Corrective Action Plans

Finding 523546 (2023-002)

Significant Deficiency 2023

PA

Questioned Costs Cash Management HUD Housing Programs

U.S. Department of Housing and Urban Development Housing Trust Fund Program – Assistance Listing No. 14.275 Recommendation: CLA recommended that PHFA review their procedures around administrative expenses charged to the HTF program. Explanation of disagreement with audit finding: There is no disa...

U.S. Department of Housing and Urban Development Housing Trust Fund Program – Assistance Listing No. 14.275 Recommendation: CLA recommended that PHFA review their procedures around administrative expenses charged to the HTF program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHFA will implement electronic time tracking, this will replace the current manual process of preparing timesheets that are entered into a database used to accumulate administrative expenses charged to federal programs. PHFA is currently in the process of implementing a Human Capital Management system that will allow employees to track the time they work on federal programs. Name of the contact person responsible for corrective action: Adrianne Trumpy, Director of Accounting Planned completion date for corrective action plan: July 1, 2024

View Audit 342838 Questioned Costs: $1

Finding 523400 (2023-002)

Significant Deficiency 2023

Houston Recovery Center, Lgc

TX

Cash Management Reporting Significant Deficiency

Finding #2023-002 – Significant Deficiency. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93...

Finding #2023-002 – Significant Deficiency. Major federal programs: U. S. Department of Treasury, Assistance Listing #21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds, Passed through Harris County, Texas, Contract #220163, Contract year: 12/01/22 – 12/31/24, Assistance Listing #93.788, Opioid STR, Passed through the Texas Health and Human Services Commission, Contract #HHS000357900001, Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23, Passed through the University of Texas Health Science Center, San Antonio, Contract #HHS000561800001, Contract year: 09/01/21 – 08/31/22. Other federal programs: U. S. Department of Health and Human Services:, Assistance Listing #93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance, Contract #5H79TI080624-03, Contract year: 09/30/21 – 09/29/22, Contract #5H79TI080624-04, Contract year: 09/30/22 – 09/29/23, Passed through the City of Houston Health Department, Assistance Listing #93.243, Contract #H79SP080300, Contract years: 11/01/21 – 10/31/22, 11/01/22 – 10/31/23 and 06/08/21 – 06/30/23, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Passed through the Texas Health and Human Services Commission, Contract #HHS000130500019. Contract years: 09/01/21 – 08/31/22 and 09/01/22 – 08/31/23. Condition and context: Houston Recovery Center is required to submit monthly reimbursement requests for five of its federal programs; one program requires reimbursement requests based on achievement of certain milestones rather than time. Out of a sample of 17 requests for the five reimbursement programs, we found six did not have evidence of review and approval as required by Houston Recovery Center’s policies and procedures. Recommendation: Training should be provided to ensure that policies and procedures regarding independent review and approval are followed. Planned corrective action: Houston Recovery Center will strengthen its internal control policies and procedures over independent review and approval of grant payment requests by shifting the primary review and approval process from the Chief Executive Officer (CEO) to the Chief Operating Officer (COO). The COO has full knowledge of allowable costs and has more availability than the CEO, which will make it easier to ensure that our policies and procedures are followed on a consistent basis. The CEO will continue in this role as backup to the COO to ensure immediate access for needed approval. We believe we have a strong system in place used by our accounting department to ensure all expenses underlying the grant payment requests are reviewed, checked for accuracy, and properly approved which further supports the reimbursement policies and procedures. Responsible officer: Leonard Kincaid, Executive Director. Estimated completion date: November 1, 2023.

View Audit 342673

Finding 523340 (2023-002)

Significant Deficiency 2023

Choice in Aging

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the ...

This condition existed due to multiple payroll systems used during the last two audit periods and untrained personnel. Current staff is fully trained on a new payroll system and capable of maintaining our newly developed processes and controls. Anicipated completion date is at the completion of the 2024 audit. Responsible contact person is Caitlin Cole, Human Resources manager.

View Audit 342622

Finding 523264 (2023-001)

Significant Deficiency 2023

Hospital Comunitario Buen Samaritano, Inc.

PR

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.512

We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 30 days after the end of ...

We agree that we have not been reporting on a timely basis current findings and results. We have established a schedule to ensure that the submission of all required annual reports is strictly adhered to. To this end, we aim to complete the year-end closing within the first 30 days after the end of the calendar year, in order to complete the audit within the first 120 days after the end of the calendar year. This plan was implemented in December 2024. However, because the report for the single audit for December 2023 was already past due by the time of implementation, the positive effects of this plan will be reflected in future reporting periods.

View Audit 342521

Finding 523150 (2023-002)

Significant Deficiency 2023

Southern Maryland Tri-County Community Action Committee, Inc.

MD

Reporting Significant Deficiency

Finding Reference: 2023-002 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. Management has implemented procedures to enhance fiscal efforts in reconciling its grants receivable accounts before preparing the SEFA. The ...

Finding Reference: 2023-002 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. Management has implemented procedures to enhance fiscal efforts in reconciling its grants receivable accounts before preparing the SEFA. The agency reevaluated the fiscal department’s needs and hired new staff, including a finance director, account payables, and part-time fiscal support specialist, and contracted with a CPA to assist with the following scope of work:  Close out accounts receivable and payable.  Account for any grants received during the fiscal year.  Monitor budget-to-actual program expenditures throughout the grant year.  Reconcile grants receivable balances to the general ledger. Name of the contact person responsible for corrective action: Michael Young, President, (301) 274-4474. Corrective action completed as of : December 31, 2023. Auditor’s Note: The stated completion date for the corrective action plan is based on the Agency's representation. The implementation of these corrective actions has not been audited by the auditors and will be subject to review during the next audit period.

View Audit 342468

Finding 523139 (2023-005)

Significant Deficiency 2023

Central Minnesota Jobs and Training Services

MN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the allocation of individual employees' time. This policy should ensure that all r...

MFIP and TANF Youth – Assistance Listing No. 93.558 Recommendation: The Organization should implement a comprehensive documentation retention policy that includes specific procedures for maintaining records supporting the allocation of individual employees' time. This policy should ensure that all relevant documentation, such as timesheets and work allocation records, is retained for the required period and is easily accessible for audit purposes. Additionally, staff responsible for timekeeping and financial recordkeeping should receive training on the importance of documentation retention and the specific requirements under the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To establish a standardized cost allocation methodology for staff time, CMJTS implemented in-person monthly allocation meetings with the executive team and program managers responsible for programming, staffing, and budget oversight. These meetings provide a thorough review of program expenditures and staff time, ensuring accurate alignment with funding requirements. Conducting payroll allocation reviews in a group setting allows the executive team to validate cost assignments, address changes in percentage allocations across cost categories, and maintain compliance with administrative regulations and funding guidelines. Name(s) of the contact person(s) responsible for corrective action: Jake Humphrey Planned completion date for corrective action plan: Implemented

View Audit 342459

Finding 522901 (2023-004)

Significant Deficiency 2023

Clarkson University

NY

Questioned Costs Cash Management Internal Control / Segregation of Duties § 200.303

Management accepts this finding and notes that the University’s policy regarding drawdowns was updated in August 2023 to clarify our procedures to include a secondary review by someone other than the preparer of the drawdown request. “Awards from federal agencies are not paid in full or in advance a...

Management accepts this finding and notes that the University’s policy regarding drawdowns was updated in August 2023 to clarify our procedures to include a secondary review by someone other than the preparer of the drawdown request. “Awards from federal agencies are not paid in full or in advance at the time they are awarded to the University. Instead, the University is required to draw funds down from the federal agencies payment systems periodically to reimburse the University for its expenses on all of our federal grants. The Research Accountant accesses the federal payment systems periodically to prepare cash drawdowns for reimbursement of expenditures on federal grants at the University. The Research Accountant receives a report on all sponsored projects. That list of grants can be used to run an expense detail report for the period of time that the reimbursement request is covering on a monthly schedule throughout the year. That list of grants can also be used to check that our records are up to date and accurate as far as award amounts and budgets are concerned. The payment request amount is calculated as the difference between the Cumulative Expenses as of the end date of the month you are doing the drawdown for and the Cumulative Expenses as of the last day of the period the last drawdown was requested. This calculation is done on each active award and the sum of all of the calculated payment requests is the total amount of the drawdown to be requested. The payment calculations are reviewed and approved by either the Sr. Research Accountant, Associate Controller or Controller. In the event the Sr. Research Accountant prepares the drawdown, the Associate Controller or the Controller must review and approve prior to submission. After receiving approval, whoever initiated the drawdown will submit and certify the drawdown. In no circumstance, shall the preparer submit and certify without first obtaining approval from the Associate Controller or Controller.” It has also been the practice in the Controller’s Office that drawdowns are posted to the General Ledger by the AR Specialist/Cashier as they appear in the M&T bank account which the bank reconciliation process is then separate from and performed by someone other than the person preparing the drawdown. The Controller’s Office also documented Drawdown Procedures in order to clarify the process. In July 2023, the Controller’s Office added an additional Research Accountant bringing the staff from one to two employees to better share and segregate job duties.

View Audit 342222 Questioned Costs: $1

Finding 522899 (2023-002)

Significant Deficiency 2023

Clarkson University

NY

Matching / Level of Effort / Earmarking Student Financial Aid Significant Deficiency § 200.303

Management accepts this finding and notes that loan disbursement notifications are automatically sent to students (we mail notifications to parents and have copies of those saved). There was a glitch in the system that was discovered while going through the audit that occurred on 2 dates in 2023 (Ma...

Management accepts this finding and notes that loan disbursement notifications are automatically sent to students (we mail notifications to parents and have copies of those saved). There was a glitch in the system that was discovered while going through the audit that occurred on 2 dates in 2023 (May 31, 2023 and September 3, 2023) which has since been fixed. Financial Aid worked with the Office of Information Technology to develop a daily report that will notify the Director of Financial Aid of anyone that did not receive a notification.

View Audit 342222

Finding 522826 (2023-001)

Significant Deficiency 2023

Clarkson University

NY

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

The University has taken several steps to address the continuing concerns raised in this audit. With regard to journal entry review and posting processes, effective July 1, 2023 all manual journal entries are processed through a PeopleSoft workflow that requires secondary approval by either the Cont...

The University has taken several steps to address the continuing concerns raised in this audit. With regard to journal entry review and posting processes, effective July 1, 2023 all manual journal entries are processed through a PeopleSoft workflow that requires secondary approval by either the Controller or one of the two Associate Controllers prior to posting to the general ledger system. Without this approval action, a manual journal entry will not post to the general ledger. The listing of open manual journal entries is maintained within the PeopleSoft workflow tool for the three authorized reviewers. In January 2023, the University purchased the FloQast workflow management system in an effort to address internal control concerns identified in the prior year audit. This product is specifically designed to manage financial account reconciliation, variance analysis and closing processes. FloQast receives a daily file import of the PeopleSoft trial balance for all general ledger accounts. Reconciliation of each general ledger account is assigned to a University staff member for either monthly or quarterly review. Reconciliations occur within the FloQast system with secondary staff approvals as needed for key general ledger accounts. FloQast will provide user alerts to any reconciled account becoming out of balance due to adjusting entries. Further, as historical balances are added to the FloQast system, variance analysis reports will be generated down to the individual account level. Finally, monthly, quarterly and annual closeout procedures are being built into the FloQast workflow process to allow for timely identification and status tracking of each process, by both the process owner and the final approver. While accounting processes exist in an internal process memo utilized by the Controller’s Office staff, a formalized process and procedures manual is being developed and will be maintained on a publically facing page of the University intranet to allow all campus users access for reference. As of July 18, 2023, the University added two new positions; Internal Auditor, reporting directly to the Vice President of Financial Affairs and the Audit Committee Chair, and Project Accounting Analyst, reporting to the Controller. While the Internal Auditor will have broad ranging oversight to University systems, it is expected that further University-wide policies and procedures will be developed as a result of these reviews, including those directly impacting financial operations and controls. The purpose of the Project Accounting Analyst position is to review and monitor net asset balances at the project level. A key component of the position involves meeting with campus account managers in conjunction with the Budget Office staff on a quarterly basis to review current activity, address questions related to transactional activity and promote prompt and timely close out of projects. In conjunction with this work, stale projects are being reviewed for potential closeout or ability to utilize available funding sources for current operations. All of these activities are designed to maintain better insight and control over net asset balances. This position is also tasked with developing policies and procedures around the creation and management of project accounts. Over the past year, Management has utilized the resources of the National Association of College and University Business Officers (NACUBO) for consulting, training and advising purposes. Management will continue to utilize this resource and other available resources to further enhance knowledge and develop best practices. Management has committed to contracting with an outside accounting firm to provide further training, support and best practice guidance to the accounting staff. Further, an effort is underway to fill current vacancies within the Controller’s Office with individuals trained to a higher level of accounting knowledge, as well as knowledge specific to the higher education and not for profit fund accounting sector. Through the current audit cycle, a series of reports and procedures have been developed to aid in a more timely and accurate preparation of financial statements.

View Audit 342222

Finding 522723 (2023-003)

Significant Deficiency 2023

Hilltown Community Health Centers, Inc.

MA

Reporting Significant Deficiency

2023-003-The audit and reporting package were not submitted by the due date September 30, 2024. As per the Code of Federal Regulations, Section 200.512-Report Submission, the audit must be completed and the data collection formant reporting package must be submitted within the earlier of 30 calendar...

2023-003-The audit and reporting package were not submitted by the due date September 30, 2024. As per the Code of Federal Regulations, Section 200.512-Report Submission, the audit must be completed and the data collection formant reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors’report, or nine months after the end of the audit period. The due date for the submission was

View Audit 342116

Finding 522715 (2023-002)

Significant Deficiency 2023

Hilltown Community Health Centers, Inc.

MA

Reporting Significant Deficiency

2023-002-The financial close process including the grant schedule was not completed within the standard period. To fill vacant positions with experienced staff and training on EMR system

View Audit 342116

Finding 522699 (2023-002)

Significant Deficiency 2023

Unity Medical Center INC

TN

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.512

Section 200.507 of the Uniform Guidance states that the single audit shall be completed, and reporting submitted within the earlier of 30 calendar days after receipt of the auditors' report, or nine months after the end of the fiscal year unless a longer period is specified. Going forward, we will c...

Section 200.507 of the Uniform Guidance states that the single audit shall be completed, and reporting submitted within the earlier of 30 calendar days after receipt of the auditors' report, or nine months after the end of the fiscal year unless a longer period is specified. Going forward, we will complete our audits and submit the required reports by the deadlines.

View Audit 342055

Finding 522690 (2023-001)

Significant Deficiency 2023

Yeshiva Tzoin Yosef Pupa, Inc. and Affiliates

NY

Internal Control / Segregation of Duties Reporting School Nutrition Programs

Recommendation: The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit fi...

Recommendation: The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight. Anticipated Completion Date: 06/30/2025. Actions Taken: The Organization has begun implementing the above-mentioned recommendations. The Organization will ensure that it has a working compliance calendar to assist in meeting the reporting deadline. Additionally, the Organization has engaged the audit firm for their upcoming fiscal year-end, and the audit firm has put it on its calendar to begin the audit process well in advance. The Organization’s board of directors has agreed to oversee the auditing and reporting processes to a greater extent. With these actions, the Organization expects to comply with the Uniform Guidance for single audits deadline for the fiscal year end 09/30/2024. Mr. Joseph Gombo, executive director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-371-1220. Contact Person Responsible for Corrective Action: Joseph Gombo, Executive Director

View Audit 342034

Finding 522499 (2023-004)

Significant Deficiency 2023

The Behavioral Wellness Center at Girard

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Significant Deficiency

Corrective Action: Management agrees with the findings. While we have policies and procedures as recommended by the auditors, there is an opportunity to review our policies and procedures related to the review and approval around disbursements. Through the leadership of our Chief Financial Office...

Corrective Action: Management agrees with the findings. While we have policies and procedures as recommended by the auditors, there is an opportunity to review our policies and procedures related to the review and approval around disbursements. Through the leadership of our Chief Financial Officer and our Director of Finance, our internal control policies and procedures will be evaluated and as needed, amended, with an effective date no later than June 30, 2025. Anticipated Completion Date: June 30, 2025 Contact Person: Marco Giordano, Vice President and Chief Financial Officer

View Audit 341753

Finding 522498 (2023-003)

Significant Deficiency 2023

The Behavioral Wellness Center at Girard

PA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Corrective Action: Management agrees with the finding and has subsequently supported other eligible expenses that were not included in the original submission. These amounts exceeded the funding received. Anticipated Completion Date: November 15, 2024 Contact Person: Marco Giordano, Vice President ...

Corrective Action: Management agrees with the finding and has subsequently supported other eligible expenses that were not included in the original submission. These amounts exceeded the funding received. Anticipated Completion Date: November 15, 2024 Contact Person: Marco Giordano, Vice President and Chief Financial Officer

View Audit 341753

Finding 522395 (2023-005)

Significant Deficiency 2023

Rome Housing Authority

NY

HUD Housing Programs Cash Management Significant Deficiency § 200.05

2023-005 Drawing of Capital Funds RHA is committed to ensuring that all capital fund expenditures are processed and distributed within a maximum of three days. By doing this we will stay in compliance with HUD regulations. Name of Responsible Person: Tami Lucia Executive Director Implementation d...

2023-005 Drawing of Capital Funds RHA is committed to ensuring that all capital fund expenditures are processed and distributed within a maximum of three days. By doing this we will stay in compliance with HUD regulations. Name of Responsible Person: Tami Lucia Executive Director Implementation date: October 2024

View Audit 341664

Finding 522394 (2023-004)

Significant Deficiency 2023

Rome Housing Authority

NY

HUD Housing Programs Reporting Significant Deficiency

he Executive Director has implemented procedures for the procurement of an auditor to ensure the Financia Data Schedule is filed within nine months after the conclusion of the fiscal year. Name of Responsible Person: Tami Lucia, Executive Director Implementation date: April 2024

View Audit 341664

Finding 522393 (2023-003)

Significant Deficiency 2023

Rome Housing Authority

NY

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

2023-003 Selection of the Waiting List RHA has put in place comprehensive new procedures and controls for all the staff members, including Clerks, Housing Assistants, Housing Coordinators and Project Managers, concerning the management of the waiting list process. As of September 2024m a new waitin...

2023-003 Selection of the Waiting List RHA has put in place comprehensive new procedures and controls for all the staff members, including Clerks, Housing Assistants, Housing Coordinators and Project Managers, concerning the management of the waiting list process. As of September 2024m a new waiting list will be generating following each new move-in, and the previous waiting list will be appropriately filed and preserved. Name of Responsible Person: Entire Admin Staff Implementation Date: September 2024

View Audit 341664

Finding 522350 (2023-001)

Significant Deficiency 2023

Rabble Mill

NE

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.512

Rabble Mill has implemented an updated process for invoice approvals using a new bill pay software which includes an integrated internal approval feature. This feature ensures that all items and services purchased via invoice are approved by two individuals, one of whom is a Co-Executive Director, a...

Rabble Mill has implemented an updated process for invoice approvals using a new bill pay software which includes an integrated internal approval feature. This feature ensures that all items and services purchased via invoice are approved by two individuals, one of whom is a Co-Executive Director, and neither of whom is the purchaser, prior to payment. The new system addresses the breakdown in internal controls over allowable costs by facilitating clear and documented approval of purchases.

View Audit 341607

Finding 521096 (2023-009)

Significant Deficiency 2023

City of Medford

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance was not verified for two covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also u...

Condition: Suspension and debarment compliance was not verified for two covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director

View Audit 341024

Finding 521085 (2023-007)

Significant Deficiency 2023

City of Medford

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance was not verified for five covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also ...

Condition: Suspension and debarment compliance was not verified for five covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director

View Audit 341024

Finding 521048 (2023-001)

Significant Deficiency 2023

Meadows Mental Health Policy Institute for Texas

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 20...

The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 2024, audit report are discussed below. Findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Awards Audit Significant Deficiency Federal Awards Program Audit Findings and Recommendations Finding 2023-001: Reporting – significant deficiency in internal control over compliance and compliance finding. All federal grants. Criteria: Grantees who are subject to single audit requirements are required to submit their Data Collection form to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditors’ report or 9 months after the audit period. Condition: The Institute’s Data Collection form was late for the years ended December 31, 2022, and 2023. Cause: Delays in completing the audits resulted in the Data Collection forms being submitted after 9 months from the end of the audit report. Effect: The Institute was not in compliance with single audit reporting requirements. Recommendation: Internal controls and processes should be implemented to ensure audits are completed in a timely manner to meet federal reporting deadlines. Institute Action Plan: • Hire new finance and accounting senior management [completed November 2024]. o Hired new CFO (October 2024; started January 02, 2025) o Hired new Controller (November 2024; starts February 17, 2025) Establish timeline for review and acceptance of 2024 audit [initiated December 2024]. o By May 01, 2025: Institute submits 2024 General Ledger and Trial Balance to auditor o May 01, 2025 – May 11, 2025: Auditor sends sample and other requests for information o May 12, 2025 – May 23, 2025: Audit fieldwork o Week of July 07, 2025: Auditor sends draft audit report to Institute management for review. o Week of July 21, 2025: Institute management reviews draft audit report and notes areas needing clarification and/or corrections. o By Week of August 11, 2025: Auditor provides a final revised audit report to Institute management. o Week of August 18, 2025: Institute management sends audit report to the Institute Board’s Audit and Finance Committee for review. o By week of September 1, 2025: The Audit and Finance Committee meets to review and accept final audit report on behalf of the Board. o By September 15, 2025: Data Collection Form is submitted to the Federal Audit Clearinghouse (i.e., well in advance of the September 30, 2025, submission due date for the Data Collection Form). o October 29, 2025: The Institute Board ratifies the Audit and Finance Committee’s acceptance of final audit report. • Q1-Q2 2025: Perform gap analysis evaluation of existing Accounting staff and address any gaps in coverage and provide access to and training on financial systems and historical data archives [initiated and ongoing]. Corrective Action Contact Person(s): Maryana Geller, Chief Financial and Administrative Officer Planned Completion Date for Corrective Action Plan: September 15, 2025

View Audit 340943

Finding 520695 (2023-001)

Significant Deficiency 2023

Fairfield University

CT

Student Financial Aid Special Tests & Provisions Reporting

Finding No. 2023-001 – Significant Deficiency and Noncompliance: Special Tests and Provisions – Enrollment Reporting Corrective Action The corrective action that will be taken is a graduates only enrollment report will be supplied to the National Student Clearinghouse (NSC) by the Registrar’s Offi...

Finding No. 2023-001 – Significant Deficiency and Noncompliance: Special Tests and Provisions – Enrollment Reporting Corrective Action The corrective action that will be taken is a graduates only enrollment report will be supplied to the National Student Clearinghouse (NSC) by the Registrar’s Office on a consistent schedule of submission within 60 days of each graduation period. Persons Responsible for Corrective Action The corrective action plan will be completed by Walter Rankin, Vice Provost for Graduate Continuing and Professional Studies and Danielle Quilligan, University Registrar. Completion Date Initial corrective action was completed by Lynn Kohrn, University Registrar and Allison Henderson, Assistant Registrar in October, 2023 with the submission of a graduates only enrollment report to the third-party service provider NSC. A schedule for consistent submissions of a graduates only enrollment report has already been provided to the NSC.

View Audit 340417

Finding 520548 (2023-002)

Significant Deficiency 2023

Ventures

WA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430

Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend the Organization utilize one spreadsheet for allocating payroll costs and implement additional controls to ensure the allocations to Federal grants accurately reflect the actual hours worked...

Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend the Organization utilize one spreadsheet for allocating payroll costs and implement additional controls to ensure the allocations to Federal grants accurately reflect the actual hours worked. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Ventures has stopped utilizing multiple allocation spreadsheets and will only use one spreadsheet. This single spreadsheet will be utilized for all payroll cost allocations and will be housed within the finance department under restricted access. The allocation of expenses to grants will be based on the FTE count per the payroll allocation spreadsheet. Changes to the allocations will be documented and shared with the Executive Director. Name(s) of the contact person(s) responsible for corrective action: Theo Everheart and Monique Valenzuela Planned completion date for corrective action plan: 07/31/2024

View Audit 340111 Questioned Costs: $1

Finding 520162 (2023-003)

Significant Deficiency 2023

Center for Religion and Diplomacy, Inc.

DC

Reporting Subrecipient Monitoring Significant Deficiency § 200.510

Management understands that all Federal programs (even as a sub-awardee) need to be part of the SEFA schedule. Going forward Financial Administrator will ensure to include all programs associated with Federal Award (direct or indirect) on the SEFA schedule. Carefully review all contracts to ensure t...

Management understands that all Federal programs (even as a sub-awardee) need to be part of the SEFA schedule. Going forward Financial Administrator will ensure to include all programs associated with Federal Award (direct or indirect) on the SEFA schedule. Carefully review all contracts to ensure that all contracts that are included, if any questions arise, a third-party consultant will be contacted. Anticipated Completion Date: June 30, 2024. Responsible Contact Party: Olga Batkhan, Financial Administrator.

View Audit 339747

Corrective Action Plans

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