Corrective Action Plans

Finding 568832 (2024-004)

Material Weakness 2024

ND

Allowable Costs / Cost Principles Material Weakness § 200.303

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Applicable Federal Award Number and Year - Period 6 TIN #205330283 Activities Allowed or Unallowed and Allowable Costs/Cost Pri...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Applicable Federal Award Number and Year - Period 6 TIN #205330283 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Finding Summary: There was no formal review or approval of the expenditure spreadsheet used to calculate the expenditures claimed for the federal program outside of the preparer. In addition, we noted the individual transactions were also not reviewed or approved by someone outside of the business office manager. Responsible Individuals: Kathy Morrow, Business Office Manager, Kelly VandeVorste, Interim Administrator Corrective Action Plan: Management will ensure that the information contained in supporting spreadsheets and individual transactions for federal programs is reviewed and approved by someone other than the preparer or the person initiating the transactions. Anticipated Completion Date: December 31, 2025

View Audit 360565

Finding 568831 (2024-003)

Material Weakness 2024

Rolette Community Care Center

ND

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Applicable Federal Award Number and Year - Period 6 TIN #205330283 Reporting Material Weakness in Internal Control Over Complia...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Applicable Federal Award Number and Year - Period 6 TIN #205330283 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: Rolette Community Care Center does not have an internal control system to ensure the amounts reported in the HHS Period 6 Special Report agreed to supporting documentation for each of the quarters included. In addition, there was no evidence of review of either the supporting documentation or the HHS Period 6 Special Report by someone other than the preparer. Responsible Individuals: Kathy Morrow, Business Office Manager Corrective Action Plan: Management will ensure that the information contained in the reports agrees to the supporting documentation and both documentation and the reports submitted are reviewed by someone other than the preparer. Anticipated Completion Date: December 31, 2025

View Audit 360565

Finding 568828 (2024-001)

Significant Deficiency 2024

Beth Israel Lahey Health, Inc.

MA

Subrecipient Monitoring § 200.332

Management Response and Corrective Action Plan Finding 2023-002 – Subrecipient Monitoring Federal Agency: United States Department of Health and Human Services Program Name: Research and Development (R&D) Assistance Listing Number: Various Responsible Individual: Roy Bourne, Director, Research F...

Management Response and Corrective Action Plan Finding 2023-002 – Subrecipient Monitoring Federal Agency: United States Department of Health and Human Services Program Name: Research and Development (R&D) Assistance Listing Number: Various Responsible Individual: Roy Bourne, Director, Research Finance and Operations Contact Information: rbourne2@joslin.harvard.edu; 617-309-5741 Joslin Diabetes Center’s (Center) subrecipient monitoring process did not clearly indicate risk assessment procedures or the required monitoring activities in certain audited instances. While the Center has a Subrecipient Monitoring and Management policy, review suggests that a thorough evaluation of this plan, formal documentation, and secondary oversight will improve internal control. Management agrees with the recommendation and will evaluate the subrecipient monitoring process according to 2 CFR 200.332 and update established policy where applicable. Corrective Action Plan: - Management completed the review of the Subrecipient Monitoring and Management policy for relevant updates and improvements to internal control as of May 2025 - Results of risk assessment procedures and subrecipient monitoring will be formally documented within the tracking log - Log entries were updated to reflect a reviewers note documenting material and date of review as of May 2025 - Director of Research Finance and Operations will review log semi-annually for secondary oversight Expected Completion Date: June 30, 2025 Status of Completion: Partially corrected

View Audit 360561

Finding 568827 (2024-001)

None 2024

Alma Housing Commission

MI

HUD Housing Programs

The Housing Commission has a better understanding of the Federally Insured requirements. We will monitor the bank accounts rather than strictly rely on the financial institutions. We have moved the funds over to another financial institution to receive the proper coverage.

View Audit 360558

Finding 568825 (2024-002)

Significant Deficiency 2024

City of Huntsville

AL

Subrecipient Monitoring Cash Management Reporting

We agree with the auditors comments and the following action has been taken: - Quarterly meetings will be held between the Community Development department and the Grants Manager to walk through any changes to grant reporting requirements and confirm grant deliverables are being submitted timely.

View Audit 360552

Finding 568820 (2024-001)

Material Weakness 2024

Greater Erie Community Action Committee

PA

Reporting Internal Control / Segregation of Duties

Corrective Action Plan: GECAC Finance Department has a Financial and Data Processing System that is followed in regards to posting transactions. GECAC’s Finance department has been challenged due to a shortage of staff since COVID in 2020. As a result, GECAC has experienced a tremendous amount of ...

Corrective Action Plan: GECAC Finance Department has a Financial and Data Processing System that is followed in regards to posting transactions. GECAC’s Finance department has been challenged due to a shortage of staff since COVID in 2020. As a result, GECAC has experienced a tremendous amount of turnover making it extremely difficult to stay on task with all duties. Controls have been implemented to ensure timely record keeping of all fiscal transactions: The Finance department is now fully staffed. When reconciling monthly bank statements, any transactions that are listed as an outstanding item will be researched and the necessary entries will be done to fix the problem so that the item is reconciled before the next month’s statement is issued. When running the monthly balance sheet and revenue/expense statement, any transactions that are incorrect and/or not posted, staff will make the adjusting entry(s) to correct the issue immediately. We currently have a full time Payroll/Fiscal Assistant in place. That staff has implemented a check list to ensure that all payroll transactions are recorded during the correct period. We are currently looking into upgrading our Payroll/HR software system to ensure more efficient processes which will help with time management. We will continue to evaluate and improve the financial processes and procedures as well as work on enhancing and streamlining training for new and existing accounting personnel. Contact Person: Antoinette Nicholson, Vice President of Finance Anticipated Completion Date: September 30, 2025

View Audit 360550

Finding 568817 (2024-002)

Material Weakness 2024

American Farmland Trust

DC

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

AFT remains committed to maintaining an effective system of internal control over financial reporting and compliance. To that end, AFT has taken the following corrective actions to ensure appropriate and timely compliance with FFATA filing requirements. 1. F&A Staff reviewed FFATA Training Resources...

AFT remains committed to maintaining an effective system of internal control over financial reporting and compliance. To that end, AFT has taken the following corrective actions to ensure appropriate and timely compliance with FFATA filing requirements. 1. F&A Staff reviewed FFATA Training Resources and SAM.gov resources o Ongoing Staff Training of F&A staff and staff identified in item 4. 2. Updated AFT’s Subawards Manual. The purpose of the Subawards Manual document is to assist in the preparation, administration, and management of AFT issued subawards. The Subaward Manual identifies the roles and responsibilities of AFT staff throughout the subaward lifecycle. 3. Updated Subaward Template FFATA Reporting Requirements and Data Collection 4. To ensure timely compliance with FFATA reporting requirements o Designated Contract Administrator with responsibility to file FFATA reports in connection with the execution and delivery of any subaward which occurs through our contracts management system o Will designate grant management staff to confirm filing 5. F&A Remediation o F&A is pulling the Schedule of Expenditures of Federal Awards (SEFA) data for FY22, FY23, and FY24 to determine which prime grants may have had subawards o Identify subaward agreements that require FFATA filing If AFT does not have the required information to make FFATA, AFT program, project, and/or finance staff will be tasked with obtaining the information o Make the required FFATA reports on SAM.gov 6. AFT will continue to monitor compliance with the updated procedures and FFATA requirements on a quarterly basis. o Using shared resources, finance will work with the Administrative Coordinator to verify that tracked information for issued subawards resulted in timely filing.

View Audit 360549

Finding 568814 (2024-002)

Significant Deficiency 2024

Southeast Rural Community Assistance Project, Inc.

VA

Reporting Subrecipient Monitoring § 200.328

Audit Recommendation – We recommend that management and relevant staff participate in comprehensive training on federal grant compliance – emphasizing FFATA obligations and financial reporting deadlines – to ensure a clear understanding requirements. Management should then formalize and document pro...

Audit Recommendation – We recommend that management and relevant staff participate in comprehensive training on federal grant compliance – emphasizing FFATA obligations and financial reporting deadlines – to ensure a clear understanding requirements. Management should then formalize and document procedures for FFATA reporting, including a calendar driven workflow with designated preparers and approvers, mandatory sign-off checklists, and automated reminders. Finally, the Organization should implement a centralized reporting tracking system that monitors all federal award deadlines and captures evidence of timely preparation, review, and submission for both financial and performance reports.   Management Response – We concur with the recommendation and in process of making changes the both the work flow and processes stated. Specifically, we have contracted with two outside consulting firms for both grant compliance and internal audit services from Certified Public Accountant licensed professionals. Finally, both independent consultants will report the compliance status to the CEO on a periodic basis. 

View Audit 360529

Finding 568798 (2024-001)

None 2024

Channahon School District No. 17

IL

Reporting

The District will implement a process to track the submission time of the data collection form and audit package.

View Audit 360513

Finding 568514 (2024-003)

Significant Deficiency 2024

Bmc Health System, Inc.

MA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties HUD Housing Programs § 200.303

Audit Report Reference: 2024-003 Program name: Research and Development Completion Date: September 30, 2025 Finding 2024-003 is a repeat finding (2023-001) from fiscal year end September 30, 2023. The Health System implemented change controls and audit of employee permissions per the corrective act...

Audit Report Reference: 2024-003 Program name: Research and Development Completion Date: September 30, 2025 Finding 2024-003 is a repeat finding (2023-001) from fiscal year end September 30, 2023. The Health System implemented change controls and audit of employee permissions per the corrective action plan for 2023-001.The corrective actions for repeat finding 2024-003 addresses documentation of performed controls and training for employees involved in the control activities. Workday Change Review: The HRIS team will continue with a change review audit as they have done in the previous year with a few enhancements to increase auditability. The Sr. HRIS Manager will send official communication to the HRIS team to initiate the end-of-year change review. This email will provide a clear timeline for the audit period with a hard deadline. Once complete, the HR Compliance Manager and/or the Sr. HRIS Manager will issue a written communication to document the completion of the review summary of findings (if any), and corrective actions taken (if applicable). This will remedy the issue of missing approval documentation. The team will also be reeducated around the need to document written approval and testing for changes throughout the year. Workday Security Review: The HRIS team will continue to conduct an audit of security roles and users within Workday to ensure that permissions are updated appropriately. The HRIS Analyst will generate reports for the Sr. HRIS Manager's review, identifying any required changes. The analyst will then make these updates in Workday, followed by a new report for verification. Upon successful verification, the Sr. HRIS Manager will send a formal written communication of the approved changes. Workday Terminations: To address the access provisioning deficiency as it relates to terminating employees, the management team will be re-trained in the importance of adhering to timely terminations of employees in Workday. Person Responsible: Ashley Cesarano - HR Compliance and Workplace Accommodations Manager; Karen Alvarado – Senior Manager HRIS E-mail address: Ashley.Cesarano@bmc.org; Karen.Alvarado@bmc.org

View Audit 360505

Finding 568230 (2024-002)

Significant Deficiency 2024

Bmc Health System, Inc.

MA

Subrecipient Monitoring § 200.332

Audit Report Reference: 2024-002 Program name: Research and Development Completion Date: October 30, 2024 Finding 2024-002 is a repeat finding (2023-003) from fiscal year end September 30, 2023. Boston Medical Center Health System (Health System) completed its corrective action plan for 2023-003 in ...

Audit Report Reference: 2024-002 Program name: Research and Development Completion Date: October 30, 2024 Finding 2024-002 is a repeat finding (2023-003) from fiscal year end September 30, 2023. Boston Medical Center Health System (Health System) completed its corrective action plan for 2023-003 in October, 2024. Sponsored Programs Administration (SPA) completed both elements of the 2023-003 corrective action plans: • SPA documented a risk assessment for all active subrecipients to ensure the total population was complete and up-to-date. • SPA revised and updated the standard operating procedures for subrecipient risk assessments. The auditors noted in 2024-002 that risk assessments were not complete prior to the execution of agreements for subrecipients tested. However, risk assessments were performed for all subrecipients by October 2024. The repeat finding is a result of the timing of the Health Systems review and implementation of an updated SOP. Going forward, all new amendments and new subrecipient agreements will have a risk assessment prior to execution that complies with our new SOP. As noted by the auditors, for all subrecipients tested during fiscal year end September, 2024 the Health System performed monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, review of Uniform Guidance Audit reports, and review of debarment or suspension. The Health System believes that the corrective action for 2023-003 and 2024-002 are complete and no further corrective action is required. Person Responsible: Tyler Flack - Senior Director, Sponsored Programs Finance E-mail address: Tyler.Flack@bmc.org

View Audit 360505

Finding 568228 (2024-001)

None 2024

Research Triangle Institute

NC

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Audit Finding: Item 2024-001: Error in Federal Funding Accountability and Transparency Act (FFATA) Reporting Contact Person Responsible for Corrective Action Plan: Justin Johnson, Director, Government Compliance and Internal Controls Email: jbjohnson@rti.org Phone Number: 919-541-6127 Corrective Act...

Audit Finding: Item 2024-001: Error in Federal Funding Accountability and Transparency Act (FFATA) Reporting Contact Person Responsible for Corrective Action Plan: Justin Johnson, Director, Government Compliance and Internal Controls Email: jbjohnson@rti.org Phone Number: 919-541-6127 Corrective Action Plan: Summary of Finding: FFATA requires non-federal entities to report each first-tier subaward action that obligates $30,000 or more to the FFATA Subaward Reporting System (FSRS). Our independent auditor found that a sampled subaward transaction was not reported timely to the FSRS. Corrective Action Implementation: RTI’s Government Compliance and Internal Controls department has taken the following actions to ensure the complete, accurate, and timely FFATA subaward reporting to FSRS: 1. On the automatically generated report of subaward actions to be reported to FSRS, correct the defective date parameters that prevented the subaward action from being reported timely. Completion Date: April 21, 2025. 2. On a semi-annual basis (fiscal year midpoint and fiscal year-end), manually generate the report of subaward actions to be reported to FSRS for the preceding six-month period and perform a secondary check for any actions that have not been reported timely. Completion Date: April 1, 2025.

View Audit 360502

Finding 568223 (2024-003)

Significant Deficiency 2024

National Indigenous Women's Resource Center, Inc.

MT

Subrecipient Monitoring

Internal Control over compliance - subrecipient monitoring. Non-compliance with reporting compliance requirements. Recommendation: We recommend the Center to update its polices and procedures and ensure a UEI number is obtained directly from a potential subrecipient before entering into a subaward a...

Internal Control over compliance - subrecipient monitoring. Non-compliance with reporting compliance requirements. Recommendation: We recommend the Center to update its polices and procedures and ensure a UEI number is obtained directly from a potential subrecipient before entering into a subaward agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Auction planned in response to finding: The Center has discontinued providing subawards to those subrecipients who have not provided a UEI number until said number is provided to the Center. The Center will update its policies and procedures to include and ensure a UEI number is obtained directly from a potentail subrecipient before entering into a subaward agreement.

View Audit 360498

Finding 568222 (2024-002)

Significant Deficiency 2024

National Indigenous Women's Resource Center, Inc.

MT

Subrecipient Monitoring Reporting Significant Deficiency

Internal Control over compliance - reporting. Non-compliance with reporting compliance requirements. Recommendation: We recommend the Center to carefully review grant agreements and ensure that grants personnel are familiar with the grant compliance requitements for reporting. We slo recommend the C...

Internal Control over compliance - reporting. Non-compliance with reporting compliance requirements. Recommendation: We recommend the Center to carefully review grant agreements and ensure that grants personnel are familiar with the grant compliance requitements for reporting. We slo recommend the Center to update its grant policies and procedures for the FFATA reporting requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: All grant agreements will be carefully reviewed for compliance requirements for reporting. The Center has taken steps to familiarize applicacle staff with the compliance reports for FFATA reporting, and progress has been made in the requirement to report subawards granted under FFATA reporting. We will also update our grants policies and procedures to specifically include a section for FFATA reporting of subawards.

View Audit 360498

Finding 568219 (2024-001)

Significant Deficiency 2024

Oxnard Pathway to Educated Nutrition INC

CA

Questioned Costs

Oxnard Pathway to Educated Nutrition, Inc. respectfully submits the following corrective action plan for the fiscal year ending September 30, 2024. Findings: 2024-001 CACFP-Administrative Budget Exceeded our approved budget in the Communications Category. Although a budget increase (revision) was re...

Oxnard Pathway to Educated Nutrition, Inc. respectfully submits the following corrective action plan for the fiscal year ending September 30, 2024. Findings: 2024-001 CACFP-Administrative Budget Exceeded our approved budget in the Communications Category. Although a budget increase (revision) was requested and approved for the above budget category, the amount of the increase was not sufficient to cover the total administrative costs at year’s ending. Note: Our agency did not exceed our total FY 23-24 Budget.As reflected on the UFAP DCH07, a total of $19,190.80 in unused funds were returned to CDSS in December 2024 Action Taken: Our organization will now track our administrative expenses monthly instead of quarterly. This will ensure there is enough time to request Specific Prior Written Approva/ timely budget revision, to any categories that may need to be increased or adjusted. If there are any questions regarding this plan, please call Angelita Barron at (805) 642-2720.

View Audit 360493 Questioned Costs: $1

Finding 568218 (2024-003)

Significant Deficiency 2024

Northwest Indian Fisheries Commission

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303 § 200.329

Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and...

Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and approved by the NWIFC Grants Program Manager and submitted to PSFMC. Effective immediately, the NWIFC grants program manager will increase internal controls by including documentation of internal review and approval prior to progress reports being submitted to PSMFC. Anticipated completion date: July 2025.

View Audit 360492

Finding 568217 (2024-002)

Material Weakness 2024

Northwest Indian Fisheries Commission

WA

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320 § 200.326

Person(s) responsible for corrective action: Lucy Yanez, Contract Specialist, Tracy Johnson, Accounts Payable, Tina Hurtado Controller, NWIFC staff and supervisors engaged in procurement and contracting. Management’s Response/Corrective Action Plan: The NWIFC implemented corrective measures relat...

Person(s) responsible for corrective action: Lucy Yanez, Contract Specialist, Tracy Johnson, Accounts Payable, Tina Hurtado Controller, NWIFC staff and supervisors engaged in procurement and contracting. Management’s Response/Corrective Action Plan: The NWIFC implemented corrective measures related to procurement in March of 2024. See FY23 Corrective Action Plan. However, the one procurement sample that was cited as not including “documentation of bidding, alternative price quotes or sole source documentation” contained a sole source justification that was developed before implementation of the FY23 Corrective Action Plan. The sole source justification was based on the specialized knowledge and specific expertise. Procurement samples for purchases or contracts after the implementation of the FY23 Corrective Action Plan, show compliance of adequate bidding, price quotes or sole source documentation consistent with 2 CFR 200. The NWIFC will continue to implement the FY23 Corrective Action Plan, by requiring NWIFC managers and their staff to be responsible for soliciting bids or developing sole source justifications for procurements and contracts consistent with 2 CFR 200. The Contract Specialist will ensure that bid solicitations and sole source justifications are properly documented and filed with each contract. Similarly, the audit noted that certain suspension and debarment samples selected, before the FY23 Corrective Action Plan was implemented in March 2024, lacked documentation of a suspension and debarment review prior to doing business with vendors. In response, the FY23 Corrective Action Plan, put into effect in March 2024, included measures to ensure that both new vendor and annual reviews are documented. The Accounts Payable department will continue to conduct suspension and debarment reviews for all new vendors before conducting business and perform annual reviews of all vendors, in line with the FY23 Corrective Action Plan. Anticipated completion date: Completed March 2024.

View Audit 360492 Questioned Costs: $1

Finding 568216 (2024-001)

Significant Deficiency 2024

Tallassee City Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent ...

Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior the submission of the July-September 2025 claim.

View Audit 360487 Questioned Costs: $1

Finding 568215 (2024-002)

Significant Deficiency 2024

Survivors of Torture, International

CA

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written ...

Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written policy and implement a documented process for the preparation and review of federal drawdowns, including clear evidence of review such as signoffs or electronic approvals. Responsible Individual: Andres Chavarro, Finance Manager Planned Completion date: 07/01/2025

View Audit 360483

Finding 568214 (2024-001)

Significant Deficiency 2024

Hawaiian Community Assets, Inc.

HI

Reporting Matching / Level of Effort / Earmarking Eligibility § 200.302 § 200.510

Re: FY23-24 Federal Single Audit Finding (2024-001) Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Perez, Finance Director; Jeff Gilbreath, Executive Director Hawaiʻi Community Lending (HCL) is diligent and ensures all grant requirements are met for Federal, State, and private ...

Re: FY23-24 Federal Single Audit Finding (2024-001) Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Perez, Finance Director; Jeff Gilbreath, Executive Director Hawaiʻi Community Lending (HCL) is diligent and ensures all grant requirements are met for Federal, State, and private funding awards. Due to the transitioning of its Finance Directors upon the start of the FY23-24 audit, the proper procedures to correct the CDFI ERP project account were miscommunicated, and the Schedule of Expenditures for Federal Awards (SEFA) were not reduced to reflect the proper adjustments. The corrective action being taken by HCL leadership is to ensure all loans disbursed and charged to restricted grants are reviewed thoroughly by the Finance Director. The Finance Director will review all eligibility requirements that are met, to include the eligible mapping area, as required and provided by the funder. This thorough review of eligibility will ensure that all loans charged to restricted funding will be properly allocated and charged correctly. In addition to the thorough review mentioned above, HCL will develop procedures to review the SEFA, in detail, which is prepared by a third-party accounting vendor. The procedures will include an extensive review of expenditures by the Finance Director and subsequent review and approval by the Executive Director to ensure all expenses are eligible and allocated properly to our federal grants. Once the SEFA has been fully reviewed and approved by the Finance Director and Executive Director, it will be forwarded to the auditors. Additional staff may be involved in the review and eligibility confirmation process to ensure accuracy. Internal audits of expenditures will also be completed on a quarterly basis. The anticipated completion date of this corrective action plan is June 30, 2025. Mahalo, Jeff Gilbreath Executive Director Hawaiʻi Community Lending

View Audit 360478

Finding 568192 (2024-001)

Significant Deficiency 2024

National Runaway Switchboard

IL

Cash Management Reporting

Condition: Certain expenditures were included in drawdowns in which the disbursement of funds did not occur within 3 business days per PMS guidelines. Corrective Action Taken or Planned: Management will better monitor cash reserves and ensure the Organization is complying with PMS guidelines. Manag...

Condition: Certain expenditures were included in drawdowns in which the disbursement of funds did not occur within 3 business days per PMS guidelines. Corrective Action Taken or Planned: Management will better monitor cash reserves and ensure the Organization is complying with PMS guidelines. Management is also working on a plan to build operating reserves and expand funding sources to assist in the Organization’s ability to navigate funding lapses. Anticipated Date of Completion: September 30, 2026 Name of Contact Person: Amanda Whitlock, Chief Executive Officer Management Response: Management concurs with the finding.

View Audit 360465

Finding 568158 (2024-005)

Significant Deficiency 2024

The Salvation Army Northwest Division

WA

Procurement, Suspension & Debarment § 200.214 § 200.320

The Division will formalize and adopt a procurement policy. This will also include a suspension and debarment check of vendors. Anticipated Completion Date: 8/1/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director

View Audit 360458

Finding 568153 (2024-004)

Significant Deficiency 2024

The Salvation Army Northwest Division

WA

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of re...

The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of reports will be added to the TSAMM during the review and approval of new contracts. We will also work with our funders to extend reporting due dates. Anticipated Completion Date: 12/31/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director

View Audit 360458

Finding 568135 (2024-003)

Significant Deficiency 2024

The Salvation Army Northwest Division

WA

Equipment & Real Property Management Internal Control / Segregation of Duties Special Tests & Provisions

The Division will ensure evidence of review is maintained for the inventory worksheets. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25. Responsible Contact Person: Julie Luft, NW Social Services Director

View Audit 360458

Finding 568117 (2024-002)

Material Weakness 2024

The Salvation Army Northwest Division

WA

Subrecipient Monitoring Eligibility Material Weakness

The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25...

The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25. Responsible Contact Person: Julie Luft, NW Social Services Director

View Audit 360458

Corrective Action Plans

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