Corrective Action Plans

Finding 565430 (2024-012)

Significant Deficiency 2024

MA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.303 § 200.403

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-012 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Agency review and enhance procedures and controls to ensure that costs charged to the program are allowable, approved, and accounted for properly...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-012 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: We recommend the Agency review and enhance procedures and controls to ensure that costs charged to the program are allowable, approved, and accounted for properly in the Commonwealth’s accounting system. Action taken in response to finding: During the review, supporting documentation for certain expenditure adjustments (EX) could not be located. Since then, the department has taken steps to strengthen internal controls and improve documentation practices. Under new management, enhanced oversight procedures have been implemented, requiring all expenditure adjustments to undergo review and approval by multiple levels of management and staff. To ensure transparency and audit readiness, all supporting documentation is now stored in a centralized and accessible SharePoint repository. Additionally, revised procedures are being integrated into the department's standard operating protocols to support ongoing monitoring. These updates are designed to ensure that all future adjustments are properly documented, allowable under applicable federal regulations, and readily available for review. Name(s) of the contact person(s) responsible for corrective action: Ken Luke Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565427 (2024-011)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Questioned Costs Material Weakness Reporting § 200.303

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

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

View Audit 359283

Finding 565424 (2024-010)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

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

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance has finalized a Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and efficiently. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565422 (2024-006)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Eligibility § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that RESEA program requirements are met. We further recommend...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that RESEA program requirements are met. We further recommend the Department develop a formal process to review quarterly performance reports for accuracy prior to submission. Action taken in response to finding: MDUA’s legacy system had a known issue with maintaining documents. In some instances, the legacy system did not keep a copy of correspondence. In May 2025, MDUA implemented a new, modernized UI administrative system known as EMT. During the integration process, memorializing documents the system generated was a priority. Now with a fully implemented system, all documents will be saved. In addition, the RESEA program has a required reporting standard administered through the federal SUN system. Although MDUA has an established process for completing this work, MDUA does not have an audit trail to show it was completed. Moving forward, MDUA will enhance this procedure to ensure MDUA has documentation to maintain compliance. Name(s) of the contact person(s) responsible for corrective action: John Saulnier, Director of Benefit Performance Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565420 (2024-005)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Significant Deficiency § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-005 Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that BAM case investigations are completed timely in...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-005 Unemployment Insurance, COVID-19 – Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that BAM case investigations are completed timely in accordance with the time limits established in the ET Handbook No. 395. Action taken in response to finding: Analysis showed that BAM Investigators spend a minimum of 20% of work hours devoted to clerical tasks necessary to develop an investigatory file. As part of MDUA’s modernized UI system, the new system features an electronic BAM casefile which should reduce clerical work 5% or below, and, in turn, allow additional time to investigate and complete case work. BAM has always relied on postal mail as a primary methodology to contact interested persons. By integrating the BAM casefile into the UI system, investigators can send questionnaires and notifications to interested persons through the system. In turn, interested persons may complete questionnaires and upload information into the system thereby reducing time between issuance of documents and response. Name(s) of the contact person(s) responsible for corrective action: Susan Saulnier, Director of UI Performs Planned completion date for corrective action plan: June 2026 This statistic is compiled for a year of data. Because BAM was not an on-line program, all cases prior to May 18, 2025 remain in the old format, and, therefore were not placed in the new system. As of May 19, 2025 and moving forward, all BAM cases will be held in the electronic case file. By June 2026, MDUA will have a year of data with improvements to BAM investigative methodology.

View Audit 359283

Finding 565414 (2024-007)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submi...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submitted to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance needs to update the Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and by establishing a more accurate subaward report. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565411 (2024-003)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program require...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program requirements. Action taken in response to finding: Starting July 2025, the Accounting Director (or Deputy Accounting Director when hired) will sign and date the reconciliation documentation (and retain) when reviews are performed. The standard operating procedures will be clarified that preparer and reviewer typing their names and date within the reconciliation documentation is an acceptable form of sign-off upon completion of the reconciliations and reviews. Name(s) of the contact person(s) responsible for corrective action: Keivon Spencer, Director of Accounting | DTA Finance Planned completion date for corrective action plan: June 30, 2025 and forward – Sign and date reconciliation reviews October 30, 2025 – Standard operating procedures

View Audit 359283

Finding 565381 (2024-002)

Significant Deficiency 2024

Municiapilty of Isabela

PR

Questioned Costs Reporting

Corrective Action: The Municipality will review the procedures to implement and correct the finding.

View Audit 359242

Finding 565378 (2024-002)

Significant Deficiency 2024

George J. and Hilda Meyer Foundation, Inc.

MO

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

U.S. Department of Agriculture 2024-002 Communities Facilities Loans & Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Foundation design controls to ensure that the calculation is completed in accordance with the loan agreement and funded in full prior to the end of each fisc...

U.S. Department of Agriculture 2024-002 Communities Facilities Loans & Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Foundation design controls to ensure that the calculation is completed in accordance with the loan agreement and funded in full prior to the end of each fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The USDA has waived this requirement in past years. The community obtained a waiver for the current period. Name(s) of the contact person(s) responsible for corrective action: Tiffany Goetz Planned completion date for corrective action plan: June 2, 2025

View Audit 359225

Finding 565375 (2024-001)

None 2024

Umass Memorial Health Care, Inc.

MA

Procurement, Suspension & Debarment Questioned Costs Subrecipient Monitoring § 200.318 § 200.324

2024-001 Procurement Cluster: Not applicable Grantor: Department of Health and Human Services (DHHS) Award Name: Congressionally Directed Spending Award Number: 6 CE1HS52894‐01‐04, 6 CE1HS52345‐01‐05 Award Year: FY2024 Assistance Listing Number: 93.493 Assistance Listing Title: Congressional Dire...

2024-001 Procurement Cluster: Not applicable Grantor: Department of Health and Human Services (DHHS) Award Name: Congressionally Directed Spending Award Number: 6 CE1HS52894‐01‐04, 6 CE1HS52345‐01‐05 Award Year: FY2024 Assistance Listing Number: 93.493 Assistance Listing Title: Congressional Directives Pass-through Entity: Not applicable In accordance with 2 CFR 200.318 the System must maintain procurement records of sufficient detail that include the rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. For two of two of the auditors’ selections sufficient documentation was not retained from the time of procurement during fiscal year 2023 to demonstrate sole source justification or the competitive bidding process for these samples. For one mammography technology asset, documentation of sole source vendor justification was not documented and retained by the System following Policy HA-50-42, Capital Equipment Requests. For the second selection, while competitive bids were obtained, management did not adequately retain documentation to support the vendor ultimately selected for the selected hardware component and the other bids obtained. Management has reviewed the Capital Equipment Request policy and the related capital request process and will reinforce the need to adhere to existing policies and the importance of retaining appropriate documentation during fiscal year 2025. Primary responsibility of implementing the Corrective Action Plan for this finding rests with Brian Huggins, Senior Vice President of Finance, Corporate Controller, (508) 334-0252.

View Audit 359222

Finding 565370 (2024-001)

Significant Deficiency 2024

Seattle Children's Hospital

WA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.320

FINDING 2024-001: The entity did not have a control in place to review cost transfers to federal awards to ensure the entity followed the appropriate procurement policies for these costs. Without adequate controls over cost transfers, there is an increased risk of non-compliance with procurement ...

FINDING 2024-001: The entity did not have a control in place to review cost transfers to federal awards to ensure the entity followed the appropriate procurement policies for these costs. Without adequate controls over cost transfers, there is an increased risk of non-compliance with procurement policies. Corrective Action Plan: Management will design and implement a control to review cost transfers from non-federal awards to federal awards to ensure we follow our procurement policies. This will be achieved by adding a new step to the non-payroll cost transfer form that requires the requestor to include a copy of the Procurement authorization form if the procurement policies apply. The Procurement authorization form documents the process, rationale, and justification for procurements. If the purchase being transferred did not go through the appropriate procurement procedures at the time of purchase, then the transfer from the non-federal award to the federal award will not be allowed. Management will also provide additional training around procurement and our related policies and ensure staff involved in this area are aware of the new step embedded in the non-payroll cost transfer form. Remediation Date: July 2025

View Audit 359210 Questioned Costs: $1

Finding 565360 (2024-001)

Significant Deficiency 2024

Path

WA

Subrecipient Monitoring Reporting Questioned Costs

Finding 2024-001 PATH’s Response and Corrective Action Plan PATH has an established process for completing FFATA reporting in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) in compliance with the requirements of the Federal Funding Accountability and Transp...

Finding 2024-001 PATH’s Response and Corrective Action Plan PATH has an established process for completing FFATA reporting in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) in compliance with the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109‐282) (FFATA) that are codified in Title 2 U.S. Code of Federal Regulations, Part 170 ‐ Reporting Subaward and Executive Compensation Information. Although PATH complied with all other FFATA reporting requirements, reports for two subawards were not filed by the end of the month following the month in which PATH awarded these sub‐grants greater than or equal to $30,000. For the FFATA filings that were submitted late, the cause was that an employee new to PATH that year who assumed FFATA reporting did not realize her entries were not saving in the system correctly. This issue was discovered as part of a routine management review of PATH’s FFATA reporting. When the issue was discovered, management repeated the training on the Office of Grants and Contract’s (OGC) business process for FFATA reporting with that staff member and assigned another member of the team to review entries in the last week of each month, preventing future late filings. In 2025, OGC Management will add the following actions to the FFATA reporting business process strengthen to ensure all filings are submitted in a timely manner. Action Responsible staff member Due date Repeat training on OGC’s business process for FFATA reporting with the two OGC staff members responsible for FFATA reporting for PATH OGC Management June 30, 2025 Provide monthly report to OGC management by the last day of each month confirming timely reporting OGC Staff responsible for FFATA reporting Throughout 2025

View Audit 359204

Finding 565357 (2024-001)

Material Weakness 2024

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

MN

Questioned Costs HUD Housing Programs Material Weakness

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

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

View Audit 359185

Finding 565356 (2024-001)

Significant Deficiency 2024

White Bear Lake Senior Housing, Inc. Dba: Willow Wood Apartments

MN

Questioned Costs HUD Housing Programs Significant Deficiency

Significant Deficiency in Internal Control over Compliance Recommendation: Recommend that a catchup payment is made as soon as possible to make the replacement reserve whole. Action taken in response to finding: A payment of $16,979 was deposited into the account as of March 31, 2025. Automatic paym...

Significant Deficiency in Internal Control over Compliance Recommendation: Recommend that a catchup payment is made as soon as possible to make the replacement reserve whole. Action taken in response to finding: A payment of $16,979 was deposited into the account as of March 31, 2025. Automatic payments were re-established to ensure no further issues due to lack of payment. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: March 31, 2025

View Audit 359184 Questioned Costs: $1

Finding 565343 (2024-002)

Material Weakness 2024

Housing Authority of the County of Dauphin

PA

Questioned Costs HUD Housing Programs Eligibility

Finding Number: 2024-002 Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all clients complete an annual family income reeaxaminat...

Finding Number: 2024-002 Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all clients complete an annual family income reeaxamination in accordance with Eligibility, Reporting and Housing Assistance Payment Requirements. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Kristen Runion, HCV Supervisor

View Audit 359165 Questioned Costs: $1

Finding 565340 (2024-001)

Material Weakness 2024

Housing Authority of the County of Dauphin

PA

Questioned Costs Special Tests & Provisions HUD Housing Programs

Finding Number: 2024-001 Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure the completion and accuracy of the inspection protocol. ...

Finding Number: 2024-001 Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure the completion and accuracy of the inspection protocol. The Housing Authority will continue to implement its 30-day review system for the HCV Inspection Program. Although the system cannot ensure 100% compliance, its effectiveness is demonstrated in the high percentage of compliance. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Kristen Runion, HCV Supervisor

View Audit 359165 Questioned Costs: $1

Finding 565339 (2024-003)

Significant Deficiency 2024

Cook County, Illinios

IL

Questioned Costs Reporting § 200.332

To prevent recurrence and ensure timeliness, the following corrective actions have been implemented as of May 29, 2025. Revised Internal Deadlines: Internal monthly reporting deadlines are now set ﬁve business days before the funder’s due date to allow for review and contingency time. Party(ies) re...

To prevent recurrence and ensure timeliness, the following corrective actions have been implemented as of May 29, 2025. Revised Internal Deadlines: Internal monthly reporting deadlines are now set ﬁve business days before the funder’s due date to allow for review and contingency time. Party(ies) responsible for overseeing the corrective action plan for the grant program: Wynetta L. Scales, Associate Director, Financial Planning & Analysis Juandalynn Johnson, Associate Director, Grants Management The Justice Advisory Council completed the above corrective action on May 29, 2025.

View Audit 359160

Finding 565337 (2024-001)

Significant Deficiency 2024

Cook County, Illinios

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.208 § 200.305

To address the identified non-compliance with timely subrecipient payments, the Cook County State’s Attorney Ofﬁce has implemented an internal invoice submission form designed to streamline and formalize the invoice processing workflow. This form is now utilized by all business managers and program ...

To address the identified non-compliance with timely subrecipient payments, the Cook County State’s Attorney Ofﬁce has implemented an internal invoice submission form designed to streamline and formalize the invoice processing workflow. This form is now utilized by all business managers and program managers, who have been trained and granted functional access to ensure consistent and accurate usage. Additionally, a dedicated SharePoint site has been established to manage and monitor the invoice submission process. This platform allows for real-time tracking of invoice numbers, amounts, vendor names, and payment statuses, thereby enhancing transparency and accountability. These measures collectively aim to strengthen internal controls, improve communication among parties involved, and ensure compliance with federal cash management requirements moving forward. Party(ies) responsible for overseeing the corrective action plan for the grant programs: - Nader Abusumayah, Chief Accountant, nader.abusumayah2@cookcountysao.org, 312.603.1840 The department plans on completing the above corrective action on 6/1/2025.

View Audit 359160

Finding 565324 (2024-001)

Significant Deficiency 2024

Bath Housing Development Corporation

ME

Questioned Costs Eligibility HUD Housing Programs

Finfing Number: 2024-001: Eligibility Planned Corrective Action: 1. All 2024 reexamination files will be reviewed to confirm a corresponding file is present and social security income is accruately reflected. File findings will be noted accordingly. 2. Moving forward, a Quality Control audit will ...

Finfing Number: 2024-001: Eligibility Planned Corrective Action: 1. All 2024 reexamination files will be reviewed to confirm a corresponding file is present and social security income is accruately reflected. File findings will be noted accordingly. 2. Moving forward, a Quality Control audit will occur monthly to include: - Confirmation of corresponding file for every annual reexamination completed. - 50% of all reexamination files will be audited to confirm the following: > Verification of income and assets. > Gross income is accurately reflected. > An EIV report is present; social security income reported is accurate. > A signed 50059 is present in the file. The audit will be conducted by a staff member that did not complete the reexam. Anticipated Completion Date: 1. July 31, 2025; 2. Ongoing Responsible Contact Person: Jessica Irish

View Audit 359147

Finding 565304 (2024-002)

Significant Deficiency 2024

Big Cities Health Coalition

MD

Allowable Costs / Cost Principles Questioned Costs § 200.430

Views of Responsible Officials: Our Federal funds from January 1 to July 31, 2024, were subcontracts with two partners, NACCHO and ASTHO. Each was a flat fee agreement where we were not required to maintain timesheets for contracted work. Where more work was needed than covered by a contract, BCHC u...

Views of Responsible Officials: Our Federal funds from January 1 to July 31, 2024, were subcontracts with two partners, NACCHO and ASTHO. Each was a flat fee agreement where we were not required to maintain timesheets for contracted work. Where more work was needed than covered by a contract, BCHC used other funds to cover salary. As of August 1, 2024, when we were in receipt of a direct Federal award, we did implement timesheets for effort tracking. While we do track hours work in accordance with what has been budgeted, we continue to supplement all projects (Federal and nonFederal) with additional funds. That said, we have revisited time tracking with our staff and anticipate enhanced accuracy of time capture. Further, from August to December we used a standardized 160 hours for monthly allocations as the denominator to determine payroll percentage per project. We have now started using actual hours per period for those pay periods that have more than 80 hours or months that have more than 160 hours. The implementation of a new allocation format is now in effect, and along with increased diligence on effort tracking across our team, we believe we will enhance accuracy.

View Audit 359141

Finding 565303 (2024-001)

Significant Deficiency 2024

Big Cities Health Coalition

MD

Questioned Costs Procurement, Suspension & Debarment § 200.317 § 200.320 § 200.327

Views of Responsible Officials: BCHC is in the process of composing a formal procurement policy, which will address requirements for open competition and establish thresholds for different procurement amounts/processes. The policy will clearly outline the conditions where a noncompetitive purchase i...

Views of Responsible Officials: BCHC is in the process of composing a formal procurement policy, which will address requirements for open competition and establish thresholds for different procurement amounts/processes. The policy will clearly outline the conditions where a noncompetitive purchase is allowable. We anticipate having this policy written by June 1 and will submit to the BCHC Board for review and approval. I

View Audit 359141 Questioned Costs: $1

Finding 565297 (2024-003)

None 2024

Nutrition Education Services, Inc.

LA

Questioned Costs Allowable Costs / Cost Principles

Recommendation: The Executive Director must ensure that any amended budgets for salaries are properly reflected in the accounting system before processing the payroll that includes the change. Copies of the payroll that is budgeted for administrative salaries should be provided for review and to ...

Recommendation: The Executive Director must ensure that any amended budgets for salaries are properly reflected in the accounting system before processing the payroll that includes the change. Copies of the payroll that is budgeted for administrative salaries should be provided for review and to ensure that the correct pay rate is used for computing payroll expenditures.

View Audit 359131 Questioned Costs: $1

Finding 565221 (2024-002)

Significant Deficiency 2024

Ouachita Multi-Purpose Community Action Program, Inc.

LA

Questioned Costs Subrecipient Monitoring Cash Management

Management will have the employee responsible for the review of the LIHEAP Agency Invoice Reports sign each weekly report as approved.

View Audit 359115

Finding 565207 (2024-002)

Significant Deficiency 2024

American Academy McAllister Institute of Funeral Service, Inc.

NY

Questioned Costs Special Tests & Provisions Student Financial Aid

Finding 2024-002 - Special Tests and Provisions - Federal Direct Loan Program Student Notification – Significant Deficiency Name of Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Award Identification Number an...

Finding 2024-002 - Special Tests and Provisions - Federal Direct Loan Program Student Notification – Significant Deficiency Name of Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Award Identification Number and Year: P268K243382 2024 Name of Pass-through Entity: N/A Planned Corrective Action: The failure to timely send out the required notification of Federal Direct Student Loan Program proceeds credited to one student’s account, as noted in the auditor’s findings, was an administrative oversight. In May 2025, the Institute reviewed and revised its current procedures to ensure that all required notifications are made. Under the revised procedures, an employee independent from the student loan proceed crediting notification process is to review that notifications are sent out within prescribed time frames in accordance with U.S. Department of Education regulations to all students receiving and being credited with Federal Direct Loan Program amounts and that copies of the notifications are maintained in each applicable student’s file.

View Audit 359094

Finding 565206 (2024-001)

Significant Deficiency 2024

American Academy McAllister Institute of Funeral Service, Inc.

NY

Student Financial Aid Questioned Costs Special Tests & Provisions

Finding 2024-001 – Special Tests and Provisions – Exit Counseling – Significant Deficiency Name of Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Award Identification Number and Year: P268K243382 2024 Name of ...

Finding 2024-001 – Special Tests and Provisions – Exit Counseling – Significant Deficiency Name of Federal Agency: U.S. Department of Education Federal Program Name: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Award Identification Number and Year: P268K243382 2024 Name of Pass-through Entity: N/A Planned Corrective Action: The failure to document the exit conference of one student borrower in the Federal Direct Loans Program, as noted in the auditor’s findings, was an administrative oversight. In May 2025, the Institute reviewed and revised its current procedures to ensure that all exit conferences are documented. Under the revised procedures, an employee independent from the exit conference process is to review that any student that has not enrolled in a new semester or that is enrolled at less than half time status has received proper exit conferencing and that the exit conferencing has been properly documented.

View Audit 359094

Corrective Action Plans

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