Corrective Action Plans

Finding 499522 (2024-003)

Significant Deficiency 2024

ND

Questioned Costs Special Tests & Provisions Significant Deficiency § 200.303

Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the...

Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program and there was no formal review of the balance in comparison to the required minimum reserve balance. Responsible Individual: Mandy Robinson, Administrator Corrective Action Plan: We will implement additional control processes to ensure a formal review over the reserve fund reconciliation and a formal review of the balance in comparison to the required minimum reserve balance is completed by staff separate from the preparer. Anticipated Completion Date: 12/31/2024

View Audit 322385

Finding 499462 (2024-008)

Material Weakness 2024

Outpatient Medical Center, Inc.

LA

Cash Management Questioned Costs Subrecipient Monitoring § 200.305

2024-008 Cash Management Corrective action planned: Federal draws will be made with approval of the Director of Financial Operations or their designee for expenditures that have been incurred and recorded in the general ledger. Electronic documentation will be organized by draw to ensure proper d...

2024-008 Cash Management Corrective action planned: Federal draws will be made with approval of the Director of Financial Operations or their designee for expenditures that have been incurred and recorded in the general ledger. Electronic documentation will be organized by draw to ensure proper documentation is maintained. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Cathy Liles, Director of Fiscal Operations

View Audit 322303 Questioned Costs: $1

Finding 499458 (2024-007)

Material Weakness 2024

Outpatient Medical Center, Inc.

LA

Questioned Costs Allowable Costs / Cost Principles Material Weakness

2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. ...

2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. Internal auditing has already been implemented to ensure compliance with reporting requirements. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Richard Bruce, Chief Operating Officer

View Audit 322303

Finding 497631 (2024-001)

Significant Deficiency 2024

Howard Payne University

TX

Questioned Costs Student Financial Aid Significant Deficiency

Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FA...

Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FAFSA after a term will be reviewed to determine how much Title IV aid they are eligible to have disbursed. The R2T4 calculation will be processed to learn the percentage earned. Exception to the R2T4 will be if student completed the module/term successfully. Person Responsible for Corrective Action Plan: Karen LaQuey, Director of Student Financial Aid Anticipated Date of Completion: Immediately

View Audit 320424 Questioned Costs: $1

Finding 497459 (2023-001)

Significant Deficiency 2024

Community Action for Improvement, Inc.

GA

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

2024-001 – Tri-Partite Board Composition Condition: At times during the year, less than 1/3 of the members of the board of directors of Community Action for Improvement, Inc. were representative of the low-income individuals and families served by the Organization. This is a repeat of prior year a...

2024-001 – Tri-Partite Board Composition Condition: At times during the year, less than 1/3 of the members of the board of directors of Community Action for Improvement, Inc. were representative of the low-income individuals and families served by the Organization. This is a repeat of prior year audit findings 2021-001, 2022-002 and 2023-001. Recommendation: We recommend that Community Action for Improvement, Inc. establish procedures to ensure the composition of the members of its board of directors meets this requirement. Corrective Action Plan: The Board of Directors for CAFI has a Membership Committee. Their role is to guide the recruitment and retention of Board members. At the time of this plan (8/16/24) all Board seats are filled. The Committee embarked on a Board Development Plan, lowered their Board seats, and worked hard to ensure a full Board. Person(s) Responsible: Board of Directors / Jennifer Corcione Timing for Implementation: Implemented by 9/01/2024.

View Audit 320245

Finding 496969 (2024-003)

Significant Deficiency 2024

Northland Health Partners Community Health Center

ND

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of...

Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.

View Audit 319712

Finding 496933 (2024-001)

Significant Deficiency 2024

Cccs Farm Labor Housing Corporation

CO

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. Th...

We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. These include the hiring of a new compliance manager and the cross-collaboration of three property accountants, with a master trial balance shared to support teammates when they are on vacation or turnover occurs. We will work to re/file these forms immediately and begin tracking their status to prevent inaccurate/untimely filing.

View Audit 319674

Finding 485406 (2024-002)

None 2024

Lincoln Christian University

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...

2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.

View Audit 318153

Finding 485338 (2024-001)

Significant Deficiency 2024

Berkshire Retirement Home INC

MA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to e...

Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was immediately increased from $1,135,927 to $1,182,615 to be above the minimum required threshold of $1,164,177 when identified. The new process implemented will assess potential organizational revenue growth ahead of insurance renewal to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Planned completion date for corrective action plan: 8/12/2024

View Audit 318084

Finding 485172 (2024-002)

Significant Deficiency 2024

Regis University

CO

Student Financial Aid Questioned Costs Special Tests & Provisions

Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...

Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.

View Audit 317977

Finding 485144 (2024-001)

Significant Deficiency 2024

East Central Kansas Economic Opportunity Corporation

KS

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...

August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation

View Audit 317959

Finding 479547 (2024-002)

Significant Deficiency 2024

Health Services, Inc.

AL

Special Tests & Provisions Eligibility Significant Deficiency

Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing...

Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application. The supervisor will also review the application to ensure that all signatures and demographic data has been included. o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.

View Audit 316096

Finding 478290 (2024-004)

Significant Deficiency 2024

Epsom Elderly Housing, Inc.

NH

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...

Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing

View Audit 314973

Finding 478285 (2024-004)

Significant Deficiency 2024

Belmont Elderly Housing, Inc.

NH

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...

Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing

View Audit 314972

Finding 478174 (2024-001)

Significant Deficiency 2024

Village of Lawrence, Inc.

KS

HUD Housing Programs Reporting Significant Deficiency § 200.512

The Board of Directors will designate an individual to document financial statement preparation processes which ensure timely submission of the Single Audit Reporting Package.

View Audit 314842

Finding 477896 (2024-001)

Significant Deficiency 2024

Clinica Campesina Family Health Services

CO

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.

View Audit 314530

Finding 1230047 (2023-001)

Material Weakness 2023

Monterey County Business Council

CA

Cash Management Reporting Significant Deficiency

Finding Reference: 2023-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over rep...

Finding Reference: 2023-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of the Treasury, the Organization is required to submit the single audit to the Federal Audit Clearinghouse within 30 days of the issuance of the audit report or nine months after the end of the Organization’s fiscal year. During our reporting period we noted that the audit was not completed and filed timely. Cause: The Organization met the requirements for a single audit for the first time during the year ended December 31, 2023. Due to a lack of expertise in federal grant reporting requirements, the Organization overlooked the requirement to perform a single audit and file with the clearinghouse in a timely manner Corrective Action: In June 2025, Monterey County Business Council employed a CFO Consultant with 30+ years’ experience in finance and accounting who has performed a deep dive into the accounting framework. The Consultant has been engaged to assist the Organization in completing financial and single audits for the years ended December 31, 2022, 2023, and 2024. It is expected that the Organization will be caught up with federal clearinghouse filings by the end of 2025 or early 2026 at the latest. Under the consultant’s guidance, the Organization has made progress in financial reporting and will be filing the 2023 audit by September 30, 2026. Audits for subsequent years will be audited thereafter. Name of Responsible Person: Chris Steinbruner, CPA Questioned Cost: None Chris Steinbruner, CPA MCBC Board Member (831)-222-6111

View Audit 411327

Finding 1229946 (2023-002)

Material Weakness 2023

Northwoods Stewardship Center

VT

Matching / Level of Effort / Earmarking Significant Deficiency § 200.306

View of responsible officials and planned corrective action: Northwoods management will train all employees included in USFW activities to use a USFWS code on our current time sheet tracking. This will be implemented in September 2025, and will be reviewed monthly by management, through current time...

View of responsible officials and planned corrective action: Northwoods management will train all employees included in USFW activities to use a USFWS code on our current time sheet tracking. This will be implemented in September 2025, and will be reviewed monthly by management, through current time sheet review procedures. We will review time tracking methods with USFWS grant partners to ensure all tracking requirements for the program, and per agreement, are met. Quarterly, program director match contribution will be reconciled from time sheet reports with the general ledger for USFW agreements by the Business Manager. Northwoods management will obtain a review of matching contributions documentation procedures from a qualified non-profit accountant.

View Audit 411190

Finding 1227715 (2023-001)

Material Weakness 2023

SOUTHWEST INDIGENOUS WOMENS COALITION

AZ

Reporting Significant Deficiency

Management Response: Management concurs with the finding. During the FY2023 audit period, the Organization experienced significant administrative and staffing challenges that affected the timely organization and retention of audit documentation necessary to complete the Single Audit within the requi...

Management Response: Management concurs with the finding. During the FY2023 audit period, the Organization experienced significant administrative and staffing challenges that affected the timely organization and retention of audit documentation necessary to complete the Single Audit within the required timeframe. While management recognizes the importance of timely audit completion, there was no intent to delay compliance with federal reporting requirements. Since FY2023, SWIWC has substantially strengthened its financial management and audit readiness processes. The Organization has substantially revised its financial policies and procedures, centralized audit documentation, established standardized record retention practices, enhanced grant-specific compliance files, and implemented audit preparation checklists and tracking systems designed to support timely completion of future audits. Management believes these improvements significantly reduce the likelihood of similar delays occurring in future audit periods. Anticipated Completion Date: Planned Implementation completion by 9/30/2026; ongoing monitoring. Responsible Party: Executive Director and Chief Financial Officer.

View Audit 409697

Finding 1227163 (2023-003)

Material Weakness 2023

County of Rockingham

NH

Procurement, Suspension & Debarment Significant Deficiency Internal Control / Segregation of Duties

Corrective Action Taken or Planned: 1. The Finance Office composed a specific "Federally Funded" Request for Proposal (RFP) document to be used going forward for contracts funded by federal awards. The Appendix section of this RFP template lists all of the specific provisions cited in Appendix II to...

Corrective Action Taken or Planned: 1. The Finance Office composed a specific "Federally Funded" Request for Proposal (RFP) document to be used going forward for contracts funded by federal awards. The Appendix section of this RFP template lists all of the specific provisions cited in Appendix II to 2 CFR Part 200 that may apply. 2. The Finance Office will work to educate departmental individuals invovled in procurement regarding the use of the "Federally Funded" RFP when composing a request for proposal for which the funding of the contract would come from a federal award. The Appendix section of this RFP template will serve as a procurement checklist for the Appendix II, 2 CFR Part 200 requirements, and sample language for contract language is provided in the RFP template for RFP respondents to include in any proposed agreement. 3. The Finance Office will review contracts funded by federal awards and, if certain required contractual provisions cited in Appendix II to 2 CFR Part 200 were excluded in the executed contract, the Office shall work with the particular vendor and the Commissioners Office to have contract amendments (that incorporate the missing federally required provisions) composed and agreed to by both parties as soon as possible after the discovery of non-compliance. Implementation date of corrective action: December 08, 2025 Person responsible for corrective action: Charles Nickerson, Senior Director of Finance

View Audit 409334

Finding 1227160 (2023-001)

Material Weakness 2023

County of Rockingham

NH

Allowable Costs / Cost Principles Eligibility Significant Deficiency § 200.303 § 200.334

Corrective Action Taken: 1. Formalized record retention policies: A formal record retention policy specific to federal grant programs was implemented to ensure full compliance with 2 CFR 200.334. This policy applies regardless of whether documentation is stored internally or by third-party systems. ...

Corrective Action Taken: 1. Formalized record retention policies: A formal record retention policy specific to federal grant programs was implemented to ensure full compliance with 2 CFR 200.334. This policy applies regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent complete and accurate records. 2. Auditing timing advocacy and preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, though no fault of the County, as observed during the FY 2023 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal audit readiness reviews: Beginning with FY2025, the County conducts internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Implementation date of corrective action: October 24, 2025 Person Responsible for corrective action: Charles Nickerson, Senior Director of Finance

View Audit 409334

Finding 1224640 (2023-009)

Material Weakness 2023

Serenity House of Clallam County

WA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency § 200.317 § 200.318 § 200.327

Procurement Recommendation: We recommend that management develop, adopt, and implement written procurement and conflict-of-interest policies that comply with Uniform Guidance requirements. These policies should address procurement standards, including methods of procurement and oversight, and establ...

Procurement Recommendation: We recommend that management develop, adopt, and implement written procurement and conflict-of-interest policies that comply with Uniform Guidance requirements. These policies should address procurement standards, including methods of procurement and oversight, and establish standards of conduct governing conflicts of interest for employees, officers, and agents involved in the administration of federal awards. Management should also ensure that these policies are communicated to relevant personnel and applied consistently. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In 2024 new maintenance staff was employed 3 bids are required for capital projects. If one contractor has personal relationship with employee conflict of interest form is filed. Name(s) of the contact person(s) responsible for corrective action: Kristin Cowan Planned completion date for corrective action plan: July 2024

View Audit 407897

Finding 1224639 (2023-008)

Material Weakness 2023

Serenity House of Clallam County

WA

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.303

Reporting Recommendation: We recommend that the auditee implement procedures to ensure that Form 19-lA reimbursement requests are reviewed prior to submission to confirm that expenditures are charged to the correct approved budget line items. This may include maintaining a reconciliation between the...

Reporting Recommendation: We recommend that the auditee implement procedures to ensure that Form 19-lA reimbursement requests are reviewed prior to submission to confirm that expenditures are charged to the correct approved budget line items. This may include maintaining a reconciliation between the general ledger, the approved grant budget, and the Form 19-lA, as well as implementing supervisory review and approval of reimbursement submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. 2026 Action taken in response to finding: Reoccurring bills such as utilities, loan payments, contract services and credit card payments do not require an expense request to be included for on going bills. We will review our procedures and update our financial policy. 2023 Our financial process includes at least two reviews prior to creating a bill in our accounting system, payments are reviewed by the director or the Deputy Director when signed. We do not use a auto signature all checks are reviewed. 2023 The Grantor billing is a P&L detailed report for that grant and provides reconciliation monthly This is sorted into grant line items designated billable and non-billable for compliance. Total program cost and billable to grant are tracked every month, by the grant finance manager for compliance prior to billing any grants. Timecards are reviewed, expense requests are reviewed and payments are reviewed. Prior to submission of the invoice to grantor. 2023 Grant finance manager pulls copy of timecards, bills and checks to ensure compliance with reimbursements are accurate. Name(s) of the contact person(s) responsible for corrective action: Cora Alyea Planned completion date for corrective action plan: July 2023

View Audit 407897

Finding 1224638 (2023-007)

Material Weakness 2023

Serenity House of Clallam County

WA

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.430

Allowable Costs/Payroll Disbursements Recommendation: We recommend that the auditee implement procedures to ensure that: all employee pay rates charged to Federal awards are appropriately approved and documented, and complete and accurate timesheets or equivalent time-and-effort records are maintain...

Allowable Costs/Payroll Disbursements Recommendation: We recommend that the auditee implement procedures to ensure that: all employee pay rates charged to Federal awards are appropriately approved and documented, and complete and accurate timesheets or equivalent time-and-effort records are maintained for all payroll costs charged to Federal awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Most Federal grants are renewed annually and have not requested any salary rate adjustments. Payroll line items are a lump sum. Serenity House since 2020 performs annually in May a market rate survey for all job positions to ensure wage rates are equitable to fair market for our County and Non-Profit job type. The sources are documented in the workbook that the annual raise percentages; wage adjustments are calculated for board approval. Our annual performance raises and adjustments is a pool of 1 to 5%, and 3 to 6 employees are below market rate each year. People with a market adjustment do not receive a merit increase. 2023 Merit increase is% that is allocated based on performance scores and management team comparison to everyone in that job category. People are scored by manager this score is reviewed by all managers that have employees in that grouped job class. The reviewing managers agreed highest performer with a 5% and lowest performer 1% Raise distribution is based on the performance review score. 2022 Employees are hired for a specific job when they are given their first time card grant line items for the grant they work on are on the time sheet. That time sheet is reviewed and corrected by the immediate supervisor then reviewed by the operations manager. Turned into the main office receptionist who checks submission against the employee list. Checks math and signatures, initials the times card takes up to payroll. 2023 Payroll double checks each time card when entering time into the payroll module. After all time is enter another employee checks the system addition to timecard. 2020 When Checks are manually signed the time is on the timecard and each check is reviewed. Each employee Name(s) of the contact person(s) responsible for corrective action: Kristin Cowan Planned completion date for corrective action plan: July 1 2023

View Audit 407897

Finding 1224235 (2023-013)

Material Weakness 2023

International Fertilizer Development Company

AL

Questioned Costs Reporting Significant Deficiency § 200.512

2023-013-Late filing of the data collection form Suggested Action: Enhanced internal controls and timelines around the year-end close and audit coordination to ensure timely completion of future audits and related filings. Responsible Official: Global Finance Director Completion Date: 6/30/2026

View Audit 407579

Corrective Action Plans

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