Finding 1174800 (2025-002)

Material Weakness Repeat Finding
Requirement
M
Questioned Costs
-
Year
2025
Accepted
2026-02-20
Audit: 388356
Organization: Epidaurus Dba Amity Foundation (AZ)

AI Summary

  • Core Issue: The Organization failed to comply with federal subrecipient monitoring requirements for REO grants, including timely risk assessments and payment processing.
  • Impacted Requirements: Risk assessments were not conducted before payments, follow-up procedures were delayed, and subrecipient payments exceeded the 30-day processing rule.
  • Recommended Follow-Up: Define roles for compliance tracking, implement a review system for subrecipient monitoring, and ensure timely processing of payments and corrective actions.

Finding Text

Assistance Listing Number and Title: ALN 17.270, Reentry Employment Opportunities Federal Agency: U.S. Department of Labor Federal Award Numbers: YF-39537-23-60-A-4 Grant period: February 1, 2023 through July 31, 2026 Criteria: The Organization's Reentry Employment Opportunities (REO) grants are subject to subrecipient monitoring requirements. As a result, the Organization must conduct risk assessments, monitor subrecipients, follow up on any identified deficiencies, and ensure compliance with the 30-day rule for processing subrecipient payment requests. Condition: The Organization did not fully comply with federal subrecipient monitoring requirements for REO grants. Specifically, risk assessments procedures were not performed prior to first payments to subrecipient, and certain follow up procedures for monitoring were not done timely. Additionally, payment requests from subrecipients were not processed within the required 30-day timeframe. Cause: The Organization lacked a formalized monitoring plan and sufficient staffing resources to ensure timely reviews and follow-up on identified deficiencies. Effect: The grantee could not perform necessary subrecipient monitoring procedures timely. Context: The Organization provided payments to four subrecipients during the year. All four subrecipients had risk assessments performed after payments were made. As a result, the Organization could not provide documentation showing that it met compliance requirements for subrecipient monitoring, such as verifying eligibility (including confirming subrecipients were not suspended or debarred) or appropriately assessing subrecipient risk. Further, one subrecipient out of the four submitted their Corrective Action Plan response to the Site Visit Report after the 30 day deadline and there was no extension granted. As a result, the Organization did not comply with internal monitoring policies to follow up/ensure that Corrective Action Plans be submitted within 30 days. For the 24 subawardee payments selected, none of the payments were processed within the required 30-day rule. Questioned costs: None Repeat Finding: No Recommendation: We recommend the Organization clearly define roles and responsibilities for tracking compliance with unique requirements of Federal contracts. This includes implementing a system of review and approval to ensure the compliance surrounding subrecipient monitoring has been done. Views of responsible officials of the auditee: The Organization concurs with the finding. The Organization has taken and continues to take corrective actions to strengthen its subrecipient monitoring framework and ensure full compliance with federal requirements under 2 CFR 200. Specifically, the Organization has implemented the following actions: revised subaward agreements, formalized subrecipient monitoring policies and procedures, implemented pre-award risk assessments prior to payment, enhanced post-award monitoring, and improved payment processing controls.

Corrective Action Plan

Condition: The Organization did not fully document compliance with certain federal subrecipient monitoring requirements, including completion of pre-award risk assessments prior to initial payments, timely follow-up on monitoring deficiencies, and processing subrecipient payments within the required 30-day timeframe. Response: The Organization concurs with the finding. Corrective Action Plan: The Organization has taken and continues to take corrective actions to strengthen its subrecipient monitoring framework and ensure full compliance with federal requirements under 2 CFR 200. Specifically, the Organization has implemented the following actions: 1. Revised Subaward Agreements The Organization has revised its subaward agreements to ensure compliance with 2 CFR 200.332(a), including all required federal award identification elements, flow-down provisions, performance requirements, and administrative controls. Revised agreements have been executed with subrecipients as required. 2. Formalized Subrecipient Monitoring Policies and Procedures The Organization has adopted a comprehensive Subrecipient Selection, Evaluation, Award, and Post-Award Oversight Policy, which establishes a risk-based lifecycle approach to subrecipient management. The policy addresses pre-award risk assessment, subaward issuance, post-award monitoring, corrective actions, and closeout procedures in accordance with 2 CFR 200.332 and related requirements. 3. Pre-Award Risk Assessments Implemented Prior to Payment Prior to the start of subrecipient enrollments and program operations, the Organization collected narrative and qualitative information regarding subrecipient capacity, experience, and readiness. However, this information had not yet been formally documented using a standardized evaluation and risk rating tool. As part of the corrective action, the Organization has now formalized these practices through a structured pre-award risk assessment template that results in an actionable risk rating (Low, Moderate, or High) and directly informs monitoring intensity and oversight activities. The Organization has implemented standardized pre-award risk assessments for all subrecipients, and risk assessments have been completed for each current subaward using the new template. Suspension and debarment status is verified through SAM.gov prior to subaward execution and documented in the organization records. 4. Enhanced Post-Award Monitoring and Follow-Up Procedures The Organization has strengthened post-award monitoring practices using monitoring plans informed by assigned risk levels. Monitoring activities include scheduled site visits, desk reviews, and documented follow-up on identified deficiencies. During the second half of FY 2024–2025, the Organization further enhanced its follow-up processes by implementing a more structured Corrective Action Plan (CAP) tracking system, including formal email reminders to subrecipients regarding CAP submission deadlines, written acknowledgment upon receipt of CAPs, and documented review and resolution of submitted CAPs. These improvements have resulted in more timely follow-up and clearer documentation of compliance activities. 5. Improved Payment Processing Controls The Organization has implemented internal controls to improve the timeliness of subrecipient payment processing, including clearer review workflows, tracking mechanisms, and staffing adjustments to support compliance with the 30-day payment rule. Responsible Official: Gloria Meridew, Director of Finance Anticipated Completion Date: Corrective actions have been fully implemented as of the date of this letter. The Organization will continue to monitor compliance and maintain documentation to support sustained adherence to federal subrecipient monitoring and payment requirements.

Categories

Subrecipient Monitoring

Other Findings in this Audit

  • 1174801 2025-003
    Material Weakness Repeat
  • 1174802 2025-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $1.35M
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $603,692
17.270 REENTRY EMPLOYMENT OPPORTUNITIES $192,374