Corrective Action Plans

Finding 563976 (2024-003)

Significant Deficiency 2024

County of Kern

CA

Allowable Costs / Cost Principles Period of Performance Significant Deficiency § 200.303

Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were i...

Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were incurred). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor’s Controllers office provides training on accrual basis of accounting at year-end training. All personnel related to recording the expenditures related to this program will be required to attend the meeting. In addition, the Auditor’s office will require all department heads and chief fiscal officers to sign off on the accuracy and completeness of their revenue and expenditures prior to closing each fiscal year going forward. Names of the contact persons responsible for corrective action: Aimee Espinoza, Auditor-Controller and Alonzo Solis, AC Senior Accountant. Planned completion date for corrective action plan: June 30, 2025, is not feasible due to the issuance date so expected completion date to June 30, 2026.

View Audit 358146

Finding 563974 (2024-002)

Significant Deficiency 2024

County of Kern

CA

Allowable Costs / Cost Principles Period of Performance Significant Deficiency § 200.303

Block Grants for Community Mental Health Services - Assistance Listing No. 93.958 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were incurred). ...

Block Grants for Community Mental Health Services - Assistance Listing No. 93.958 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were incurred). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor’s Controllers office provides training on accrual basis of accounting at year-end training. All personnel related to recording the expenditures related to this program will be required to attend the meeting. In addition, the Auditor’s office will require all department heads and chief fiscal officers to sign off on the accuracy and completeness of their revenue and expenditures prior to closing each fiscal year going forward. Names of the contact persons responsible for corrective action: Aimee Espinoza, Auditor-Controller and Alonzo Solis, AC Senior Accountant. Planned completion date for corrective action plan: June 30, 2025, is not feasible due to the issuance date so expected completion date to June 30, 2026.

View Audit 358146

Finding 563969 (2024-001)

Significant Deficiency 2024

Fouke School District

AR

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

We concur with the recommendation and will contact DESE to ensure that the correct process is used to move the unallowable costs totaling $843 to the Operating Fund. To correct the payroll issue of charging unallowable costs, the payroll clerk will run reports quarterly to verify all payroll charge...

We concur with the recommendation and will contact DESE to ensure that the correct process is used to move the unallowable costs totaling $843 to the Operating Fund. To correct the payroll issue of charging unallowable costs, the payroll clerk will run reports quarterly to verify all payroll charges to any federal fund are appropriate.

View Audit 358144 Questioned Costs: $1

Finding 563968 (2024-001)

Material Weakness 2024

Commonbond Communities

MN

Internal Control / Segregation of Duties Material Weakness Reporting

Corrective action – Management has designed and implemented an improved month end procedure and related review process, it will continue documenting its training program and developing team members, and more fully utilizing the accounting modules in its Enterprise Resource Planning system to add mor...

Corrective action – Management has designed and implemented an improved month end procedure and related review process, it will continue documenting its training program and developing team members, and more fully utilizing the accounting modules in its Enterprise Resource Planning system to add more system-based controls. Name of contact person – Jennifer Anderson, Interim Chief Financial Officer Proposed completion date – Management has begun the corrective action and is expected to have additional processes in place and training done by December 31, 2025.

View Audit 358143

Finding 563967 (2024-001)

None 2024

603 Legal Aid

NH

Subrecipient Monitoring Internal Control / Segregation of Duties

Planned Corrective Action: The 603LA Accounting Manual has been updated and completed, taking into consideration the requirements of the 2023 LSC Financial Guide, including the completion of the Self-Assessment Questionnaire (Appendix 9) of the Guide. The Board of Directors reviewed, approved, and ...

Planned Corrective Action: The 603LA Accounting Manual has been updated and completed, taking into consideration the requirements of the 2023 LSC Financial Guide, including the completion of the Self-Assessment Questionnaire (Appendix 9) of the Guide. The Board of Directors reviewed, approved, and codified the Accounting Manual at the May 28, 2025 Board of Directors meeting. Responsible Person: Controller. Date of Completion: Compliant as of May 2025.

View Audit 358140

Finding 563963 (2024-001)

Material Weakness 2024

Dequeen School District

AR

Procurement, Suspension & Debarment Allowable Costs / Cost Principles School Nutrition Programs

The District has implemented controls to ensure that USDA donated foods is tracked and credited on future FSMC invoices. The District made journal entries from Operating to cover the $244,203 that had been originally approved verbally by CNU. We then found out this was not an approved expense from C...

The District has implemented controls to ensure that USDA donated foods is tracked and credited on future FSMC invoices. The District made journal entries from Operating to cover the $244,203 that had been originally approved verbally by CNU. We then found out this was not an approved expense from Child Nutrition and corrected the expense.

View Audit 358138

Finding 563959 (2024-001)

Significant Deficiency 2024

Greenville County Commission on Alcohol and Drug Abuse

SC

Cash Management

Procedures have been put in place to request reimbursements timely on a monthly basis.

View Audit 358124

Finding 563943 (2024-001)

Significant Deficiency 2024

The Colonial Williamsburg Foundation

VA

Allowable Costs / Cost Principles Reporting

2024-001 – Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Management’s Corrective Action Plan: The program director will review the payroll data quarterly to ensure that the costs are accurate and allowable and provide documented evidenc...

2024-001 – Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Management’s Corrective Action Plan: The program director will review the payroll data quarterly to ensure that the costs are accurate and allowable and provide documented evidence of timely review to the Grant Officer. Estimated Completion Date: June 30, 2025 Individual(s) Responsible for Corrective Action Plan: Ramona Vogel (Hill), Executive Director, Historic Area Interpretation & Operations, (757) 220-7762

View Audit 358119

Finding 563942 (2024-004)

Significant Deficiency 2024

Town of North Haven, Connecticut

CT

Procurement, Suspension & Debarment § 200.318 § 200.326

Description of Finding The Town’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Although the Town did not have a policy in place in conformity with the federal uniform guidance criteria, the Town did follow their procedures as it ...

Description of Finding The Town’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Although the Town did not have a policy in place in conformity with the federal uniform guidance criteria, the Town did follow their procedures as it relates to the contracts under the procurements applicable to the Town's major programs. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action The Town will develop a conforming procurement policy including all essential elements. Name of Contact Person Richard Monico, Director of Administration/Procurement Projected Completion Date June 30, 2025

View Audit 358117

Finding 563939 (2024-003)

None 2024

845 Housing Corporation

RI

Internal Control / Segregation of Duties

The Corporation is applying for their auditee unique entity identifier. When it is received, the Corporation will file the Data Collection Form for the year ended December 31, 2024 with the Federal Audit Clearinghouse.

View Audit 358112

Finding 563938 (2024-001)

None 2024

845 Housing Corporation

RI

Questioned Costs

The management agent pressed charges and prosecuted the employee and recovered $48,200 from the auditee’s insurance company in total (less $2,500 deductible). The management agent implemented additional internal control procedures over the processing and review of the auditee’s cash account and cash...

The management agent pressed charges and prosecuted the employee and recovered $48,200 from the auditee’s insurance company in total (less $2,500 deductible). The management agent implemented additional internal control procedures over the processing and review of the auditee’s cash account and cash reconciliations by their employees. Those charged with governance of the auditee also retained the services of a different auditing firm to conduct the 2024 audit of the Corporation. In addition, those charged with governance have requested the Executive Director to perform more stringent review of the operational and financial activity and reports provided by the management agent monthly.

View Audit 358112 Questioned Costs: $1

Finding 563936 (2024-001)

Material Weakness 2024

Trees Forever, Inc.

IA

Cash Management Internal Control / Segregation of Duties

Finding 2024-001 – Review of Expense Details for Compliance Condition: From the selections made for internal controls testing, the auditor noted no review/approval for compliance with the terms of the grant agreement was conducted prior to submission of the costs to the grantor. Recommendation: W...

Finding 2024-001 – Review of Expense Details for Compliance Condition: From the selections made for internal controls testing, the auditor noted no review/approval for compliance with the terms of the grant agreement was conducted prior to submission of the costs to the grantor. Recommendation: We recommend management implement processes and controls to perform a review of expenses being submitted for reimbursement to document approval of costs in compliance with the terms of the grant. View of responsible officials and planned corrective actions: Management agrees with the finding and will conduct an internal review of federal expenditures for compliance with the requirements applicable to each federal grant received prior to submission for reimbursement. Anticipated Completion Date: May 31, 2025

View Audit 358111

Finding 563934 (2024-001)

Material Weakness 2024

Learning Grove, Inc.

KY

Subrecipient Monitoring Reporting § 200.329

Corrective Action Plan: Finding 2024‐001 Responsible: Roseann Hayes, Emily Lewis, George Moore DD Recommendation: We recommend the Organization establish procedures for the preparation, review and timely submission of all reporting requirements. This can include implementing a system to track report...

Corrective Action Plan: Finding 2024‐001 Responsible: Roseann Hayes, Emily Lewis, George Moore DD Recommendation: We recommend the Organization establish procedures for the preparation, review and timely submission of all reporting requirements. This can include implementing a system to track reporting deadlines and timely submission as well as designating individuals with the responsibilities of preparation, review, and submission of reports. Additionally, we recommend the Organization designate someone to review the grant documents for all compliance requirements to ensure nothing is missed. Corrective Action Summary: • Advancement and Finance will create an updated Grants Management process • This Grants Management process will: o Be documented o Clearly define roles for Advancement and Finance staff o Create a flowchart to define what type of grant has been awarded (conditional vs. unconditional) o Assure awarded grants are reviewed for all performance, outcomes, invoicing and reporting requirements o Define who sets up calendar reminders for grant milestones (i.e. reporting) o Define how Program staff will be selected to receive these calendar reminders Anticipated Completion Date: 6/30/2025

View Audit 358106

Finding 563872 (2024-002)

Significant Deficiency 2024

Federation of American Scientists

DC

Material Weakness Reporting Internal Control / Segregation of Duties

Identifying Number: 2024-001 Finding: Current management noted that the audited financial statements as of and for the year ended June 30, 2023, were materially misstated for certain contribution transactions recorded in error in the amount of $7,997,654. Those errors were corrected and recorded in...

Identifying Number: 2024-001 Finding: Current management noted that the audited financial statements as of and for the year ended June 30, 2023, were materially misstated for certain contribution transactions recorded in error in the amount of $7,997,654. Those errors were corrected and recorded in fiscal year 2024, which is not in accordance with U.S. GAAP. Corrective Actions Taken or Planned: The entire finance team was new in FY24. During an internal review, management identified that certain revenue transactions had been recorded incorrectly in the prior fiscal year (FY23), resulting in a materially misstated ending balance for FY23 and, consequently, an inaccurate beginning balance for FY24. Because FY23 had already been closed and audited, the necessary corrections were recorded in FY24. Management proactively informed the new auditors of these adjustments. Due to the materiality of the correction, the auditors determined that the FY23 ending balance needed to be reinstated. As a result, they expanded their scope to include a re-audit of FY23 to ensure the accuracy of the reinstated balances, which extended the overall audit timeline. It’s important to emphasize that this finding was self-identified and communicated by management, and the correction was properly recorded in FY24. No further corrective action is required for FY25. Throughout FY24, the finance team has worked diligently to strengthen internal policies, processes, controls, and systems, which contributed to a clean audit result for FY24. This finding relates solely to FY23 and does not reflect the current state of financial management. Name of Responsible Person: Manizha Nabieva, CFO Projected Date of Completion: 05/28/2025 Identifying Number: 2024-002 Finding: Federation of American Scientists’ fiscal year 2024 data collection form was not submitted within nine months after the end of the audit period. Corrective Actions Taken or Planned: The delay in filing the data collection form was directly related to the delay in finalizing the audit, as noted in the first finding above. Since this was our first year working with RSM, the audit scope expanded significantly due to the reinstatement of beginning balances. The auditors required additional time to ensure the accuracy of the financial statements before issuing their final report. We will finalize and submit the data collection form as soon as the audit is complete, but no later than May 28, 2025. To prevent similar delays in the future, we have already initiated discussions with our auditors regarding the FY25 audit and plan to begin the audit process in October 2025. Name of Responsible Person: Manizha Nabieva, CFO Projected Date of Completion: 5/28/2025

View Audit 358091

Finding 563866 (2024-007)

Material Weakness 2024

Hitchcock Independent School District

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

Finding Reference Number: 2024-007 Description of Finding: Lack of Semi-Annual Certifications for Special Education Personnel (Controls over Compliance - Special Education Cluster) Corrective Action Planned:The district has implemented new procedures for fiscal year 2025 to ensure that semiannual ce...

Finding Reference Number: 2024-007 Description of Finding: Lack of Semi-Annual Certifications for Special Education Personnel (Controls over Compliance - Special Education Cluster) Corrective Action Planned:The district has implemented new procedures for fiscal year 2025 to ensure that semiannual certifications are prepared, signed, and retained for all employees working solely on federal programs, including the Special Education Cluster (IDEA). A tracking system has been established, and staff training has been completed to reinforce documentation requirements. The district will continue to monitor compliance to ensure procedures are consistently applied. Responsible Contact Person: Patrick M. Faour, Interim Superintendent Anticipated Completion Date: August 30, 2025

View Audit 358090

Finding 563861 (2024-006)

Material Weakness 2024

Hitchcock Independent School District

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding Reference Number: 2024-006 Description of Finding: Unauthorized Use of Child Nutrition Funds (Controls over Compliance - Child Nutrition Cluster) Corrective Action Planned: The district is conducting a full review of interfund activity involving Child Nutrition funds to ensure compliance wit...

Finding Reference Number: 2024-006 Description of Finding: Unauthorized Use of Child Nutrition Funds (Controls over Compliance - Child Nutrition Cluster) Corrective Action Planned: The district is conducting a full review of interfund activity involving Child Nutrition funds to ensure compliance with the grant requirements. Staff will be trained on programspecific requirements, including reviewing all expenditures for allowability. The District will evaluate the impact of budget amendments that may be necessary if significant reimbursements to the Child Nutrition fund must be made from the general fund. Responsible Contact Person: Patrick M. Faour, Interim Superintendent Anticipated Completion Date: August 31, 2025

View Audit 358090

Finding 563860 (2024-001)

None 2024

Independent Housing I, Inc. - Independence House 023-Eh-020

MA

HUD Housing Programs Eligibility

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2024-001: Major Program: Section 8 Housing Assistance Payments Program, Federal Assistance Listing Number 14.195 RECOMMENDATION The auditor recommends the Project organize the archived tenant informa...

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2024-001: Major Program: Section 8 Housing Assistance Payments Program, Federal Assistance Listing Number 14.195 RECOMMENDATION The auditor recommends the Project organize the archived tenant information and include original information in the active tenant files. ACTION TAKEN The Project will be organizing the archived tenant information and including the original information in the active tenant files. The Project will continue to train staff on the HUD Handbook requirements for tenant files.

View Audit 358077

Finding 563859 (2024-001)

Material Weakness 2024

North Slope Borough

AK

Reporting § 200.303 § 200.510

: Borough Finance staff have redesigned the methodology for the fiscal year end reconciliation between the amounts reported to grantors, the amounts recorded in the General Ledger and the amounts reported in the Schedule of Expenditures of Federal Awards (SEFA). Going forward the amounts recorded...

: Borough Finance staff have redesigned the methodology for the fiscal year end reconciliation between the amounts reported to grantors, the amounts recorded in the General Ledger and the amounts reported in the Schedule of Expenditures of Federal Awards (SEFA). Going forward the amounts recorded in the General Ledger will tie to the amounts reported in the SEFA and any reconciling items will be noted on the reconciliation between the General Ledger and the amounts reported to the grantors. Completion Date: June 30, 2025

View Audit 358074

Finding 563854 (2024-002)

Significant Deficiency 2024

School District 12 Education Foundation Dba Five Star Education Foundation

CO

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-002: Internal Control Over Financial Reporting– Significant Deficiency Audit Finding: Management is responsible for the design and implementation of internal controls over year-end financial reporting, including controls over procedures used to enter transaction in the general ledge...

Finding 2024-002: Internal Control Over Financial Reporting– Significant Deficiency Audit Finding: Management is responsible for the design and implementation of internal controls over year-end financial reporting, including controls over procedures used to enter transaction in the general ledger and record recurring and nonrecurring adjustments to the financial statements on an accrual basis. During the course of the audit, journal entries were required to reconcile accounts receivable, accrued expenses, and accrued PTO from a cash basis to an accrual basis, which indicate a lack of operating effectiveness of internal controls over the financial reporting process. Audit Recommendation: We recommend School District 12 Education Foundation (dba Five Star Education Foundation) review policies and procedures related to the year-end financial reporting process and controls should be implemented to ensure accrual basis financial reporting can be achieved. Management’s Response and Corrective Action Plan: School District 12 Education Foundation (dba Five Star Education Foundation) agrees with the finding and recommendation. These transactions were proactively shared with the auditor at the commencement of the audit and discussed. Actions were already taken to fix these processes. In 2023 an outside professional was hired to mitigate these circumstances and ensure adherence to GAAP accounting. Management is hiring new accountants to alleviate future issues in this space. Management is in the process of implementing enhanced processes and procedures to achieve the proper recording of transactions on an accrual basis. A year-end checklist will be used to ensure that all accruals are booked in accounts receivable and payables. Contact and Completion Date: Shannon Hancock, 720-972-4342, shannon.hancock@5starfoundation.org, is the primary contact, and the Executive Director at School District 12 Education Foundation (dba Five Star Education Foundation). The corrective action is expected to be resolved before the end of the next fiscal year-end of December 31, 2025.

View Audit 358066

Finding 563849 (2024-001)

Significant Deficiency 2024

School District 12 Education Foundation Dba Five Star Education Foundation

CO

Reporting Cash Management

Finding 2024-001: Late Submission of Reports Audit Finding: School District 12 Education Foundation (dba Five Star Education Foundation) is required to submit Monthly Financial Reports by the 10th of each month for the periods January through February and by the 15th of each month for the remain...

Finding 2024-001: Late Submission of Reports Audit Finding: School District 12 Education Foundation (dba Five Star Education Foundation) is required to submit Monthly Financial Reports by the 10th of each month for the periods January through February and by the 15th of each month for the remaining months through December. In addition, School District 12 Education Foundation (dba Five Star Education Foundation) is required to submit Quarterly Reports by the 15th of each month. In our audit, we found that 2 out of 8 Reports tested were submitted after the 15th of the following month. After reviewing all the reports with School District 12 Education Foundation (dba Five Star Education Foundation), we noted 3 monthly reports, out of a total of 50 required reports, and 7 quarterly reports, out of a total of 25 required reports, were submitted untimely Audit Recommendation: We recommend School District 12 Education Foundation (dba Five Star Education Foundation) review and follow policies and procedures to ensure timely submission of reports. Management’s Response and Corrective Action Plan: School District 12 Education Foundation (dba Five Star Education Foundation) agrees with the finding and recommendation. Late submissions occurred due to delays in responses from the grantor and verbal approval of changes in due dates from the grantor. Management will be more proactive in documenting communication regarding reports to ensure that, if they are submitted late, there is clear evidence of approved date modifications, why and what date they were initially submitted. Management is now aware that the grantor’s system only reflects the final submission date once approved, not the initial submission date for reports that required modification at the request of the grantor. To address this, School District 12 Education Foundation (dba Five Star Education Foundation) will implement a process to document the initial submission date along with any backup documentation of delays, including communications with Adams County or other relevant parties. Additionally, Adams County has a clear policy that while timely submission of reports is required by the original grant agreement, grantees who communicate a need for additional time by the 15th of the month are considered compliant. Adams County also noted that, based on School District 12 Education Foundation (dba Five Star Education Foundation’s) history and previous communications, they would not consider this a finding or an indicator of poor performance. Moving forward, School District 12 Education Foundation (dba Five Star Education Foundation) will ensure that any anticipated delays are formally communicated to Adams County in writing (not verbally) before the due date and that records of these communications are retained for audit purposes. Contact and Completion Date: Shannon Hancock, 720-972-4342, shannon.hancock@5starfoundation.org, is the primary contact, and the Executive Director at School District 12 Education Foundation (dba Five Star Education Foundation). The corrective action is already in place and active as of this audit.

View Audit 358066

Finding 563847 (2024-001)

Material Weakness 2024

Seminole County Board of Edcuation

GA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: ...

FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021), S425U210012 (Year: 2021) Questioned Costs: $72,595 Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund programs revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were properly recorded. Corrective Action Plans: Our office was unaware our financial program could automatically generate employee's supplemental checks in addition to standard monthly checks. Now that we are aware, Ivey McLendon and I will monitor our financial program's automatically generated claims closely to adapt our manual accrual entries. Estimated Completion Date: June 30, 2025 Contact Person: Sherry Gray, Financial Director Telephone: (229) 524-2433 Email: sgray@seminole.k12.ga.us

View Audit 358065 Questioned Costs: $1

Finding 563835 (2024-002)

Material Weakness 2024

Oslc Developments, Inc.

OR

Reporting Subrecipient Monitoring Material Weakness § 200.502

Recommendation: We recommend the organization revisit its policies and procedures surrounding management’s review of grant and other contractual agreements to ensure all federal assistance, including subawards, are properly identified as such at the time the agreements are signed or received, and ar...

Recommendation: We recommend the organization revisit its policies and procedures surrounding management’s review of grant and other contractual agreements to ensure all federal assistance, including subawards, are properly identified as such at the time the agreements are signed or received, and are properly included on the SEFA. ODI agrees with the auditors’ recommendation. Consistent with response to finding 2024-001, we have reviewed the design and implementation of internal controls procedures around accounting for grants and contracts. This has resulted in revision of our new funding form including identifying federal and nonfederal designations in subcontracts from states, and determination of conditions to ensure compliance with U.S. GAAP. Responsible staff member, Laurie Larson-Lewis, Finance Manager, completion date 5/31/2025.

View Audit 358060

Finding 563820 (2024-002)

None 2024

The University of Alabama in Huntsville

AL

Procurement, Suspension & Debarment § 200.320 § 200.520

Procurement Cluster: Research and Development (R&D) Federal Agency: Various Assistance Listing Title and Number: Various Award Name: Various Award Identifying Number: Various Award Year: Fiscal year 2024 Pass-Through Entity: VariousThe University concurs with the auditors' finding. The University di...

Procurement Cluster: Research and Development (R&D) Federal Agency: Various Assistance Listing Title and Number: Various Award Name: Various Award Identifying Number: Various Award Year: Fiscal year 2024 Pass-Through Entity: VariousThe University concurs with the auditors' finding. The University did not communicate the change in auditee status and the resulting impact on the micro-purchase threshold to Procurement Services in a timely manner. This oversight led to continued application of the higher $75,000 threshold after the University no longer qualified under 2 CFR 200.320(a)(1)(iv). To address this issue, management is implementing the following corrective actions: 1. Cross-Functional Communication Protocol – A formal communication protocol will be established between Accounting and Financial Reporting and key compliance stakeholders to ensure timely notification of changes in auditee status or other compliance-related designations following the completion of the annual financial statement audit. 2. Policy Update and Staff Training – Procurement policies and procedures will be updated to reflect the requirement that UAH is subject to the lower micro-purchase threshold. Staff will be trained to take appropriate action when the University either qualifies for or no longer meets the criteria for a higher micro-purchase threshold, including timely adjustments to procurement policies and procedures. 3. Monitoring and Review – The Controller’s Office will conduct an annual review of auditee status immediately upon issuance of the audited financial statements, with documented confirmation sent to key compliance stakeholders. The University expects to complete this corrective action plan by September 30, 2025. For follow-up questions or if you need any additional information, please feel free to contact Brad Cooper, Interim Chief Financial Officer, at jbc0038@uah.edu who is responsible for this corrective action.

View Audit 358049

Finding 563817 (2024-005)

Significant Deficiency 2024

Waimanalo Health Center

HI

Procurement, Suspension & Debarment Subrecipient Monitoring

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-005 - Procu...

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-005 - Procurement, Suspension and Debarment - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00646-22-03, 2 H80CS005646-23-00, 4 H8GCS48213-01-01, 1 H8LCS51923-01-00 for 2023 and 2024 - (Significant Deficiency) During our audit, we noted that certain employees have no record of an exclusion search conducted during 2024. There were also certain employees for whom an exclusion search was not consistently conducted on a monthly basis. Recommendation We recommend that the Center train its personnel in relation to the exclusion screening and proper documentation thereof and that the Center conduct regular reviews to ensure the completeness of exclusion search documentation. Action Taken Management agrees with the finding and will be conducting training for its personnel to help ensure the accuracy, completeness and timeliness of exclusion searches. Effectivity Date: June 30, 2025

View Audit 358045

Finding 563814 (2024-004)

Material Weakness 2024

Waimanalo Health Center

HI

Special Tests & Provisions Eligibility Material Weakness

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-004 - Speci...

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-004 - Special Tests and Provisions (Material Weakness) During our audit, we noted that the Center did not properly determine the sliding fee discount of certain eligible patients based on information provided during the patient registration process. Recommendation We recommend that the Center conduct training of all of its personnel who are involved in determining the sliding fee scale of patients. We also recommend that an internal audit of a sample of patient charts be conducted periodically to ensure that patients' sliding fee scale discounts or category is properly and accurately determined based on information provided by patients. Finally, we recommend that such internal audit be documented. Action Taken Management agrees with the finding and will be establishing policies and procedures and conducting training for all personnel involved in determining patients' sliding fee scale to help ensure the accuracy of the process. Management will also implement an internal audit of a sample of patient charts and will ensure that such audits are properly documented. Effectivity Date: June 30, 2025

View Audit 358045

Corrective Action Plans

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