Corrective Action Plans

Finding 502962 (2023-005)

Significant Deficiency 2023

Campbell County

WY

Subrecipient Monitoring § 200.331

Community Services Block Grant, ALN 93.569 Condition/Cause/Context: The County did not follow the documented policy or procedure for evaluating potential subgrantees’ risk of noncompliance prior to award of subgrants for purposes of determining the appropriate subrecipient monitoring. The County wa...

Community Services Block Grant, ALN 93.569 Condition/Cause/Context: The County did not follow the documented policy or procedure for evaluating potential subgrantees’ risk of noncompliance prior to award of subgrants for purposes of determining the appropriate subrecipient monitoring. The County was not aware of their own policy and requirements of Uniform Guidance related to pass-through entities” responsibility to perform and retain written risk assessment as part of subrecipient monitoring. The County does have a policy in place in conformity with Federal Uniform Guidance criteria relating to evaluating the risk of noncompliance prior to awarding subgrants. However, the policy was not followed during the fiscal year under audit. Views of Responsible Officials and Planned Corrective Action: The Campbell County Board of Commissioners concur with this finding and the related audit recommendation. Campbell County perpetually evaluates, updates, and compiles formal written policies and procedures for grants administration. The grants administration policy is consistent with the requirements of Uniform Guidance, as documented within the previously compiled and adopted County Uniform Guidance implementation package. In response to the criteria and condition of the finding regarding the written risk assessment was performed for the overall program and for the subrecipients. However, the written formal documentation was not retained for three of the four subrecipients through oversight. Formal checklists will be compiled and maintained within each grant file to ensure compliance with Guidance and retention of relevant documentation. The following individuals can be contacted for further information: Commissioner’s Office: Shelly Edwards, Chief Finance Executive, Sandra Beeman, Administrative Director and Kristin Young, Grants Management Specialist

View Audit 324926

Finding 502900 (2023-001)

Significant Deficiency 2023

Reset to Success Foundation, Inc.

IL

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles

We will engage with an outside consultant/independent CPA firm to review and manage the internal control process. This corrective action will be implemented by December 31, 2024 by the Administrator and Board.

View Audit 324851

Finding 502724 (2023-008)

Significant Deficiency 2023

Martin University

IN

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring § 200.303

United States Department of Education 2023-008 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Under an institution’s Program Participation Agreement with the Department of Education and the Gramm-Leach-Bliley Act, schools must protect student financ...

United States Department of Education 2023-008 Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Under an institution’s Program Participation Agreement with the Department of Education and the Gramm-Leach-Bliley Act, schools must protect student financial aid information, with particular attention to information provided to institutions by the Department or otherwise obtained in support of the administration of the federal student financial aid programs. Auditors’ Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leach-Bliley Act that have not been completed and documented and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a new SIS and Financial Aid processing system. The new systems are Jenzebar products and are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024

View Audit 324814

Finding 502715 (2023-007)

None 2023

County of Lee, Virginia

VA

Questioned Costs Subrecipient Monitoring Cash Management

The County will obtain and review periodic financial statements and/or underlying documentation and obtain a copy of the annual audit report in accordance with Uniform Guidance.

View Audit 324806 Questioned Costs: $1

Finding 502709 (2023-013)

Significant Deficiency 2023

Grady County

OK

Subrecipient Monitoring Period of Performance Reporting § 200.1 § 200.303 § 200.329 § 200.344

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 324754

Finding 502708 (2023-012)

Material Weakness 2023

Grady County

OK

Subrecipient Monitoring § 200.332

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 324754

Finding 502707 (2023-007)

Material Weakness 2023

Grady County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 324754

Finding 502706 (2023-006)

Material Weakness 2023

Grady County

OK

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

We will work to implement a risk assessment plan. We will implement controls to help make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement...

We will work to implement a risk assessment plan. We will implement controls to help make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 324754

Finding 502674 (2023-003)

Material Weakness 2023

City of Homer, Alaska

AK

Subrecipient Monitoring Material Weakness Reporting § 200.512

Finding 2023-003 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Planned Corrective Actions: The Finance Department is continuing its efforts in establishing and enforcing internal deadlines to ensure the financial statements ar...

Finding 2023-003 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Planned Corrective Actions: The Finance Department is continuing its efforts in establishing and enforcing internal deadlines to ensure the financial statements are audited within the appropriate reporting deadlines. The department has shifted staff duties to ensure the FY24 financial statements will be completed within the appropriate reporting deadlines. Individual(s) Responsible for Corrective Action Plan Elizabeth Fischer (Finance Director) Jenna deLumeau (Controller) Anticipated Completion Date: The department has developed internal deadlines to ensure the FY24 financial statements will be completed within the appropriate reporting deadlines. This has been completed.

View Audit 324691

Finding 502672 (2023-002)

Significant Deficiency 2023

County of Kings, California

CA

Subrecipient Monitoring Reporting § 200.332

Corrective Action Plan: ...

Corrective Action Plan: To ensure compliance with 2 CFR Part 200, Uniform Administrative Requirements, Post Federal Award Requirements, the county (Human Services Agency) will follow Kings County’s subrecipient monitoring policy and procedure. In addition, it will establish a procedure and checklist that is specific to FFA, GH, and STRTP subrecipients, due to the unique structure and involvement of CDSS. The County (Human Services Agency) will draft written policies and procedures for monitoring identified subrecipients receiving Foster Care Title IV-E funds that will include the following steps: •Annually, the County (Human Services Agency) will request from each placement agency utilized a copy of their audited financial statements and complete an annual risk assessment of each FFA, GH, and STRTP agency receiving Foster Care Title IV-E funds to determine the agency’s risk of non-compliance withFederal statutes and regulations. The risk level determined for each agency will determine the appropriate level of subrecipient monitoring. •To ensure compliance with the management decision letters and audit findings of CDSS, the County (Human Services Agency) will follow up with each agency with a request for their corrective action plan. This will be done promptly after receipt of the subrecipient’s audit report, ensuring that subrecipients are aware of any issues and can take appropriate and timely corrective action. Contact Information of Responsible Official: Atonya Moore Deputy Director – Fiscal Kings County Human Services Agency 559-852-2214

View Audit 324690

Finding 502627 (2023-004)

Material Weakness 2023

Promise Healthcare Nfp

IL

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.320

Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industr...

Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Winter 2025

View Audit 324609 Questioned Costs: $1

Finding 502543 (2023-002)

None 2023

Brooklyn Bureau of Community Service Dba Brooklyn Community Services

NY

Subrecipient Monitoring Special Tests & Provisions

Finding 2023-002 Evaluation of federal compliance requirements when receiving subawards U.S. Department of Health and Human Services Community Services Block Grant (Federal Assistance Listing #93.569) Federal Award Numbers: 60204, 60215, 60225, and 60235 Federal Award Year: 2020-2023 Responsible O...

Finding 2023-002 Evaluation of federal compliance requirements when receiving subawards U.S. Department of Health and Human Services Community Services Block Grant (Federal Assistance Listing #93.569) Federal Award Numbers: 60204, 60215, 60225, and 60235 Federal Award Year: 2020-2023 Responsible Officials Contact Information: 1) Monae Priolenau-Jones Telephone 718-310-5610, mpriolenau@wearebcs.org 2) Jodi Querbach Telephone 718-310-5600, X 1015 jquerbach@wearebcs.org View of Responsible Officials and Corrective Action Plan: BCS was notified that we must administer the Community Services Block grant program through a tripartite board for our fatherhood program. BCS has since received an advisory opinion from an Assistant General Counsel of the Department of Youth and Community Development stating that “the tripartite board requirement applies to local community action agencies [CAA], which is DYCD, not sub recipients...” Accordingly, as a sub recipient, BCS is not responsible for the implementation of the tripartite advisory committee. Moreover, the creation of the tripartite advisory committee would require BCS to have a board of directors which would include elected officials. It is in the sole discretion of BCS to decide whether to include an elected official on the board, as being mandated to do so by this directive may pose a potential conflict for BCS that may run contrary to state and federal laws. The BCS Board and Executive Management have implemented a comprehensive plan to complete the fiscal 2024 financial close and issue audited financial statements by November 30th, 2024. This marks an eight-month acceleration compared to fiscal 2023. This will be accomplished through better utilization of the general ledger system, a sequenced workplan with deadlines, and by assigning all tasks to specific staff. Step two of the same plan will deliver monthly financial statements within 21 days of the month end, starting with November 2024. These statements will be reviewed by Executive Management

View Audit 324549

Finding 502532 (2023-002)

None 2023

Cuyuna Regional Medical Center

MN

Reporting Subrecipient Monitoring § 200.512

Identifying Number: 2023-002 Finding: Late Issuance of 2023 Single Audit Reporting Package Corrective Actions Taken or Planned: The Center will issue the single audit reporting package after the external audit is completed. Our single audit was performed timely, however, the purposeful delay of the ...

Identifying Number: 2023-002 Finding: Late Issuance of 2023 Single Audit Reporting Package Corrective Actions Taken or Planned: The Center will issue the single audit reporting package after the external audit is completed. Our single audit was performed timely, however, the purposeful delay of the external audit impacted our ability to finalize. Contact Persons(s) Responsible for Correction Action: Katie Berg, CFO Completion Date: October 30, 2024

View Audit 324527

Finding 502476 (2023-001)

Material Weakness 2023

United Piedmont Center for Educational Excellence, INC

NC

Cash Management Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.305

To address these issues - UPCEE has hired a new Contract Manager (that comes highly recommended and has worked successfully with other TRIO programs) who will continue to do the following: • Oversee office management processes, budgets, and enhance our current way of working with federal timelines....

To address these issues - UPCEE has hired a new Contract Manager (that comes highly recommended and has worked successfully with other TRIO programs) who will continue to do the following: • Oversee office management processes, budgets, and enhance our current way of working with federal timelines. • Ensure billings are kept timely and entered in the financial system for QuickBooks Online and now updates data entry after each completed month. These changes allow for the immediate completion and availability of data to be used for 990 completion and audit processing. • Work in tandem with the UPCEE Executive Director to ensure these tasks are done. With the implementation of these new processes, UPCEE feels very confident that this will prevent any further need for risk management.

View Audit 324484

Finding 502397 (2023-003)

Significant Deficiency 2023

Pacific States Marine Fisheries Commission

OR

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.329

Timely Performance Reporting for Pacific Fisheries Data Program, 11.437; and Bipartisan Budget Act of 2018 (Disaster Relief Program), 11.022 Recommendation: CLA recommends for the Commission to implement stronger internal monitoring to ensure reports are completed by program managers and submitted ...

Timely Performance Reporting for Pacific Fisheries Data Program, 11.437; and Bipartisan Budget Act of 2018 (Disaster Relief Program), 11.022 Recommendation: CLA recommends for the Commission to implement stronger internal monitoring to ensure reports are completed by program managers and submitted to the Grants Manager timely to ensure ample time for internal review and upload to the Federal Agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will set an internal deadline at least one week prior to the external report due date. The Grant & Contract Specialist will coordinate with the Finance Officer to submit report timely in the event the Grant & Contract Specialist is absent. Name(s) of the contact person(s) responsible for corrective action: Michael Arredondo and Ngu Castro. Planned completion date for corrective action plan: October 15, 2023

View Audit 324412

Finding 502372 (2023-002)

Significant Deficiency 2023

Pacific States Marine Fisheries Commission

OR

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.318

Sufficient Documentation for Noncompetitive Proposals for Pacific Fisheries Data Program, 11.437 Recommendation: CLA recommends increased internal monitoring to ensure that noncompetitive procurements are sufficiently justified and that internal Sole Source Justification Forms are completed correct...

Sufficient Documentation for Noncompetitive Proposals for Pacific Fisheries Data Program, 11.437 Recommendation: CLA recommends increased internal monitoring to ensure that noncompetitive procurements are sufficiently justified and that internal Sole Source Justification Forms are completed correctly and retained for all vendors procured under noncompetitive methods. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will modify its subcontractor request form and PO form to require competitive supporting documents or non-competitive justification documents to be attached with the subcontractor request or PO form. Contract Specialist and Purchasing Specialist will review request package to ensure all required paperwork completed properly before moving forward with the process. In the pipe line, Requisition Module in Navision Software will be designed to put a hard stop if a purchase order of $10,000 or greater is missing supporting document for competitive/non-competitive procurements. Name(s) of the contact person(s) responsible for corrective action: Kathy Ameral and Michael Arredondo. Planned completion date for corrective action plan: October 15, 2023

View Audit 324412 Questioned Costs: $1

Finding 502353 (2023-001)

Significant Deficiency 2023

Universal Technology College of Puerto Rico, INC

PR

Student Financial Aid Subrecipient Monitoring Allowable Costs / Cost Principles

This years Single Audit will be planned with enough time alongside the auditor in order to ensure submission before the due date. No later than October 15, 2024 we will already have engaged an auditor to perform and begin the Single Audit for the year ending September 30, 2024.

View Audit 324396

Finding 502110 (2023-001)

Material Weakness 2023

The Homeless Families Foundation

OH

Questioned Costs Cash Management Reporting § 200.516

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2023 through December 31, 2023 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Fin...

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2023 through December 31, 2023 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Recommendation. Uniform Guidance stipulates that reimbursements are paid to subrecipients in a timely manner. The Organization did not pay subrecipients in a timely manner for the months of January through June 2023, resulting in $261,999 of untimely reimbursements. b. Action Taken or Planned on the Finding The Organization met with subrecipients prior to December 31, 2023 to establish increased control processes, including outlining documentation requirements, timeframes for reimbursement submission, identifying correct staff contacts for timely communications, and formalizing a timeframe for approving/distributing subrecipient disbursements. The Organization has paid all reimbursements through December 2023 as of February 2024.

View Audit 324321 Questioned Costs: $1

Finding 502092 (2023-001)

Significant Deficiency 2023

Ripley County, Missouri

MO

Subrecipient Monitoring Reporting § 200.510

This audit has taught me a lot concerning what is required with the SEFA report in the County Budget process. I will print out a copy of all Community Development Block Grant Funds that were expensed in the year in a report from QuickBooks. I will include those with the SEFA (Schedule of Expenditure...

This audit has taught me a lot concerning what is required with the SEFA report in the County Budget process. I will print out a copy of all Community Development Block Grant Funds that were expensed in the year in a report from QuickBooks. I will include those with the SEFA (Schedule of Expenditures of Federal Awards) report. I will also follow up with Alan Lutes, Executive Director with Ozark Foothills Regional Planning Commission, when I complete the SEFA report and have their office review the report to make sure all Community Development Block Grant Funds are included that were expenses that year from their office. In addition, I will include all supporting documents in the budget process to review with the County Commissioners at the time of the budget approval.

View Audit 324279

Finding 502000 (2023-007)

Significant Deficiency 2023

Woodward-Granger Community School District

IA

Subrecipient Monitoring Period of Performance

The subaward will be updated to include elements required by Uniform Guidance, Part 200.332.

View Audit 324201

Finding 501999 (2023-005)

None 2023

Woodward-Granger Community School District

IA

Subrecipient Monitoring

The District will review its procedures to ensure compliance with Uniform Guidance, Part 200.332 and Part 200.501.

View Audit 324201

Finding 501995 (2023-004)

Material Weakness 2023

Cleveland Urban Minority Alcoholism Outreach Project, Inc.

OH

Questioned Costs Subrecipient Monitoring Material Weakness § 200.302 § 200.328 § 200.415

1. A critical aspect of Cleveland UMADAOP’s updating of financial policies and procedures will be training on the proper and timely completion of federal forms 2. Weekly meetings will be held with Program Directors with a standard agenda item of upcoming due dates within the subsequent four weeks. 3...

1. A critical aspect of Cleveland UMADAOP’s updating of financial policies and procedures will be training on the proper and timely completion of federal forms 2. Weekly meetings will be held with Program Directors with a standard agenda item of upcoming due dates within the subsequent four weeks. 3. During these meetings, Directors will be required to provide status updates and draft submissions when applicable. 4. Once a quarter, a federal compliance requirement will be selected to have a deep dive review. 5. An HQ Administrative Assistant will be hired to monitor compliance as well as adherence to deadlines and will prepare a monthly report for the Executive Director’s review.

View Audit 324194 Questioned Costs: $1

Finding 501978 (2023-002)

None 2023

Lincoln County

MT

Subrecipient Monitoring

FINDING 2023-002: Late Audit Submission Response: Lincoln County will enSure it will be done by the deadline for FY- 24.

View Audit 324140

Finding 501936 (2023-002)

Material Weakness 2023

Dayton School District #8

OR

Subrecipient Monitoring Reporting Material Weakness § 200.508 § 200.510

Finding 2023-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education CFDA Title and Number 10.555 National School Lunch Program cluster Name of Federal Agency: U.S. Dep...

Finding 2023-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education CFDA Title and Number 10.555 National School Lunch Program cluster Name of Federal Agency: U.S. Department of Agriculture Compliance/Internal Control over Compliance: Auditee Responsibilities Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Expenditures of federal awards and not be detected and corrected. Because the Auditee’s SEFA was completed incorrectly, and not reconciled to the general ledger the SEFA was materially misstated, prior to auditors’ correction recommendations. Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • No reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: No Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. District’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: October 1, 2024 Responsible Person: Director of Business Services, Yamhill County School District No. 8

View Audit 324120

Finding 501932 (2023-002)

Material Weakness 2023

Housing Authority of Chelan County and the City of Wenatchee

WA

HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding ref number: 2023-002 Finding caption: The Housing Authority had inadequate internal controls for ensuring compliance with the Housing Quality Standards enforcement requirements of its Housing Voucher Cluster program. Name, address, and telephone of Housing Authority contact person: Joanna Te...

Finding ref number: 2023-002 Finding caption: The Housing Authority had inadequate internal controls for ensuring compliance with the Housing Quality Standards enforcement requirements of its Housing Voucher Cluster program. Name, address, and telephone of Housing Authority contact person: Joanna Tepley, Finance Director 1555 S. Methow Street Wenatchee, WA 98801 (509) 663-7421 Corrective action the auditee plans to take in response to the finding: The HCV department will be creating an Excel spreadsheet for the inspector to complete and utilize to better manage compliance dates. It will include the failed inspection date, compliance due date, tenant and landlord names, passed date, abatement start date, and memos. In addition, the supervisor will be monitoring this spreadsheet and auditing inspection compliance more frequently. Anticipated date to complete the corrective action: Immediately

View Audit 324117

Corrective Action Plans

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