

View Audit 360502

Finding 568219 (2024-001)

Significant Deficiency 2024

Oxnard Pathway to Educated Nutrition INC

CA

Questioned Costs

Oxnard Pathway to Educated Nutrition, Inc. respectfully submits the following corrective action plan for the fiscal year ending September 30, 2024. Findings: 2024-001 CACFP-Administrative Budget Exceeded our approved budget in the Communications Category. Although a budget increase (revision) was re...

Oxnard Pathway to Educated Nutrition, Inc. respectfully submits the following corrective action plan for the fiscal year ending September 30, 2024. Findings: 2024-001 CACFP-Administrative Budget Exceeded our approved budget in the Communications Category. Although a budget increase (revision) was requested and approved for the above budget category, the amount of the increase was not sufficient to cover the total administrative costs at year’s ending. Note: Our agency did not exceed our total FY 23-24 Budget.As reflected on the UFAP DCH07, a total of $19,190.80 in unused funds were returned to CDSS in December 2024 Action Taken: Our organization will now track our administrative expenses monthly instead of quarterly. This will ensure there is enough time to request Specific Prior Written Approva/ timely budget revision, to any categories that may need to be increased or adjusted. If there are any questions regarding this plan, please call Angelita Barron at (805) 642-2720.

View Audit 360493 Questioned Costs: $1

Finding 568218 (2024-003)

Significant Deficiency 2024

Northwest Indian Fisheries Commission

WA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303 § 200.329

Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and...

Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and approved by the NWIFC Grants Program Manager and submitted to PSFMC. Effective immediately, the NWIFC grants program manager will increase internal controls by including documentation of internal review and approval prior to progress reports being submitted to PSMFC. Anticipated completion date: July 2025.

View Audit 360492

Finding 568217 (2024-002)

Material Weakness 2024

Northwest Indian Fisheries Commission

WA

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320 § 200.326

Person(s) responsible for corrective action: Lucy Yanez, Contract Specialist, Tracy Johnson, Accounts Payable, Tina Hurtado Controller, NWIFC staff and supervisors engaged in procurement and contracting. Management’s Response/Corrective Action Plan: The NWIFC implemented corrective measures relat...

Person(s) responsible for corrective action: Lucy Yanez, Contract Specialist, Tracy Johnson, Accounts Payable, Tina Hurtado Controller, NWIFC staff and supervisors engaged in procurement and contracting. Management’s Response/Corrective Action Plan: The NWIFC implemented corrective measures related to procurement in March of 2024. See FY23 Corrective Action Plan. However, the one procurement sample that was cited as not including “documentation of bidding, alternative price quotes or sole source documentation” contained a sole source justification that was developed before implementation of the FY23 Corrective Action Plan. The sole source justification was based on the specialized knowledge and specific expertise. Procurement samples for purchases or contracts after the implementation of the FY23 Corrective Action Plan, show compliance of adequate bidding, price quotes or sole source documentation consistent with 2 CFR 200. The NWIFC will continue to implement the FY23 Corrective Action Plan, by requiring NWIFC managers and their staff to be responsible for soliciting bids or developing sole source justifications for procurements and contracts consistent with 2 CFR 200. The Contract Specialist will ensure that bid solicitations and sole source justifications are properly documented and filed with each contract. Similarly, the audit noted that certain suspension and debarment samples selected, before the FY23 Corrective Action Plan was implemented in March 2024, lacked documentation of a suspension and debarment review prior to doing business with vendors. In response, the FY23 Corrective Action Plan, put into effect in March 2024, included measures to ensure that both new vendor and annual reviews are documented. The Accounts Payable department will continue to conduct suspension and debarment reviews for all new vendors before conducting business and perform annual reviews of all vendors, in line with the FY23 Corrective Action Plan. Anticipated completion date: Completed March 2024.

View Audit 360492 Questioned Costs: $1

Finding 568216 (2024-001)

Significant Deficiency 2024

Tallassee City Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent ...

Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior the submission of the July-September 2025 claim.

View Audit 360487 Questioned Costs: $1

Finding 568215 (2024-002)

Significant Deficiency 2024

Survivors of Torture, International

CA

Questioned Costs Cash Management Significant Deficiency § 200.303

Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written ...

Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written policy and implement a documented process for the preparation and review of federal drawdowns, including clear evidence of review such as signoffs or electronic approvals. Responsible Individual: Andres Chavarro, Finance Manager Planned Completion date: 07/01/2025

View Audit 360483

Finding 568153 (2024-004)

Significant Deficiency 2024

The Salvation Army Northwest Division

WA

Internal Control / Segregation of Duties Questioned Costs Reporting

The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of re...

The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of reports will be added to the TSAMM during the review and approval of new contracts. We will also work with our funders to extend reporting due dates. Anticipated Completion Date: 12/31/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director

View Audit 360458

Finding 568135 (2024-003)

Significant Deficiency 2024

The Salvation Army Northwest Division

WA

Equipment & Real Property Management Internal Control / Segregation of Duties Special Tests & Provisions

The Division will ensure evidence of review is maintained for the inventory worksheets. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25. Responsible Contact Person: Julie Luft, NW Social Services Director

View Audit 360458

Corrective Action Plans

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