Corrective Action Plans

Finding 555242 (2022-005)

Significant Deficiency 2022

MN

Special Tests & Provisions Allowable Costs / Cost Principles Significant Deficiency

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submi...

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. *Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: *A regular internal review and audit process will be revisited to ensure that backup, storage, and retention practices are being followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. *Any discrepancies or issues identified during audits will be addressed promptly, and corrective actions will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: *Training sessions will be conducted for all relevant staff on the updated backup, storage, and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. *Refresher training will be provided quarterly to ensure ongoing compliance and awareness.

View Audit 353875

Finding 555141 (2022-006)

Significant Deficiency 2022

Valencia Shelter for Victims of Domestic Violence

NM

Questioned Costs Matching / Level of Effort / Earmarking HUD Housing Programs § 200.303

Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal and grantor requirements regarding the program requirements. Explanation of disagreement with audit finding: There is no disagr...

Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal and grantor requirements regarding the program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: VSS agrees with CLA and has updated our financial policies. We have hired an accountant, in addition to our Finance Director and Finance Coordinator to create a system of posting and review. Fair Market Rents will be reviewed along with the HQS worksheet and Income Limits during annual recertification for active participants in the HUD program. Name(s) of the contact person(s) responsible for corrective action: Jessica Franco, Director of Finance Planned completion date for corrective action plan: XXX

View Audit 353736 Questioned Costs: $1

Finding 555136 (2022-005)

Significant Deficiency 2022

Valencia Shelter for Victims of Domestic Violence

NM

Questioned Costs Period of Performance Allowable Costs / Cost Principles

Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal cost principals and requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...

Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal cost principals and requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: VSS agrees with CLA in creating internal controls over reviewing year end entries. We have hired an accountant, in addition to our Finance Director and Finance Coordinator to create a system of posting and review. Name(s) of the contact person(s) responsible for corrective action: Jessica Franco, Director of Finance Planned completion date for corrective action plan: 10/1/2022

View Audit 353736 Questioned Costs: $1

Finding 554995 (2022-002)

Significant Deficiency 2022

White Shield School

ND

Reporting Subrecipient Monitoring Significant Deficiency § 200.302 § 200.327

RECOMMENDATION: The School should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 353603

Finding 554994 (2022-001)

Significant Deficiency 2022

White Shield School

ND

Internal Control / Segregation of Duties Reporting Significant Deficiency

RECOMMENDATION: We recommend that management and the governing board be aware of the lack of segregation of duties and implement controls whenever possible to mitigate this risk. The governing board should remove the managers from the list of check signers. Action Taken: The School agrees with this...

RECOMMENDATION: We recommend that management and the governing board be aware of the lack of segregation of duties and implement controls whenever possible to mitigate this risk. The governing board should remove the managers from the list of check signers. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 353603

Finding 554472 (2022-009)

Significant Deficiency 2022

East End Neighborhood House Association

OH

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Action: To address the issue, the management will develop and document a clear policy for obtaining and retaining eligibility documentation. This policy should outline the specific types of documentation required and the procedures for collectin...

Views of Responsible Officials and Planned Corrective Action: To address the issue, the management will develop and document a clear policy for obtaining and retaining eligibility documentation. This policy should outline the specific types of documentation required and the procedures for collecting and storing them. Set up a monitoring and reporting system to track the status of eligibility documentation. Regularly review reports to ensure that all required documentation is up-to-date and complete. Anticipated Date of Completion: Ongoing analysis; expected to be completed by December 1, 2025.

View Audit 353100

Finding 553994 (2022-007)

Significant Deficiency 2022

California Fire Safe Council, Inc.

CA

Subrecipient Monitoring Reporting Significant Deficiency § 200.328 § 200.329

Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Contact Person: Jessica Martinez, Deputy Director Co...

Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Contact Person: Jessica Martinez, Deputy Director Corrective Action Plan: In response to the FY21 Corrective Action Plan, CFSC implemented an updated Reporting Policy in June 2024 to ensure compliance with timely and accurate reporting to funders. This policy includes defined responsibilities for grant reporting and procedures for tracking report deadlines. To further strengthen compliance and eliminate late submissions, CFSC will implement the following corrective actions: 1.Report Deadline Tracking: CFSC will enhance its report tracking to flag upcoming report due dates and set reminder alerts for responsible staff. 2.Late Submission Justification: Any delays in submission (whether approved by funder or not) must be documented in the grant file. 3.Quarterly Compliance Audits on Reporting: CFSC will conduct quarterly internal audits to review: a.Timeliness of report submissions (ensuring they met funder deadlines) b.Accuracy & completeness of reports filed in the Master Grant File. c.Corrective actions for any delayed or missing reports. Anticipated Completion Date: These corrective actions will be fully implemented by the end of Quarter 2 of FY25.

View Audit 352633

Finding 553992 (2022-005)

Significant Deficiency 2022

California Fire Safe Council, Inc.

CA

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.403

Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Contact Person: Joel Rusco, Chief Financial and Admi...

Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Contact Person: Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Corrective Action Plan: In response to the FY21 Corrective Action Plan, CFSC implemented a Subrecipient Monitoring Policy in June 2024 to ensure compliance with the Uniform Guidance for monitoring subrecipients of federal funding, including audit requirements and the verification of suspension and debarment status. To further strengthen compliance and ensure timely verification, CFSC will implement the following actions: 1.Mandatory Pre-Award Verification Timing & Documentation: a.Suspension and debarment status must be verified on SAM.gov by the assigned Grant Specialist before the execution of any subaward agreements. b.The verification data and results will be documented by the assigned Grant Specialist and included in the Risk Assessment process prior to award issuance. c.Any subrecipients flagged as high risk due to past audit findings will undergo enhanced pre-award due diligence before subaward execution to be carried out by the assigned Grant Specialist. 2.Grant Compliance Oversight & Approval: a.The Grants Manager (or designee) will review and approve all subrecipient compliance checks before final award execution. b.Any exceptions or delays in verification must be documented and approved by the CFAO & Deputy Director before proceeding. 3.Quarterly Compliance Audits: a.The Grants Manager (or designee) will conduct quarterly internal audits of subrecipient monitoring files to confirm that suspension & debarment verification was completed timely before subaward execution. b. The Grants Manager will be responsible for reporting any identified deficiencies to senior management and ensuring timely correction for policy reinforcement. Anticipated Completion Date: These corrective actions will be fully implemented by the end of Quarter 2 of FY25, with ongoing monitoring and enforcement thereafter.

View Audit 352633

Finding 540863 (2022-108)

Significant Deficiency 2022

Pancare of Florida, INC

FL

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328

2021-108 Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance ...

2021-108 Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. Source documentation for grant reporting is retained and maintained in grant folders on the shared drive for future reference. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer Anticipated Completion Date: Implemented

View Audit 350520

Finding 540610 (2022-004)

Significant Deficiency 2022

Schoodic Institute at Acadia National Park

ME

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties

Audit Finding Reference 2022-004 Improve Controls Over Cash Management & Application of Indirect Cost Rate Planned Corrective Action: Federal reimbursement requests will include at least two or more individuals. Review of the reimbursement request, including the application of the indirect rate, ...

Audit Finding Reference 2022-004 Improve Controls Over Cash Management & Application of Indirect Cost Rate Planned Corrective Action: Federal reimbursement requests will include at least two or more individuals. Review of the reimbursement request, including the application of the indirect rate, will be formally documented and a copy of the documentation will be maintained in our records. Planned Implementation Date of Corrective Action: March 14, 2025 Persons Responsible for Corrective Action: Kirk Geadelmann, Finance Director Tyler Piebes, Bookkeeper Nick Fisichelli, President & CEO

View Audit 350382

Finding 540607 (2022-002)

Significant Deficiency 2022

Schoodic Institute at Acadia National Park

ME

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Audit Finding Reference: 2022-002 Document Policies & Procedures Over Federal Awards Planned Corrective Action: Uniform Guidance Policies & Procedures was presented, reviewed & approved by the Schoodic Institute Board of Directors on July 10, 2023. Planned Implementation Date of Corrective Acti...

Audit Finding Reference: 2022-002 Document Policies & Procedures Over Federal Awards Planned Corrective Action: Uniform Guidance Policies & Procedures was presented, reviewed & approved by the Schoodic Institute Board of Directors on July 10, 2023. Planned Implementation Date of Corrective Action: July 10, 2023 Person Responsible for Corrective Action: Kirk Geadelmann, Finance Director

View Audit 350382

Finding 538766 (2022-005)

Significant Deficiency 2022

New Hampshire Children's Trust

NH

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties

Audit Finding Reference: 2022-005 Improve Controls Over Cash Management and Application of Indirect Cost Rate Planned Corrective Action: Having the Executive Director review and approve state and federal invoices prior to final submission. An indirect analysis spreadsheet was also created to track ...

Audit Finding Reference: 2022-005 Improve Controls Over Cash Management and Application of Indirect Cost Rate Planned Corrective Action: Having the Executive Director review and approve state and federal invoices prior to final submission. An indirect analysis spreadsheet was also created to track and adjust indirect rate, if necessary, across all sub-contracts receiving federal funds. Planned Implementation Date of Corrective Action: Implemented Executive Director approval on 5/26/2023 for state invoices, which include federal funds that are passed through to NHCT. Indirect analysis spreadsheet implemented on 7/1/2023. Person Responsible for Corrective Action: Director of Finance

View Audit 349473

Finding 538764 (2022-004)

Significant Deficiency 2022

New Hampshire Children's Trust

NH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency § 200.318

Audit Finding Reference: 2022-004 Improve Controls and Documentation Over Procurement Planned Corrective Action: Revise Policy and Procedure Policies to require prior written approval from the Executive Director prior to entering into any agreement for expenditures between $10,000 and $49,999. If i...

Audit Finding Reference: 2022-004 Improve Controls and Documentation Over Procurement Planned Corrective Action: Revise Policy and Procedure Policies to require prior written approval from the Executive Director prior to entering into any agreement for expenditures between $10,000 and $49,999. If it is a sole source, written justification must be submitted and approved by Executive Director prior to execution of agreement. If multiple bids were obtained, these must also be submitted and the selected vendor approved by Executive Director prior to execution of agreement. Planned Implementation Date of Corrective Action: 2/5/2025 Person Responsible for Corrective Action: Director of Finance

View Audit 349473

Finding 538762 (2022-003)

Significant Deficiency 2022

New Hampshire Children's Trust

NH

Allowable Costs / Cost Principles Significant Deficiency

Audit Finding Reference: 2022-003 Improve Internal Controls Over Timesheet Approvals Planned Corrective Action: Executive Director’s bi-weekly timesheet approved by Director of Finance to ensure allowability of charges to federal awards in accordance with applicable cost principles. Planned Implem...

Audit Finding Reference: 2022-003 Improve Internal Controls Over Timesheet Approvals Planned Corrective Action: Executive Director’s bi-weekly timesheet approved by Director of Finance to ensure allowability of charges to federal awards in accordance with applicable cost principles. Planned Implementation Date of Corrective Action: Implemented on 1/20/2023 upon becoming aware of the deficiency. Person Responsible for Corrective Action: Director of Finance

View Audit 349473

Finding 538760 (2022-002)

Significant Deficiency 2022

New Hampshire Children's Trust

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Audit Finding Reference: 2022-002 Update Documented Policies and Procedures Of Federal Awards Planned Corrective Action: Update Financial Policies and Procedures to reflect Uniform Guidance language surrounding areas of deficiency. Planned Implementation Date of Corrective Action: Implemented 12/6...

Audit Finding Reference: 2022-002 Update Documented Policies and Procedures Of Federal Awards Planned Corrective Action: Update Financial Policies and Procedures to reflect Uniform Guidance language surrounding areas of deficiency. Planned Implementation Date of Corrective Action: Implemented 12/6/2023 upon becoming aware of the deficiency. Revised Financial Policies and Procedures to reflect the changes. Person Responsible for Corrective Action: Director of Finance

View Audit 349473

Finding 530096 (2022-002)

Significant Deficiency 2022

Pasadena Symphony Association

CA

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team. I was engaged as the new Chief Executive Officer in November 2023, and have since hired a new General Manager, Dir...

Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team. I was engaged as the new Chief Executive Officer in November 2023, and have since hired a new General Manager, Director of Development, and worked closely with our accounting firm, who was engaged to replace the original CFO, after her retirement in 2022. Since this new team has assumed leadership, we have transitioned to new accounting and billing software platforms and developed or renewed policies and procedures that have improved monitoring, tracking, approval, and reporting procedures for all expenditures and revenues, across the organization. We have also upgraded to a cloud-based server/filesharing system and reorganized the filing and archival systems and procedures to ensure that files and documents are organized more clearly and more accessibly for key staff members, current and into the future. Anticipated Completion Date: Already implemented.

View Audit 348149

Finding 530095 (2022-001)

Significant Deficiency 2022

Pasadena Symphony Association

CA

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.512

Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team who initially were charged with tracking this grant and its reporting requirements. I was engaged as the new Chief ...

Corrective Action Plan: In the time since the initial audit was due at the end of 2022, the organization experienced a substantial turnover in its senior administrative leadership team who initially were charged with tracking this grant and its reporting requirements. I was engaged as the new Chief Executive Officer in November 2023, and have since hired a new General Manager, Director of Development, and worked closely with our accounting firm, which was engaged to replace the original CFO, after her retirement in 2022. Since this new team has assumed leadership, we have transitioned to new accounting and billing software platforms, developed or renewed policies and procedures to monitor, track, and report all expenditures and revenues, and to more accurately monitor, track, and report on impending grant reporting deadlines and requirements. We have also upgraded to a cloud -based server/file-sharing system and reorganized the filing and archival systems and procedures to ensure that files and documents are organized more clearly and more accessibly for both current and future staff members. Anticipated Completion Date: Already implemented.

View Audit 348149

Finding 530092 (2022-005)

Significant Deficiency 2022

South Big Horn Hospital District

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

2022-005 - Reporting Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 2025

View Audit 348143

Finding 530091 (2022-004)

Significant Deficiency 2022

South Big Horn Hospital District

WY

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2022-004 - Required debt reserve compliance Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 20 5

View Audit 348143

Finding 529160 (2022-004)

Significant Deficiency 2022

Oregon Coalition Against Domestic & Sexual Violence

OR

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

Contact person(s) responsible: Executive Director, Keri Moran-Kuhn Recommendation: We recommend that management implement procedures to ensure that all required reporting is submitted in a timely manner and in accordance with CFR 200.512 deadlines. Management’s Response: Corrective Action Plan: Duri...

Contact person(s) responsible: Executive Director, Keri Moran-Kuhn Recommendation: We recommend that management implement procedures to ensure that all required reporting is submitted in a timely manner and in accordance with CFR 200.512 deadlines. Management’s Response: Corrective Action Plan: During this time, the Coalition went through several temporary fiscal staff and one permanent hired staff that had made mistakes, with the effect of having to make adjustments in order to attempt to close accounting records. Controls have been put into place and permanent accounting manager, started in October 2024 and now on staff as of March 2025. Anticipated completion date: 09/30/25

View Audit 347141

Finding 528926 (2022-010)

Significant Deficiency 2022

Iliff School of Theology

CO

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

Condition: Our audit procedures identified instances of MPNs not being properly maintained. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school has also ensured that this third-...

Condition: Our audit procedures identified instances of MPNs not being properly maintained. Planned Corrective Action: The Iliff School of Theology has contracted with a professional, third-party processing company to administer its student aid programs. The school has also ensured that this third-party processor is properly reviewing MPNs to meet federal requirements. Contact person responsible for corrective action: Jason Warr, VP for Business, Controller Anticipated Completion Date: May 2024

View Audit 346905

Finding 526785 (2022-004)

Material Weakness 2022

Greater Bethel Temple Incorporated

PA

Questioned Costs Reporting School Nutrition Programs

Procure the services of an accounting professional to verify the accuracy and adherence to accounting methods and reporting procedures to assist with the administration of the Child and Adult Care Food Program (CACFP)

View Audit 345819 Questioned Costs: $1

Finding 526442 (2022-002)

Significant Deficiency 2022

State Education Resource Center

CT

Reporting Significant Deficiency

Description of Finding: As per the Code of Federal Regulations, Section 200.512 - Report Submission, the audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the...

Description of Finding: As per the Code of Federal Regulations, Section 200.512 - Report Submission, the audit must be completed and the data collection form and 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 September 30, 2022. The audit and reporting package was not submitted by the due date September 30, 2022. Statement of Concurrence or Nonconcurrence: The State Education Resource Center agrees with this finding. SERC experienced staffing shortages and related difficulties during the fiscal year. As such, SERC was not able to prepare timely for the audit for the Uniform Guidance, Data Collection Form, and reporting package to be filed by the due date. Corrective Action: In May of 2024, the State Education Resource Center hired a new Chief Financial Officer whose focus is to bring the organization up to date on all audits and reporting and to ensure that the Fiscal team has the proper tools and guidance to perform their tasks and to improve policy and process for the department. This will also aid in ensuring all necessary efforts will be taken to ensure timely submission of the audit, Data Collection Form, and reporting packages. Name of Contact Person: Jim Fried, Chief Financial Officer, 860-740-4263, fried@ctserc.org will be responsible for completing the corrective action plan. Projected Completion Date: The anticipated date for completing the corrective action plan is June 30, 2025. The action plan will be monitored on a bi-annual basis to ensure ongoing compliance.

View Audit 345377

Finding 524436 (2022-002)

Significant Deficiency 2022

Anchorage Concert Association

AK

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.512

Finding 2022-002 Significant Deficiency over Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Willow Zamos, Business Manager; 907-272-1471 Planned Corrective Action: Anchorage Concert Association will establish additional controls when receiving future federal fund...

Finding 2022-002 Significant Deficiency over Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Willow Zamos, Business Manager; 907-272-1471 Planned Corrective Action: Anchorage Concert Association will establish additional controls when receiving future federal funding to ensure a timely audit of the program(s) is performed. Anticipated Completion Date: Already implemented.

View Audit 343739

Finding 524435 (2022-001)

Significant Deficiency 2022

Anchorage Concert Association

AK

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2022-001 Documentation of Approval - Allowable Costs – Significant Deficiency in Internal Control over Compliance Name of Contact Person: Willow Zamos, Business Manager; 907-272-1471 Planned Corrective Action: Anchorage Concert Association will improve procedures to ensure documentation of i...

Finding 2022-001 Documentation of Approval - Allowable Costs – Significant Deficiency in Internal Control over Compliance Name of Contact Person: Willow Zamos, Business Manager; 907-272-1471 Planned Corrective Action: Anchorage Concert Association will improve procedures to ensure documentation of invoice approval is retained in vendor files. Anticipated Completion Date: Already implemented.

View Audit 343739

Corrective Action Plans

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