Corrective Action Plans

Finding 1158146 (2024-001)

Material Weakness 2024

NV

Allowable Costs / Cost Principles § 200.303

CORE, Powered by The Rogers Foundation has discontinued the use of the Payroll Action Forms for tracking labor allocations. As of August 2025, all grant-funded positions have been converted to hourly status, with time and effort now documented directly by employees through Paylocity, the Organizatio...

CORE, Powered by The Rogers Foundation has discontinued the use of the Payroll Action Forms for tracking labor allocations. As of August 2025, all grant-funded positions have been converted to hourly status, with time and effort now documented directly by employees through Paylocity, the Organization’s timekeeping system. Employees clock in and out and designate the appropriate labor allocations for each portion of their workday. Human Resources pulls the Paylocity timecard reports for all grant-funded positions for each pay period. These timecards undergo a documented, multi-level review and approval process: first by the Program Manager, then by the Grant Manager. Approved timecards are uploaded to a secure shared drive, where the Grant Accountant uses them to prepare Requests for Reimbursement (RFRs). Before submission, the Grant Manager performs a final review of all expenses and supporting documentation and provides written sign-off on the total amount. CORE, Powered by The Rogers Foundation has designed and implemented, multi-level internal control system to ensure all payroll charges are properly authorized, supported, and retained prior to inclusion in RFRs, thereby preventing recurrence of the issue identified in the audit.

View Audit 370066

Finding 1158132 (2024-002)

Material Weakness 2024

Cook Inlet Native Head Start

AK

Allowable Costs / Cost Principles § 200.303

Federal Award Finding: Finding: 2024-002 Journal Entry Approval - Significant Deficiency in Internal Control over Compliance Name of Contact Person: John Cutter Corrective Action: - Extend the above policy specifically to federal grant-related transactions. - Require grant manager or finance directo...

Federal Award Finding: Finding: 2024-002 Journal Entry Approval - Significant Deficiency in Internal Control over Compliance Name of Contact Person: John Cutter Corrective Action: - Extend the above policy specifically to federal grant-related transactions. - Require grant manager or finance director review for any adjusting entries impacting federal awards. - Ensure that all adjustments are clearly tied to grant documentation and compliance rules (Uniform Guidance 2 CFR 200). Proposed Completion Date: September 30, 2025

View Audit 370059

Finding 1158123 (2024-001)

Material Weakness 2024

Tulsa Community Foundation

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more ...

Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more in-depth federal award process and collaborate with project partners to ensure their understanding of the compliance requirements as per Uniform Guidance (UGG) 2 CFR 200.303. The Foundation will also begin internal monitoring to ensure project partners are following established policies and procedures through the duration of each award. To support this corrective action, the Foundation has hired an experienced senior accountant to strengthen internal capacity. The qualified senior accountant will oversee federal grants and ensure ongoing compliance with internal controls and help to prevent recurrence of the issue. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by December 31, 2025.

View Audit 370045

Finding 1158045 (2024-004)

Material Weakness 2024

Hamilton County Area Neighborhood Development, Inc.

IN

Cash Management Period of Performance Matching / Level of Effort / Earmarking § 200.303

Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management's Corrective Actions: During 2025, Hamilton County Area Neighborhood Development, Inc. (HAND) hired a con...

Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management's Corrective Actions: During 2025, Hamilton County Area Neighborhood Development, Inc. (HAND) hired a controller to assist with the preparation of the parent company and subsidiaries financials while instituting improved internal control policies. As such, HAND with the assistance of its controller will establish effective internal control systems to ensure the compliance with the requirements for grant agreements and cash management compliance requirements

View Audit 369997

Finding 1158020 (2024-002)

Material Weakness 2024

Young Women's Christian Association of Kalamazoo, Michigan

MI

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

Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grant...

Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grants, the Organization was unable to provide enrollment forms or supporting documentation. These forms are necessary to verify that participants met the program's eligibility criteria. YWCA Response- The YWCA Victim Services acknowledges this finding and has implemented the following corrective action plan to ensure compliance. Corrective Action Plan - Procedures exist to ensure all clients are enrolled and eligible for services under the STOP grant. In addition to documentation in the Apricot system, an additional legal screening process and intake forms are used to determine eligibility and complete client enrollment within a Victim Services application called MyCase. During the audit, documentation for the four identified cases from MyCase was erroneously excluded, causing the finding. As a subsequent event, the documentation for intake and eligibility for the four identified cases was provided to the external auditors. This process will continue, and future audits will include client documentation for both systems. Additionally, Enforcement of enrollment procedures within Apricot, and oversight from department Directors, has been made a priority. Time Frame for Correction -Appropriate procedures were in place during the full audit year of 2024 and will continue into future years. Corrective action related to documentation within the Apricot system was implemented in August 2025. Individuals Responsible - Jessica Glynn, Vice President of Victim Services and Kellie Swikoski, Grant Manager.

View Audit 369986 Questioned Costs: $1

Finding 1157967 (2024-002)

Material Weakness 2024

Iclei – Local Governments for Sustainability Usa, INC

MI

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

2024-002 - Lack of Independent Review and Approval Auditor Description of Condition and Effect: During our testing of Allowable Costs/Cost Principles, of the 12 items tested, we noted all 12 instances where time sheets were missing evidence of review and approval. In addition, there was no evidence ...

2024-002 - Lack of Independent Review and Approval Auditor Description of Condition and Effect: During our testing of Allowable Costs/Cost Principles, of the 12 items tested, we noted all 12 instances where time sheets were missing evidence of review and approval. In addition, there was no evidence of review and approval of the hourly rate or salary for all the employees tested. During Cash Management testing, of the three items tested, all three drawdown requests were missing evidence of review and approval. Finally, during our testing of Reporting, all four of the reports selected for testing lacked evidence of review and approval. The Organization did not comply with the federal requirements as noted per 2 CFR 200.303. Auditor Recommendation: We recommend the Organization adheres to their internal control process of an independent review and approval of transactions, cash management and reporting related to federal grant programs. Corrective Action: While the Organization has controls in place to ensure proper review and approval, Management will ensure to have this process documented going forward. Responsible Person: Dora Gonzales Anticipated Completion Date: December 2025

View Audit 369971

Finding 1157911 (2024-004)

Material Weakness 2024

Local Redevelopment Authority of the Lands and Facilities of Naval Station Roosevelt Roads

PR

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Cash Management § 200.303 § 200.339 § 200.511

2024-004 Water and Waste Disposal Loans and Grants (Section 306C) (Not A Major Program) Reserve Account The Finance Department will transferer the amount of $151,462 to fully fund the Reserve Account to meet the $201,982 balance required by the loan agreement. Starting in Fiscal Year 2025-2026, LRA’...

2024-004 Water and Waste Disposal Loans and Grants (Section 306C) (Not A Major Program) Reserve Account The Finance Department will transferer the amount of $151,462 to fully fund the Reserve Account to meet the $201,982 balance required by the loan agreement. Starting in Fiscal Year 2025-2026, LRA’s Finance Department will implement within its monthly accounting closing procedures the reconciliation and review of all transfers from General Account to Reserve Account. The monthly reconciliations and review will provide full compliance with USDA reserve account requirements, eliminates repeated findings in future audits and will improve transparency in reporting strengthening accountability and reduced risk of federal payments. LRA Finance Department will establish a formal review process to ensure all prior year findings are properly tracked and resolved. Jamille E Muriente Díaz, Financial Affair Director Telephone: 787-705-7188 Email: Jamille.muriente@lra.pr.gov Target Completion Date - 6/30/2026

View Audit 369939

Finding 1157762 (2024-002)

Material Weakness 2024

Vibrant Hawaii

HI

Internal Control / Segregation of Duties § 200.303

All reimbursement claims submitted under federal or state food service programs shall undergo documented management review prior to submission, in compliance with 2 CFR §200.303 and program requirements. Claims must be signed and dated by the Program Director (or designee) and reviewed by the CEO or...

All reimbursement claims submitted under federal or state food service programs shall undergo documented management review prior to submission, in compliance with 2 CFR §200.303 and program requirements. Claims must be signed and dated by the Program Director (or designee) and reviewed by the CEO or CFO on a sample basis to verify compliance.

View Audit 369902

Finding 1157688 (2024-004)

Material Weakness 2024

Michael Fields Agricultural Institute, Inc.

WI

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.308

Finding 2024-004 – Key Personnel Requirements ● Issue: No internal controls to track/approve changes in key personnel (repeat of 2023-007). ● Corrective Actions: 1. Formalize procedures for notifying federal funders of personnel changes. ● Responsible Party: Operations Manager, Executive Director ● ...

Finding 2024-004 – Key Personnel Requirements ● Issue: No internal controls to track/approve changes in key personnel (repeat of 2023-007). ● Corrective Actions: 1. Formalize procedures for notifying federal funders of personnel changes. ● Responsible Party: Operations Manager, Executive Director ● Timeline: Finalize procedure by December 2025.

View Audit 369871

Finding 1157649 (2024-001)

Material Weakness 2024

Beadle and Spink Enterprise Community, Inc.

SD

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

2024 – 001 Reporting (Compliance, Internal Controls Over Compliance) Material Weakness – ALN 10.767 Intermediary Relending Program Condition: Testing of the reporting requirements disclosed that the quarterly and semiannual IRP reports were not submitted to USDA Rural Development. Corrective Action ...

2024 – 001 Reporting (Compliance, Internal Controls Over Compliance) Material Weakness – ALN 10.767 Intermediary Relending Program Condition: Testing of the reporting requirements disclosed that the quarterly and semiannual IRP reports were not submitted to USDA Rural Development. Corrective Action Plan: BASEC management and staff has taken USDA Rural Development provided LINC training on September 30, 2025 and has been in contact with Clark Guthmiller, IRP specialist with USDA Rural Development. BASEC has implemented a procedure with IRP reporting to be done the month following the quarter end (April, July, October and January). The procedure includes the following steps: 1. In Porfol (loan software), Executive Director will review the Master Loan List for IRP Direct and IRP Revolved for quarter end to ensure all IRP loans are listed and all payment information is current as of month end. 2. Executive Director will then pull the Delinquency report to ensure IRP (revolved and direct) delinquency statuses. 3. Executive Assistant will review that all IRP loans are up to date and payment information is accurate and return to Executive Director 4. Executive Director will log into LINC (USDA system for loan reporting) and update the loan information and submit each month after quarter end. BASEC’s IRP approaching year budget will be submitted to USDA Rural Development by October 31st to allow time for any questions or corrections to ensure an approval from USDA prior to the new year. Emily Rodgers Executive Director

View Audit 369860

Finding 1157632 (2024-001)

Material Weakness 2024

Chicago Park District

IL

Subrecipient Monitoring Special Tests & Provisions § 200.303

Finding 2024-001: Reporting – Recordkeeping Planned Corrective Action: The Chicago Park District will implement the following strategies to improve the management of the Summer Food Service Program (SFSP).  Review and analyze audit findings with staff, Area Managers, and Administration in order to ...

Finding 2024-001: Reporting – Recordkeeping Planned Corrective Action: The Chicago Park District will implement the following strategies to improve the management of the Summer Food Service Program (SFSP).  Review and analyze audit findings with staff, Area Managers, and Administration in order to prevent findings.  2025 DMC, has a new line at the bottom of the page, that will have staff print their name and then second line for signature and date. See attached for example.  Hold a citation meeting of sites that received ISBE citations in 2024, prior to the start of summer. In 2025, electronically send ISBE citations in real time, once wellness receives the citation is emailed to Park Supervisor and Area Manager.  Continue train monitors to review SFSP binders, check food temperature, date of service and signature recorded on all invoices and DMC, and attendance. Ensure seasonal monitors will be onsite for the duration of meal service.  Mandate that at least three of staff members per site are trained in SFSP (pending number of staff at park location).  Provide multiple in person trainings before start of the season to all field staff emphasize the importance of accuracy and details when following the Policy and Procedures of the Summer Food Service Program. Name of the Contact Person Responsible for Corrective Action: Farah Tunks, Director of Programming Meghan O’Boyle, Wellness Manager Anticipated Completion Date: September 30, 2025

View Audit 369845

Finding 1157584 (2024-001)

Material Weakness 2024

Fulton County Government

GA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Fulton County District Attorney's Office has maintained compliance with their policy and procedure regarding time and effort management since August 2024. The SAKI grant employees per policy complete activity reports which document their activities on a biweekly basis, reflect time worked, and t...

The Fulton County District Attorney's Office has maintained compliance with their policy and procedure regarding time and effort management since August 2024. The SAKI grant employees per policy complete activity reports which document their activities on a biweekly basis, reflect time worked, and then sign those reports. Those reports are then reviewed and signed by a supervisor with a knowledge of their work. Those reports are maintained and kept in the Fulton County District Attorney's Office.

View Audit 369827 Questioned Costs: $1

Finding 1157583 (2024-002)

Material Weakness 2024

Fulton County Government

GA

Subrecipient Monitoring § 200.303 § 200.331

The Fulton County Department of Behavioral Health and Developmental Disabilities (DBHDD) performs continuous monitoring activities with program subrecipients by conducting weekly meetings, reviewing monthly reports, invoices, and conducts quarterly performance reviews. DBHDD will strengthen its subr...

The Fulton County Department of Behavioral Health and Developmental Disabilities (DBHDD) performs continuous monitoring activities with program subrecipients by conducting weekly meetings, reviewing monthly reports, invoices, and conducts quarterly performance reviews. DBHDD will strengthen its subrecipient monitoring internal controls by properly documenting these reviews in order to be incompliance with 2 CFR 200.331, and the County’s Subrecipient Monitoring Policy.

View Audit 369827

Finding 1157582 (2024-003)

Material Weakness 2024

Fulton County Government

GA

Subrecipient Monitoring § 200.303 § 200.331

The Department of Senior Services follows the monitoring standards established by the pass-through entity and has implemented process improvements to ensure that all Program Year 2024-2025 compliance processes were met. The current period monitoring plan, risk assessments and monitoring have been co...

The Department of Senior Services follows the monitoring standards established by the pass-through entity and has implemented process improvements to ensure that all Program Year 2024-2025 compliance processes were met. The current period monitoring plan, risk assessments and monitoring have been completed. The Department will maintain an annual monitoring plan to ensure that all subrecipients are monitored in compliance with 2 CFR 200 requirements.

View Audit 369827

Finding 1157579 (2024-002)

Material Weakness 2024

Better Family Life, Inc.

MO

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsib...

Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsible Fatherhood Grants Award Period: September 30, 2023 – September 29, 2024 Award Period: September 30, 2024 – September 29, 2025 Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Teen Pregnancy Prevention Education Assistance Listing Number: 93.297 Assistance Listing Program Title: Adolescent Health Programs Award Period: July 1, 2023 – June 30, 2024 Award Period: July 1, 2024 – June 30, 2025 Management response to 2024-002: In response to the auditors’ recommendation, management has addressed this deficiency by assigning appropriate personnel to review and approve all Federal reporting before submission. Additionally, management has implemented specific procedures for review and approval of drawdown requests, which include reviewing the indirect cost rate applied in all drawdown requests.

View Audit 369809

Finding 1157578 (2024-001)

Material Weakness 2024

Better Family Life, Inc.

MO

Cash Management § 200.303 § 200.305

Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsib...

Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsible Fatherhood Grants Award Period: September 30, 2023 – September 29, 2024 Award Period: September 30, 2024 – September 29, 2025 Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Teen Pregnancy Prevention Education Assistance Listing Number: 93.297 Assistance Listing Program Title: Adolescent Health Programs Award Period: July 1, 2023 – June 30, 2024 Award Period: July 1, 2024 – June 30, 2025 Management response to 2024-001: In response to the auditors’ recommendation, management has addressed this deficiency by assigning appropriate personnel to properly track and monitor drawdown requests to ensure the costs requested for reimbursement have been incurred, are complete and accurate, and in line with Federal award requirements. Additionally, management has implemented specific procedures for review and approval of all drawdown requests.

View Audit 369809

Finding 1157538 (2024-001)

Material Weakness 2024

Washington State Building & Construction Trades Council

WA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

The Council has implemented procedures to include documentation of approval for all grant-funded expenditures to strengthen internal controls and ensure compliance with federal standards.

View Audit 369756

Finding 1157517 (2024-001)

Material Weakness 2024

Coburn Place Safehaven Ii, Inc.

IN

Matching / Level of Effort / Earmarking Reporting § 200.303

Views of Responsible Officials and Planned Corrective Action: We agree with the recommendation and have implemented the recommendation as noted.

View Audit 369728

Finding 1157447 (2024-005)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Cash Management Subrecipient Monitoring § 200.303 § 200.305

U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...

U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25

View Audit 369689

Finding 1157446 (2024-004)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25

View Audit 369689

Finding 1157438 (2024-003)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Reporting HUD Housing Programs Significant Deficiency § 200.303

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25

View Audit 369689

Finding 1157414 (2024-001)

Material Weakness 2024

Partnership4health Community Health Board

MN

Subrecipient Monitoring Cash Management Significant Deficiency § 200.303 § 200.305

Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal poli...

Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal policy where any payment remittance advices' must be responded to and completed within two weeks of receipt to ensure that payments are deposited, and member counties of the CHB are reimbursed for the expenses that were submitted for in a prompt manner. Anticipated Completion Date: August 15, 2025

View Audit 369676

Finding 1157412 (2024-001)

Material Weakness 2024

Denver Health and Hospital Authority

CO

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

FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a man...

FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025

View Audit 369665

Finding 1157390 (2024-003)

Material Weakness 2024

Educare of Omaha, Inc.

NE

Cash Management Eligibility Material Weakness § 200.303

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR...

US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2025

View Audit 369654

Finding 1157364 (2024-002)

Material Weakness 2024

Keystone Restituere Justice Center, Inc.

PA

Cash Management § 200.303 § 200.305

Finding 2024-002: Material weakness in internal controls over compliance – cash management Recommendation: Management should improve the monitoring of actual expenditures ot better algin cash needs and draw down requests with actual expenditures incurred. Explanation of Disagreement with Audit Findi...

Finding 2024-002: Material weakness in internal controls over compliance – cash management Recommendation: Management should improve the monitoring of actual expenditures ot better algin cash needs and draw down requests with actual expenditures incurred. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: In April of 2024, KRJC established a financial policy that ensures that funds are only drawn down for expenses incurred and/or accrued during the reporting period. All expenses are booked into KRJC’s accounting system. KRJC then calculates any funding due from BJA and then completes a draw down for any payments due. In an effort to ensure that funds are never overdrawn but that KRJC can pay sub-awardees and contracts in a timely manner, this process may occur multiple times in any given quarter. In addition, KRJC has worked to develop a pool of unrestricted funds and is working to develop an operating reserve, using private funds, that will allow the organization some additional flexibility in our financial operations and will ultimately allow KRJC to shift to quarterly drawdowns. Planned completion date for corrective action plan: July 2024

View Audit 369651

Corrective Action Plans

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