Corrective Action Plans

Finding 575819 (2024-002)

Significant Deficiency 2024

TX

Subrecipient Monitoring Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has assigned an employee charged with ensuring monitored visits occur in compliance with 4337 of the Texas Department of Agriculture - Child and Adult Care Food Program - Child Care Centers Handbook. This employee ensures mo...

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has assigned an employee charged with ensuring monitored visits occur in compliance with 4337 of the Texas Department of Agriculture - Child and Adult Care Food Program - Child Care Centers Handbook. This employee ensures monitored visists occur and meals monitored do not include snacks. Monitored visits are based on the meal times with the greatest number of meals served at the centers. These were discovered before the audit and procedures were implemented to rectify these two instances before year-end. Twinkle Wonders Rice: This facility was formely called Kaleidoscope. Because of the change in management, the facility did not have a full program year to be monitored. This is where confusion emerged regarding amount of monitors and monitoring events needed versus what actually occured. Top Leaders: This facility was monitored three times during the year. Two of these monitors were PM snacks. There were monitored August 2024 and a follow-up was scheduled for September 2024. The facility must be given enough time to correct its recommendations. Because the issue was so close to the end fo the program year, there was not enough time to proceed with the follow-up and another monitoring of an additional meal. The facility's next monitoring event was a meal, but it was visited in the following program year.

View Audit 365800

Finding 575779 (2024-003)

Significant Deficiency 2024

Town of Mountain Village

CO

Procurement, Suspension & Debarment Subrecipient Monitoring

COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The Town should update all contracts to include a suspension and debarment paragraph to verify status with every renewal or collecting certification from the proposed entity. Additionally, th...

COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The Town should update all contracts to include a suspension and debarment paragraph to verify status with every renewal or collecting certification from the proposed entity. Additionally, the Town should update procedures to ensure that a vendor’s status is checked in SAM.gov prior to contracting with a vendor. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The Town will require all contracts related to federal awards to include a suspension and debarment paragraph to verify status with every renewal or collecting certification from the proposed entity. Additionally, procedures have been updated to ensure that a vendor’s status is checked in SAM.gov prior to contracting with a vendor. Name of the Contact Person Responsible for Corrective Action: Lizbeth Lemley, Finance Director Planned Completion Date for Corrective Action Plan: Procedure updates will be complete by September 30, 2025, and these actions will be implemented upon execution of the next contract related to a federal award.

View Audit 365751

Finding 575778 (2024-004)

Material Weakness 2024

St. Jude's Ranch for Children, Inc.

NV

Subrecipient Monitoring § 200.332

System of Internal Controls Over Compliance: Subrecipient Monitoring; U.S. Department of Treasury, Assistance Listing #21.027, Coronavirus State and Local Fiscal Recovery Funds, Passed Through State of Nevada Criteria: In accordance with 2 CFR 200.332, the auditee must maintain a system of internal ...

System of Internal Controls Over Compliance: Subrecipient Monitoring; U.S. Department of Treasury, Assistance Listing #21.027, Coronavirus State and Local Fiscal Recovery Funds, Passed Through State of Nevada Criteria: In accordance with 2 CFR 200.332, the auditee must maintain a system of internal control over compliance to ensure they provide each subrecipient within the required appropriate document the performance of internal controls over the compliance for subrecipient monitoring. Condition: The Organization did not appropriately implement internal controls necessary to ensure appropriate documentation was available to support the performance of controls in compliance with 2 CFR 200.332. Context: The Organization did not identify funds being passed through from one subsidiary of the Organization to a second subsidiary in a timely manner and based on this timing did not appropriately document the performance of internal controls over the compliance of subrecipient monitoring. Cause: The Organization did not identify its only subrecipient for this award in a timely manner. Effect: The Organization was not able to properly document its performance of internal controls over most of the requirements outlined in 2 CFR 200.332 for the award based on untimely identification of its subrecipient. Recommendation: We recommend management design and implement a system of internal controls over compliance where consideration of possible subrecipients is considered when the award is being applied for and that well documented and supportable internal controls over subrecipient monitoring are implemented when there are subrecipients identified under an award. Views of Responsible Officials and Planned Corrective Actions: SJRC NV Region is addressing its missing controls related to the requirements of 2 CFR 200.332. We acknowledge that SJRC must ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the information required under 2 CFR 200.332 at the time of the subaward all requirements. This includes that every subaward is clearly identified to the subrecipient as a subaward and includes at the time of the subaward and if any data elements change, that there must be an approved subaward modification. We will also ensure we meet the requirements under 2 CFR 200.332 to include our obligations to risk assess and monitor any subrecipients. The timeframe for correction is immediate and full accounting system control improvements will be implemented as part of our 2025 fiscal year-end close. Submitted by: Dr. Christina Vela, DPP Chief Executive Officer St. Jude's Ranch for Children, Inc. and its subsidiaries cvela@stjudesranch.org

View Audit 365748

Finding 575775 (2024-002)

Material Weakness 2024

Community Action Team, Inc.

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

2024-002 Federal Award Special Reporting - Federal Funding Accountability and Transparency Act (FFATA)- Material Non-Compliance and Material Weakness in Internal Controls over Compliance (Repeat of finding 2023-003} Recommendation: The Organization should establish written policies and procedures r...

2024-002 Federal Award Special Reporting - Federal Funding Accountability and Transparency Act (FFATA)- Material Non-Compliance and Material Weakness in Internal Controls over Compliance (Repeat of finding 2023-003} Recommendation: The Organization should establish written policies and procedures regarding review of grant agreements for compliance requirements along with written policies and procedures for first-tier subawards including tracking and proper internal control procedures. Action Taken: Management concurs with the finding and has defined corrective action to address it. We understand a material weakness is identified in the internal control over special reporting. We have identified gaps in our reporting processes and worked to implement changes to ensure compliance with special reporting requirements. The responsibility for reporting under the Federal Funding Accountability and Transparency Act (FFATA) will be within the Fiscal Department. Policies and procedures will be updated regarding special reporting requirements. The Fiscal department will also be responsible for reviewing all contracts to identify all compliance requirements. Tracking procedures will be implemented to ensure reports are filed timely. The above identified corrective action was implemented in July 2024. Stacey Wilson, Fiscal Director, has implemented a tracking system for the FFATA.

View Audit 365745

Finding 575774 (2024-002)

Material Weakness 2024

North Valley Caring Services

CA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302

Management concurs with the finding and will revise procedures to ensure detailed, timely recording of USDA Foods distributions. Staff will receive training on documentation requirements, and management will implement periodic compliance reviews. These corrective actions are expected to be complet...

Management concurs with the finding and will revise procedures to ensure detailed, timely recording of USDA Foods distributions. Staff will receive training on documentation requirements, and management will implement periodic compliance reviews. These corrective actions are expected to be completed by March 1, 2025.

View Audit 365739

Finding 575773 (2024-001)

Material Weakness 2024

North Valley Caring Services

CA

Subrecipient Monitoring Eligibility

Management concurs with the finding. NVCS was followed guidance received from the pass‐through entity but did not fully implement the required proxy documentation format. Management will revise procedures to ensure that the “Volunteer Proxy: [Name]” designation is clearly included where applicable...

Management concurs with the finding. NVCS was followed guidance received from the pass‐through entity but did not fully implement the required proxy documentation format. Management will revise procedures to ensure that the “Volunteer Proxy: [Name]” designation is clearly included where applicable and will provide training to distribution staff. Internal monitoring will be implemented to ensure future compliance. The corrective action is expected to be fully implemented by March 1, 2025.

View Audit 365739

Finding 575769 (2024-002)

Material Weakness 2024

Catherine's Health Center

MI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a ...

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.

View Audit 365733

Finding 575722 (2024-001)

Material Weakness 2024

Town of Warren

RI

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214

Finding 2024-001 Suspension & Debarment - Management concurs with the finding. The Town will design and implement polcies and procedures regrding verification of enetity suspension and deparment. Contact person - Brian Sullivan. Project Completion Date 9/30/2025

View Audit 365704

Finding 575688 (2024-004)

Material Weakness 2024

Mesa County, Colorado

CO

Subrecipient Monitoring Eligibility

The County concurs with this finding and will be working to improve the timeliness of Medicaid eligibility determinations by using the COGNOS reports to determine which cases are approaching the due date. Ongoing cases will be reviewed to verify continued eligibility.

View Audit 365700

Finding 575687 (2024-003)

Material Weakness 2024

Mesa County, Colorado

CO

Subrecipient Monitoring § 200.332

The County concurs with this finding and will be working to enhance internal controls over the adherence to our policies and procedures in accordance with 2 CFR 200.332 to ensure compliance with subrecipient monitoring requirements.

View Audit 365700

Finding 575670 (2024-005)

Significant Deficiency 2024

Indiana Diaper Bank, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...

Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft a new CRM to track benefit limitation and mandatory documentation. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.

View Audit 365678

Finding 575669 (2024-004)

Significant Deficiency 2024

Indiana Diaper Bank, Inc.

IN

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

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identif...

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. As a result, three of the sixty transactions tested did not include sufficient documentation to support eligibility determinations, representing instances of noncompliance with the eligibility requirements under the federal program. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.

View Audit 365678 Questioned Costs: $1

Finding 575657 (2024-003)

Material Weakness 2024

City of Cherry Hills Village

CO

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

Federal Progarm Name: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (CSLFRF Progarm) - Assistance Listing No. 21.027 Recommendation: We recommend that the Annual Report be approved by someone other than preparer prior to submission. Explanation of disagreement with audit finding: Ther...

Federal Progarm Name: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (CSLFRF Progarm) - Assistance Listing No. 21.027 Recommendation: We recommend that the Annual Report be approved by someone other than preparer prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken is response to finding: The City will create and enact financial reporting procedures that outlines how to handle reporting for funding such as ARPA to ensure that these reports are being reviewed and approved before submission in the future. Name of the contact person responsible for corrective action: Kelly Newman, Director of Finance and Administration. Planned completion date for corrective action plan: December 31, 2025.

View Audit 365663

Finding 575582 (2024-002)

Material Weakness 2024

City of East Chicago

IN

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.328

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur ...

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: To ensure proper implementation of the policies and procedures in place related to SLFRF reporting, in the future, no submittal of reports will be approved without the City Controller and a Senior Staff Accountant reviewing and approving the P&E reports. This will ensure policies and procedures are followed and possibly added to, if needed, to ensure compliance over SLFRF reporting. Anticipated Completion Date: Corrective action is now in effect as of August 18, 2025.

View Audit 365567

Finding 575581 (2024-001)

Material Weakness 2024

City of East Chicago

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2024-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Offici...

FINDING 2024-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: A Suspension and Debarment policy was adopted at the conclusion of the 2023 audit, however, the policy was not presented to and officially adopted by the East Chicago Board of Works until the August 22, 2024, meeting. This oversight resulted in a delay of the anticipated enactment of the policy resulting in there being sufficient time to enact the new policy for the current audit year of 2024. The current summary schedule of prior audit findings reflects the issue as partially corrected, providing the supporting documents consisting of Board of Works actions in regard to the policy. Going forward, all steps are in place for correction of the situation. See policy below. CITY OF EAST CHICAGO SUSPENSION/ OR DEBARMENT POLICY FOR VENDOR WHEN FEDERAL FUNDS/ ASSISTANCE INVOLVED: The following specific provisions to be followed under the City of East Chicago purchasing policy and procedure for determining Suspension and Debarment status of any vendor doing business with the City for which federal funds and/ or federal assistance are to be utilized by City. A. SAM search, verification by contracted vendor or contractual provision. Prior to any purchase for which federal funds or federal assistance is to be utilized by the City, the purchasing agency, or its designee, shall: 1. Examine and verify the status of any vendor participating in or to be contracting for business with the City utilizing federal funds and or federal assistance for debarment and suspension status to determine whether the vendor is qualified to participate. The check or verification for debarment and suspension shall be performed using the System for Award Management (SAM) or any similar system currently approved for such purpose. The City Departments/ Boards responsible for facilitating, coordinating and utilizing federal funds will be required to conduct and complete the SAM search, or its approved equivalent, as such procedures and methods are amended, on all vendors with whom the City intends to conduct business utilizing federal funds. Further the City or entity responsible shall provide a hard copy proof and verification of each SAM search for record keeping. 2. Require each contracted vendor utilizing federal funds to certify that the contracted vendor was not suspended or debarred; or 3. Add a clause to appropriate contract to ensure that the contracted vendors were not suspended or debarred. 4. Further these policy requirements for determination of suspension and/ or debarment status of any vendor doing business with the City of East Chicago, in which federal funds and/or federal assistance are utilized shall pertain to "Covered Transactions" under 2 C.F. R. pt. 180, subpt. 8 which include those government contracts for goods and services awarded under a non-procurement transaction (e.g. grant or cooperative agreement) that are expected to equal or exceed $25,000, or meet certain other specified criteria. B. No business with a debarred or suspended entity. It is specifically directed and required that the City of East Chicago, shall not conduct any business with any firm, individual, or entity that has been identified as having been debarred or suspended for such purposes, in conformance with applicable law; in particular, 2CFR 180.300 a. 2 CFR 180.300 states: When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified. You must do this by: 1. Checking SAM Exclusions; or 2. Collecting a certification from that person; or 3. Adding a clause or condition to the covered transaction with that person. Anticipated Completion Date: Corrective action is now in effect as of August 18, 2025.

View Audit 365567

Finding 575580 (2024-005)

Significant Deficiency 2024

Survivor Advocacy Outreach Program

OH

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332

New policy was to be implemented by August 31, 2025 that will include written agreements with subaward programs and the Grants Manager will monitor the plan, with additional monitoring to be completed by the Exective Director periodically.

View Audit 365566

Finding 575577 (2024-001)

Significant Deficiency 2024

National Sorghum Producers Association

TX

Subrecipient Monitoring

2024-001 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Subrecipient Monitoring: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA will establish a policy and implement procedures for subrecipient monitoring and risk assessment and a record will be maintained of all ...

2024-001 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Subrecipient Monitoring: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA will establish a policy and implement procedures for subrecipient monitoring and risk assessment and a record will be maintained of all award agreements identifying or documenting subrecipients’ compliance obligation. Estimated Completion Date: September 2025 Management Contact: Tim Lust, CEO

View Audit 365562

Finding 575554 (2024-001)

None 2024

Juneau Economic Development Council

AK

Reporting Subrecipient Monitoring § 200.512

Finding 2024-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Sam Muse, Finance and Administration Director Corrective Action: JEDC will implement a policy in which, whenever Federal or State dollars are transferred to JEDC, JEDC will obtain written clarific...

Finding 2024-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Sam Muse, Finance and Administration Director Corrective Action: JEDC will implement a policy in which, whenever Federal or State dollars are transferred to JEDC, JEDC will obtain written clarification from the entity transferring the money expressly indicating whether JEDC is a contractor or a subrecipient of the monies. Additionally, JEDC will use a “checklist” to confirm and verify that determination and will seek additional clarification if there is any disagreement in the classifications. Proposed Completion Date: July 1, 2024.

View Audit 365538

Finding 575513 (2024-001)

Significant Deficiency 2024

Northern Oswego County Health Services, Inc. Dba Connextcare

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

Federal Assistance Listing Numbers: 93.224 and 93.527 2024.001 Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review it was determined that a single CDT code within ConnextCare’s practic...

Federal Assistance Listing Numbers: 93.224 and 93.527 2024.001 Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review it was determined that a single CDT code within ConnextCare’s practice management system was not set-up with the proper procedure class and was omitted from the Sliding Fee Program maintenance schedule. The procedure class was corrected in the system. ConnextCare has audited all CDT codes and has determined that there were no other instances. Additionally, ConnextCare audit all D0274 charges back to January 1st, 2024, and determine there were no other occurrences. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Tracy Wimmer, CFO at (315) 298-6569 ext. 2020. Sincerely yours, Tracy Wimmer Chief Financial Officer

View Audit 365508

Finding 575509 (2024-004)

Material Weakness 2024

Town of Marblehead

MA

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

Condition: Suspension and debarment compliance was not verified for three covered transactions. Corrective Action Plan: The Town will implement the following: • Have the Grant Coordinator review and understand compliance with the Town’s Federal Grant Awards Policy. • Have the Grant Coordinator in...

Condition: Suspension and debarment compliance was not verified for three covered transactions. Corrective Action Plan: The Town will implement the following: • Have the Grant Coordinator review and understand compliance with the Town’s Federal Grant Awards Policy. • Have the Grant Coordinator in conjunction with the compliance accountant develop a standard reporting checklist to be used by all staff preparing or reviewing Federal project submissions. • Implement a two-level review process requiring: o Department-level preparation with supporting documentation. o Grant Coordinator final review and approval before submission of Federal reports. • Require quarterly reconciliations between project expenditures and Federal reporting to ensure accuracy. Anticipated Completion Dates: o By September 30, 2025: Grant Coordinator training completed, and checklist distributed. o Ongoing: Reports will be reviewed and certified quarterly by the Grant Coordinator prior to submission. Contact Information: Donna Cotterell, Grant Coordinator

View Audit 365493

Finding 575508 (2024-003)

Significant Deficiency 2024

Town of Marblehead

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.328

Condition: As of the March 31, 2024, reporting date, the Town reported project amounts voted by the Select Board as obligated rather than purchases, contracts and agreements that met the Federal criteria of an obligation. Corrective Action Plan: Misinterpretation of Federal reporting requirements r...

Condition: As of the March 31, 2024, reporting date, the Town reported project amounts voted by the Select Board as obligated rather than purchases, contracts and agreements that met the Federal criteria of an obligation. Corrective Action Plan: Misinterpretation of Federal reporting requirements regarding the definition of an obligation. Reliance on local budgetary approvals (Select Board votes) rather than federally defined contractual commitments. Lack of documented procedures for distinguishing between appropriations/votes and obligations in Federal reporting. This was primarily due to the many changes by the US Treasury on ARPA Federal Reporting. The Select Board did obligate funds for the Town to hire a compliance accountant as an administrative service which is allowable under ARPA to ensure compliance. In addition, the Town hired a full-time grants coordinator to oversee the grants. All future reports will reflect only qualifying obligations supported by contracts, purchase orders, or agreements. Anticipated Completion Dates: o Completed in 2025: Correction of prior misreporting and adoption of revised obligation reporting practice. o By September 30, 2025: Grant Coordinator additional training and issuance of updated reporting checklist. o Ongoing: Federal obligation reports prepared quarterly, reviewed by the Grant Coordinator prior to submission. Quarterly compliance checks will be performed by the Grant Coordinator to confirm obligations are federally compliant. Contact Information: Donna Cotterell, Grant Coordinator

View Audit 365493

Finding 575491 (2024-002)

Significant Deficiency 2024

Avivo

MN

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no...

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to 2023-2024, we only had one primary HUD contract that we were solely responsible for spending and contract timelines. With the addition of three more COC grants, with different, yet close together end dates, we needed to develop a more formalized process to ensure all expenses are billed to the correct contract for the correct dates. Avivo will implement oversight check-in meetings at least one month prior to each contract end and at least one more before final grant submissions. This meeting will include program leadership, RAA, Director of Housing Compliance, and our Contracts Accountant who oversees eLOCCS pulls. We will discuss all final expenditures and any upcoming expenses that may near the end of the grant term, including staff expenditures like mileage reimbursement. We will create an oversight document that highlights all areas to consider and breaks down roles and responsibilities to drive these meetings ongoingly. Accounting and program leadership will closely monitor spending via Papersave, credit card submission and through Paycom falls within the correct payment periods. Additionally, the RAA and Program Managers in the last quarter of the grant cycle, will meet monthly to work to resolve any outstanding rent balances and oversee any staff reimbursement or other charges that may need to be accounted for. Name(s) of the contact person(s) responsible for corrective action: Courtney Knoll & Lyssa Westling. Planned completion date for corrective action plan: December 2025

View Audit 365488 Questioned Costs: $1

Finding 575471 (2024-003)

Material Weakness 2024

Lutheran Social Services of Central Ohio

OH

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring

Condition: During the year, the Organization did not have appropriate review procedures and controls in place related to cash management and reporting over federal programs Planned Corrective Action: Finance has recent changes in leadership roles and with the change in leadership, has put into plac...

Condition: During the year, the Organization did not have appropriate review procedures and controls in place related to cash management and reporting over federal programs Planned Corrective Action: Finance has recent changes in leadership roles and with the change in leadership, has put into place improvements in oversight of cash management and reporting. LSS has a philosophy of continuous improvement and with the current management LSS will ensure that all guidelines and requirements for cash management and reporting for federal programs are met. Contact person responsible for corrective action: Julie Fratianne, CFO Anticipated Completion Date: September 30, 2025

View Audit 365486

Finding 575468 (2024-002)

Material Weakness 2024

Lutheran Social Services of Central Ohio

OH

Subrecipient Monitoring Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Condition: During the current year, a lack of control procedures surrounding the review of payroll costs resulted in improper amounts of payroll to be charged to the grant. Planned Corrective Action: Finance is working with IT and HR to integrate the payroll system with LSS’ accounting system to e...

Condition: During the current year, a lack of control procedures surrounding the review of payroll costs resulted in improper amounts of payroll to be charged to the grant. Planned Corrective Action: Finance is working with IT and HR to integrate the payroll system with LSS’ accounting system to eliminate manual processes in the creation of the payroll journal entry. There will also be periodic internal audits performed to test payroll allocations. Contact person responsible for corrective action: Julie Fratianne, CFO Anticipated Completion Date: September 30, 2025

View Audit 365486

Finding 575453 (2024-002)

Material Weakness 2024

Union County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2024-001 Finding Subject: Preparation of the Schedule of Expenditures of Federal Awards Contact Person Responsible for Corrective Action: Dennis Spaeth, County Auditor Contact Phone Number and Email Address: auditor@unioncountyin.us , (765) 458-5464 Views of Responsible Officials: We concur ...

FINDING 2024-001 Finding Subject: Preparation of the Schedule of Expenditures of Federal Awards Contact Person Responsible for Corrective Action: Dennis Spaeth, County Auditor Contact Phone Number and Email Address: auditor@unioncountyin.us , (765) 458-5464 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will implement a more thorough review process of the SEFA grant information prior to submission of the Annual Financial Report. This review process will include the new information that we were provided during the audit regarding the Transit grants, Child Support grants, and others. Anticipated Completion Date: March 2026 FINDING 2024-002 Finding Subject: COVID-19-Coronavirus State and Local Fiscal Recovery Funds-Suspension and Debarment Contact Person Responsible for Corrective Action: Dennis Spaeth, County Auditor Contact Phone Number and Email Address: auditor@unioncountyin.us , (765) 458-5464 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: For current ARPA vendors, we will perform this suspension and debarment verification again and implement a new review process. It will be signed by both the Auditor and the Deputy Auditor. We will implement this for future federal awards as well. Anticipated Completion Date: August 2025 and going forward.

View Audit 365476

Corrective Action Plans

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