Corrective Action Plans

Finding 396236 (2022-003)

Significant Deficiency 2022

Houston Regional Hiv/aids Resource Group, Inc.

TX

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

2022-003 Compliance and Internal Controls over Allowable and Allocable Costs (Significant Deficiency) U.S. Department of Health and Human Services 93.918- Ryan White Title C Contract No. H7CHA36798-01-03, H76HA00684-22-00, and H76HA00684-23-00 Texas Department of State Health Services State HIV Serv...

2022-003 Compliance and Internal Controls over Allowable and Allocable Costs (Significant Deficiency) U.S. Department of Health and Human Services 93.918- Ryan White Title C Contract No. H7CHA36798-01-03, H76HA00684-22-00, and H76HA00684-23-00 Texas Department of State Health Services State HIV Service Grants Contract No. 537-18-0097-00001 and HHS001022300002 Recommendation: The Resource Group should follow its policies regarding expense reimbursement grants and ensure support for costs submitted for reimbursement comply with 2 CFR Subpart E. Corrective Action: To ensure expense reimbursement and support of cost submitted by subrecipients comply with 2 CFR Subpart E, The Resource Group will annually verify the subrecipient’s cost allocation plan. To verify costs are allowable and allocable to the grant, The Finance Director will conduct fiscal monitoring of subrecipients. The fiscal monitoring will be conducted at least annually in accordance with all state and federal statues, regulations and terms and conditions. As a component of the monitoring, The Resource Group will verify costs submitted for reimbursement are allowable, reasonable, approved and accurately submitted. This includes verification of the cost allocation plan and underlying documentation of associated expenses. The Finance Director is responsible for oversight and administration of fiscal monitoring. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. In the event the Finance Director position is vacant more than 90 days, The Resource Group will contract with an appropriate financial contractor to conduct annual monitoring as needed. In the event of extenuating circumstances and the subrecipient is not reviewed annually, The Resource Group will determine the appropriateness of all costs under the cost allocation plan through the submission of alternate supporting documentation. This will be verified prior to the close of the grant period. Progress to date 1. The Finance Director was hired in August 2023. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight department. The primary objective of the visit was to discuss financial monitoring requirements as it allies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director has developed a fiscal monitoring schedule for 2024. Onsite reviews started in February 2024. The testing period for subrecipient monitoring has been expanded to include a testing period from Fiscal Year 2022 and Fiscal Year 2023. Responsible Party: Finance Director, Garland Thompson; Executive Director, Tiffany Shepherd, MPH Date to be Corrected: August 2024

View Audit 305880 Questioned Costs: $1

Finding 396235 (2022-002)

Significant Deficiency 2022

Houston Regional Hiv/aids Resource Group, Inc.

TX

Subrecipient Monitoring § 200.303 § 200.332

2022-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) U.S. Department of Housing and Urban Development 14.241- Housing Opportunities for Persons with AIDS Contract No. 537-17-0195-00001 and HHS001022300003 Texas Department of State Health Services Sta...

2022-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) U.S. Department of Housing and Urban Development 14.241- Housing Opportunities for Persons with AIDS Contract No. 537-17-0195-00001 and HHS001022300003 Texas Department of State Health Services State HIV Service Grants Contracts No. 537-18-0097-00001 and HHS001022300002 Recommendation: The Resource Group should follow its policies to perform fiscal monitoring of its subrecipients in accordance with 2 CFR Section 200.332. Corrective Action: In accordance with 2 CFR Section 200.332, The Resource Group as the pass-through entity will ensure subrecipient fiscal monitoring is completed in 2024 to ensure compliance with federal and state requirements. The Finance Director is responsible for oversight and administration of fiscal monitoring. Fiscal monitoring will be conducted at least annually in accordance with HRSA Monitoring Standards 45 CFR 74.51 and 45 CFR 75.352. As a pass-through entity, the fiscal monitoring will include at minimum reviews of financial performance and compliance with federal and state statues, regulations and terms and conditions. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. Progress to date: 1. The Finance Director was hired in August 2023. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight department. The primary objective of the visit was to discuss financial monitoring requirements as it allies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director has developed a fiscal monitoring schedule for 2024. Onsite reviews started in February 2024. The testing period for subrecipient monitoring has been expanded to include a testing period from Fiscal Year 2022 and Fiscal Year 2023. Responsible Party: Finance Director, Garland Thompson Date to be Corrected: February-August 2024

View Audit 305880

Finding 395860 (2022-005)

Material Weakness 2022

Boulder City Hospital, Inc.

NV

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Finding 2022-005 Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As o...

Finding 2022-005 Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2022, the Hospital should have USDA debt reserves at least equal to $320,669. Responsible Individuals: Douglas B. Lewis, CFO Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.

View Audit 305482

Finding 395811 (2022-002)

Material Weakness 2022

City of Anaheim

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Finding 2022-002, ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds Following the comprehensive audit conducted on the CWWAPP 1.0 disbursement Year Ended June 30, 2022, the following exceptions have been identified that require immediate attention. Below is a summary of the exceptions obs...

Finding 2022-002, ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds Following the comprehensive audit conducted on the CWWAPP 1.0 disbursement Year Ended June 30, 2022, the following exceptions have been identified that require immediate attention. Below is a summary of the exceptions observed: Summary of Exceptions: 1.Credits applied for electric and secondary water disbursements exceeded the prescribed 60-day timeframe. 2.Recalculation of eligible credits for three out of sixty samples resulted in awarded amounts surpassing the calculated eligibility, leading to questioned costs (i.e., over award). Corrective Action Plan: 1.In order to ensure adherence to the stipulated 60-day window for credit applications, for the upcoming CWWAPP arrearage funding we have initiated immediate testing of bill notices upon receipt of the CWWAPP 2.0 disbursement check. Simultaneously, a secondary query has been implemented to validate consistency between the initial query and the present data. Should any discrepancies or technical issues arise, we will promptly seek extension from the State Water Resources Control Board (SWRCB) to facilitate timely funding. 2.To mitigate the risk of over awarding eligible customers, a final query will be conducted prior to disbursement to confirm the accuracy of awarded amounts for each eligible account. We are committed to implementing these corrective measures swiftly and effectively to uphold compliance standards and improve efficiency within the framework of the SWRCB and CWWAPP. Responsible Official: Jeff Sparks Assistant Customer Service Manager Corrective Action Plan Implementation Date: May 17th, 2024

View Audit 305456 Questioned Costs: $1

Finding 395661 (2022-003)

Material Weakness 2022

Next Move Homeless Services

CA

Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.327

Program: Continuum of Care, Emergency Solutions Grant Program Federal Financial Assistance Listing No.:14.267, 14.231 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward, Sacramento County Department of Human Assistance Award Year: 2022 Compliance ...

Program: Continuum of Care, Emergency Solutions Grant Program Federal Financial Assistance Listing No.:14.267, 14.231 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward, Sacramento County Department of Human Assistance Award Year: 2022 Compliance Requirement: Procurement, Suspension and Debarment Grant Award Number: CA0955L9T032007, CA0955L9T032108, CA0143L9T032013, CA0143L9T032114, CA1303L9T032006, CA1303L9T032107, DHA-PRTS-NM-06-22, DHA-NM-03-22, DHA-NM-03-23, DHA-NM-08-23, DHA-NM-10-23 Finding Summary: The Organization’s procurement policy did not include all the required elements as outlined in the Uniform Guidance. Additionally, the Organization did not retain documentation to support the procedures performed to ensure compliance with suspension and debarment requirements. Management’s Response: We concur. Views of Responsible Officials and Corrective Action: • Management will update policies and procedures to ensure they confirm to the Uniform Guidance regarding procurement, suspension and debarment (2 CFR 200.317 through 200.327, 2 CFR 180). • Train grant staff on new policies and procedures. Name of Responsible Person: Bryan Wagner, CFO Projected Implementation Date: December 31, 2024

View Audit 305283

Finding 394926 (2022-004)

Significant Deficiency 2022

St. Francis Center

CO

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties § 200.303

Finding 2022-004 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure costs requested for reim...

Finding 2022-004 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure costs requested for reimbursement were eligible under program requirements. Time incurred on a different program was included in error when summarizing payroll costs. Responsible Individuals: Nancy Burke, CEO Corrective Action Plan: We will implement controls and processes to review reimbursement requests to ensure allowable costs are being reimbursed through the grant. Anticipated Completion Date: December 31, 2023

View Audit 304772

Finding 394924 (2022-003)

Material Weakness 2022

St. Francis Center

CO

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303

Finding 2022-003 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure matching expenses were a...

Finding 2022-003 Federal Agency Name: Department of Housing and Urban Development Program Name: Block Grants for Community mental Health Services Federal Financial Assistance Listing: #93.958 Finding Summary: The Organization did not have adequate internal controls to ensure matching expenses were appropriately tracked to meet award requirements. In addition, it was identified that all expenses did not have adequate documentation supporting the review and approval of the amounts meeting the matching requirements. Additionally, select payroll allocations did not have supporting documentation for the amounts allocated to the program. Responsible Individuals: Nancy Burke, CEO Corrective Action Plan: We will implement controls and processes to appropriately track and monitor matching requirements in each period for all awards. In addition, we will implement approval processes to ensure proper qualification for the match requirements and allocations. Anticipated Completion Date: December 31, 2023

View Audit 304772

Finding 394879 (2022-008)

Significant Deficiency 2022

Carlton County, Minnesota

MN

Student Financial Aid Cash Management Reporting § 200.303

Finding Number: 2022-008 Finding Title: LCTS Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Ann Ozan – Fiscal Supervisor II. Corrective Action Planned: Document the review of the public health, corrections, and school district quarterly...

Finding Number: 2022-008 Finding Title: LCTS Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Ann Ozan – Fiscal Supervisor II. Corrective Action Planned: Document the review of the public health, corrections, and school district quarterly reports. Review is being done when the state report is prepared, but not currently documented. Anticipated Completion Date: December 31, 2023.

View Audit 304767

Finding 394336 (2022-007)

Significant Deficiency 2022

Williston Basin Public School District #7

ND

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303 § 200.403

2022-007 – TITLE I – INADEQUATE SUPPORTING DOCUMENTATION– ALN 84.010 – SIGNIFICANT DEFICIENCY & OTHER NONCOMPLIANCE FINDING TYPE: SIGNIFICANT DEFICIENCY & OTHER NONCOMPLIANCE Finding 2022-007 Federal Program: Title I ALN: 84.010 Federal Award Number(s) and Year(s): S010A200034, 2022 Federal Agency:...

2022-007 – TITLE I – INADEQUATE SUPPORTING DOCUMENTATION– ALN 84.010 – SIGNIFICANT DEFICIENCY & OTHER NONCOMPLIANCE FINDING TYPE: SIGNIFICANT DEFICIENCY & OTHER NONCOMPLIANCE Finding 2022-007 Federal Program: Title I ALN: 84.010 Federal Award Number(s) and Year(s): S010A200034, 2022 Federal Agency: U.S. Department of Education Questioned Cost: $7,591 Condition: We were unable to verify whether 6 of 60 expenditures totaling $7,591 were for costs allowed under the Title I grant. When projected against the total population of $1,628,283, the total projected error is $15,939. Corrective Action Plan: Agreed. WBSD#7 created a new Grants Coordinator position in July 2023 with one of the specific responsibilities for that position being oversight of all Federal Title programs. This oversight responsibility includes monitoring expenditures to ensure all expenditures are allowable within the parameters of each program and also that proper documentation for those expenditures has been maintained. Anticipated Completion Date: • Fiscal Year 2024

View Audit 304345 Questioned Costs: $1

Finding 394031 (2022-005)

Significant Deficiency 2022

City of Homer, Alaska

AK

Reporting Subrecipient Monitoring Significant Deficiency § 200.303

Finding 2022-005 Review of Reporting – Significant Deficiency in Internal Control over Compliance Planned Corrective Actions: All reporting will be reviewed by at least one other staff member to ensure accuracy prior to submission. Individual(s) Responsible for Corrective Action Plan Elizabeth Fisch...

Finding 2022-005 Review of Reporting – Significant Deficiency in Internal Control over Compliance Planned Corrective Actions: All reporting will be reviewed by at least one other staff member to ensure accuracy prior to submission. Individual(s) Responsible for Corrective Action Plan Elizabeth Fischer (Finance Director) Jenna deLumeau (Controller) Anticipated Completion Date: This has been completed.

View Audit 304153

Finding 393830 (2022-004)

Significant Deficiency 2022

Heading Home

NM

Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.320

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. Management has reviewed the existing procurement policies and procedures found in Section III Policy #301 of Heading Homes fiscal policies and procedures with appropriate staff and will...

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. Management has reviewed the existing procurement policies and procedures found in Section III Policy #301 of Heading Homes fiscal policies and procedures with appropriate staff and will enforce the policies and procedures to ensure competitive bids are obtained where required. Management has also reviewed the existing suspension and debarment policies and procedures found in Section III Policy #302 with appropriate staff and which requires these vendors to be reviewed on the SAM website to ensure they have not been suspended or debarred. While after the fact, each of the five vendors noted in this finding have since been reviewed on the SAM website and none of them returned any notices of having been suspended or debarred. Management is in the process of going back and reviewing all vendors paid $10,000 or more against the SAM website and will ensure all vendors are checked against the website who currently meet this requirement as well as for those it is anticipated will meet this threshold. Proof of the SAM website review and approval will be maintained in each vendor file. Management anticipates the above corrective action plan to be fully implemented by June 30, 2024. Personnel responsible for ensuring implementation include Connie Chavez, Chief Executive Officer, Debbie Brickman, Chief Financial Officer, and Armando Sanchez, contract accountants team lead.

View Audit 304033

Finding 393653 (2022-001)

Significant Deficiency 2022

Town of Brownington

VT

Allowable Costs / Cost Principles § 200.303

Correction Action Plan (Concerning Finding 2022-001) (Activities Allowed/ Cost Principles): Contact Person Responsible for Corrective Action: Beverly White, Chairman of the Selectboard. Corrective Action: The Town of Brownington will take the following actions to address finding 2022-001. There is a...

Correction Action Plan (Concerning Finding 2022-001) (Activities Allowed/ Cost Principles): Contact Person Responsible for Corrective Action: Beverly White, Chairman of the Selectboard. Corrective Action: The Town of Brownington will take the following actions to address finding 2022-001. There is a non-written policy that if there is a bill that requires payment prior to the board meeting, the Treasurer must contact two boards members and receive verbal permission to pay the bill and the bill would then go on the warning for the next board meeting. After verbal permission is granted, the Selectboard Member approving the expenditure, will sign the bill. The Town of Brownington will update our approval process by adding if there is a bill that requires payment prior to the board meeting, the Treasurer must contact two board members and receive verbal permission to pay the bill and the bill would then go on the warning for the next board meeting. After verbal permission is granted, the Selectboard Member approving the expenditures, will sign the bill. Anticipated Completion Date: April 30, 2024.

View Audit 303800

Finding 393572 (2022-003)

Material Weakness 2022

Johnson County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

FINDING 2022-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion. Three contracts out of seven did not include the suspension and debarment requirements. The County has al...

FINDING 2022-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion. Three contracts out of seven did not include the suspension and debarment requirements. The County has already executed addendums with the contractors to correct this issue. Contact Person Responsible for Corrective Action: Adam Gadberry Contact Phone Number and Email Address: 317.346.4392 agadberry@co.johnson.in.us Views of Responsible Officials: “We concur with the finding.” Description of Corrective Action Plan: The County has already added the suspension and debarment language to the County’s standard contracts for SLRF projects. County has also added checking for suspension and debarment to the County’s contract checklist. Anticipated Completion Date: December 31, 2023

View Audit 303741

Finding 393571 (2022-002)

Material Weakness 2022

Johnson County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2022-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, other matters. 2022 Q4 P&E report failed to include a $1,500,000 expenditure. Recommendation is that management of County design and implement a proper sy...

FINDING 2022-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, other matters. 2022 Q4 P&E report failed to include a $1,500,000 expenditure. Recommendation is that management of County design and implement a proper system of internal control including policies and procedures to ensure that the County provides Treasury with complete and accurate information for the P&E report. Contact Person Responsible for Corrective Action: Adam Gadberry Contact Phone Number and Email Address: 317.346.4392 agadberry@co.johnson.in.us Views of Responsible Officials: “We concur with the finding.” Description of Corrective Action Plan: The $1,500,000 expenditure for road repairs was one of two tranches for road repairs. The first tranche was in the proper location of -122 while the second tranche was placed in location -201 and as a result the expenditure was inadvertently missed. The County became aware of the issue and included this expenditure on the subsequent P&E Report for Q2. Moving forward as programs are added, the location of those funds should be in location -122. When they must be in a different location, access will be given to the Board of Commissioners Executive/Administrative Assistant to track expenditures. Anticipated Completion Date: June 30, 2024

View Audit 303741

Finding 393458 (2022-001)

Material Weakness 2022

North Tippah Consolidated School District

MS

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303 § 200.458

The district did not have clear guidance and was unsure of how entries shoiuld be made. This was a process that had not been done before. Request was made prior to Mississippi Department of Education guidance and before the MCAPS update was available. Entry correction ahs been made and district wil...

The district did not have clear guidance and was unsure of how entries shoiuld be made. This was a process that had not been done before. Request was made prior to Mississippi Department of Education guidance and before the MCAPS update was available. Entry correction ahs been made and district will update policy to verify correct entries.

View Audit 303675

Finding 393450 (2022-009)

Material Weakness 2022

The Center for Black Women's Wellness, Inc.

GA

Procurement, Suspension & Debarment § 200.303

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-009: Suspension and Debarment- Material Weakness Recommendation: We recommend the Organization strengthen its policies and procedures to ensure suspension and de...

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-009: Suspension and Debarment- Material Weakness Recommendation: We recommend the Organization strengthen its policies and procedures to ensure suspension and debarment is adequately documented so that goods and services are purchased in accordance with Uniform Guidance and other federal guidelines. In addition, the Organization should verify that all vendors under covered transactions are not listed on the excluded parties list system by performing a search on sam.gov and maintaining the results of such search in the vendor’s file. Grantee Response and Corrective Action Plan 2022-009: In response to the audit finding under 2 CFR part 180 regarding the necessity to verify suspension or debarment status in compliance with the excluded parties list system, it is acknowledged that while the Center for Black Women’s Wellness did not previously have a formal policy specifically addressing suspension and debarment, our practices have nonetheless complied with the requirements. Recognizing the importance of formalizing these practices into policy, we are committed to developing and implementing a comprehensive policy that explicitly addresses these checks. This initiative will be integrated with our existing compliance frameworks to ensure consistent adherence across all procurement activities. In line with our recent enhancements in internal controls, including the engagement of a Contractual CFO in 2024, this policy will reinforce our ongoing efforts to uphold the highest standards of compliance and accountability in all our operations. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

View Audit 303667

Finding 393449 (2022-008)

Material Weakness 2022

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.320

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-008: Procurement – Material Weakness Recommendation: We recommend the Organization strengthen its policies and procedures to ensure procurement is adequately doc...

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-008: Procurement – Material Weakness Recommendation: We recommend the Organization strengthen its policies and procedures to ensure procurement is adequately documented so that goods and services are purchased in accordance with Uniform Guidance and other federal guidelines. Grantee Response and Corrective Action Plan 2022-008: We acknowledge the gap identified between our policy framework and its execution, particularly in the area of maintaining supporting documentation. The Center for Black Women’s Wellness has approved policies that are designed to meet the requirements of the Uniform Guidance; however, we recognize that in practice, implementation has been inconsistent. Notably, of the sixty transactions reviewed, eight were found lacking in supporting documentation. To address this issue, we have already taken corrective measures by reinforcing our procedures and ensuring that appropriate staff are aware of these requirements. In 2024, we strengthened our oversight by engaging a Contractual CFO who will be instrumental in implementing these enhanced controls. This effort is part of our ongoing commitment to ensure full compliance and transparency in our procurement processes, thereby aligning our practices more closely with our established policies. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

View Audit 303667 Questioned Costs: $1

Finding 393448 (2022-007)

Material Weakness 2022

The Center for Black Women's Wellness, Inc.

GA

Cash Management Internal Control / Segregation of Duties § 200.303 § 200.305

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-007: Cash Management – Material Weakness Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all draw down r...

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-007: Cash Management – Material Weakness Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all draw down requests are reviewed and approved to ensure costs were accurately reported and paid before requesting reimbursement. Grantee Response and Corrective Action Plan 2022-007: We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. Previously draw down documentation was uploaded to a shared folder, in which the CEO and Fiscal Manager had access. In 2023, we implemented additional procedures to document review of drawdowns and supporting documentation. Additionally, documentation includes attaining the CEO signature on draw down documentation before the draw down is made. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

View Audit 303667

Finding 393447 (2022-006)

Material Weakness 2022

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.308 § 200.309 § 200.403

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-006 – Period of Performance – Significant Deficiency Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all...

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-006 – Period of Performance – Significant Deficiency Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all expenses include supporting documentation/invoice indicating period of performance. Grantee Response and Corrective Action Plan 2022-006: The Center for Black Women's Wellness has proactively updated our credit card policy in 2022. The CEO reviews the credit card statement monthly for discrepancies and allowable costs. Additionally, credit card holders are responsible for reviewing their credit card statements monthly for discrepancies and allowable costs. This measure aligns with our broader fiscal management improvements, which also involve the engagement of a Contractual CFO in April 2024 to oversee and refine our financial operations. These initiatives are part of our commitment to maintaining rigorous financial integrity and ensuring that all transactions are transparent and compliant with regulatory requirements. Additionally, we have resolved past documentation issues, such as those arising from the abrupt departure of an employee, by implementing robust procedures to avoid similar incidents in the future. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

View Audit 303667 Questioned Costs: $1

Finding 393446 (2022-005)

Material Weakness 2022

The Center for Black Women's Wellness, Inc.

GA

Questioned Costs Internal Control / Segregation of Duties Material Weakness § 200.303

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-005 – Non Payroll Expenses- Material Weakness Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all expense...

U.S Department of Health and Human Services FALN: 93.926 Federal Award Identification Number: 5 H49MC00119-21-00 / 6 H49MC00119-20-01 2022-005 – Non Payroll Expenses- Material Weakness Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all expenses include supporting documentation/invoice indicating nature of expense, amount, authorization and approval for payment. Grantee Response and Corrective Action Plan 2022-005: The CEO has always reviewed the credit card statement monthly for discrepancies and allowable costs. Additionally, credit card holders are responsible for reviewing their credit card statements monthly for discrepancies and allowable costs. The Center for Black Women's Wellness has proactively updated our credit card policy in 2022, which is now signed by all employees, to reinforce the policy that receipts must be submitted to cardholder within 24 hours. This measure aligns with our broader fiscal management improvements, which also involve the engagement of a Contractual CFO in April 2024 to oversee and refine our financial operations. These initiatives are part of our commitment to maintaining rigorous financial integrity and ensuring that all transactions are transparent and compliant with regulatory requirements. Additionally, we have resolved past documentation issues, such as those arising from the abrupt departure of an employee, by implementing robust procedures to avoid similar incidents in the future. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

View Audit 303667 Questioned Costs: $1

Finding 393373 (2022-001)

Material Weakness 2022

City of Crawfordsville

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2022-001 Contact Person Responsible for Corrective Action: Terri Gadd, Clerk-Treasurer Contact Phone Number: (765) 364-5150 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Starting with the 2023 reporting of State and Local Fiscal Recovery Fu...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Terri Gadd, Clerk-Treasurer Contact Phone Number: (765) 364-5150 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Starting with the 2023 reporting of State and Local Fiscal Recovery Funds (SLFRF) Compliance Reporting to U.S. Treasury: The City of Crawfordsville management will follow the following process. 1. Before processing request from designated organizations the Clerk Treasurer and Mayor or a designated person, will review documentation and approve for payment/claim processing. 2. After approval a claim will be submitted to the Clerk Treasurer office for payment. 3. Clerk Treasurer will prepare and submit monthly expenditure report to the Mayor or designated person. 4. Annually before the Clerk Treasurer, reports to the U.S. Treasury expenditures the Clerk Treasurer and Mayor, or designated person, will review and confirm expenditures. 5. Clerk Treasurer will submit report to U.S. Treasury following prompts. 6. Clerk Treasurer will notify Mayor of the annual report submission. Anticipated Completion Date: January 2024

View Audit 303629

Finding 393273 (2022-003)

Significant Deficiency 2022

Ecostudies Institute

WA

Questioned Costs Internal Control / Segregation of Duties Cash Management § 200.303

Significant Deficiency in Internal Control over Compliance and Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence should be obtained and retained by The Organization as proof of oversight of expenditure of federal funds...

Significant Deficiency in Internal Control over Compliance and Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence should be obtained and retained by The Organization as proof of oversight of expenditure of federal funds. CLA would recommend the use of an AP voucher, or similar, for each type of disbursement that leaves the Organization (check, EFT, credit card, etc.) to improve documentary evidence that costs are being reviewed and approved for appropriateness. There is no disagreement with the audit finding. Action taken in response to finding: Since Fall/Winter 2023, we have increased the emphasis and training for all staff on documenting evidence of approvals, including obtaining and retaining necessary documentation and proof of expenditure oversight for federal funds to ensure there is adequate evidence that costs are being reviewed and approved for appropriateness. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 4/1/2024

View Audit 303558 Questioned Costs: $1

Finding 393088 (2022-002)

Material Weakness 2022

Phelps County

MO

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Suspension and Debarment U.S. Department of Treasury Recommendation: We recommend the County implement internal controls to ensure that suspension and debarment assessment are performed during the procurement and contracting phase. In addition, sufficient documentation should be retained to evidence...

Suspension and Debarment U.S. Department of Treasury Recommendation: We recommend the County implement internal controls to ensure that suspension and debarment assessment are performed during the procurement and contracting phase. In addition, sufficient documentation should be retained to evidence suspension and debarment is performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review the procurement and contracting process and implement suspension and debarment assessment procedures where necessary. Name(s) of the contact person(s) responsible for corrective action: Laura Johnson and Cathy Tipton Planned completion date for corrective action plan: December 31, 2024

View Audit 303427

Finding 392926 (2022-004)

Significant Deficiency 2022

Range Mental Health Center, Inc.

MN

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

Action Taken: Range Mental Health Center, Inc. and Subsidiaries is in the process of developing internal controls to ensure timely and appropriate actions are made to ensure timely and accurate reporting as it relates to grant requirements. We are currently performing a review of all grants to ensur...

Action Taken: Range Mental Health Center, Inc. and Subsidiaries is in the process of developing internal controls to ensure timely and appropriate actions are made to ensure timely and accurate reporting as it relates to grant requirements. We are currently performing a review of all grants to ensure reporting requirements are met.

View Audit 303202

Finding 392922 (2022-005)

Significant Deficiency 2022

Range Mental Health Center, Inc.

MN

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

Action Taken: Range Mental Health, Inc. and Subsidiaries is in the process of developing internal controls to ensure timely and appropriate actions are made to ensure timely and accurate reporting as it relates to grant requirements. We are currently performing a review of all grants to ensure repor...

Action Taken: Range Mental Health, Inc. and Subsidiaries is in the process of developing internal controls to ensure timely and appropriate actions are made to ensure timely and accurate reporting as it relates to grant requirements. We are currently performing a review of all grants to ensure reporting requirements are met.

View Audit 303202

Corrective Action Plans

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