EIN: 222738766
UEI: T2L8LLW5L9R6
Audited by: McSoley McCoy & Co.
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 7, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 29, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by December 29, 2026 (112 days from today).
What is a management decision? →Finding No.: 2025-001 Criteria Pursuant to 2 CFR §200.302(b)(3), nonfederal entities must maintain financial management systems that provide for the identification of all federal awards received and expended, including accurate, current, and complete disclosure of expenditures by federal award. Further, 2 CFR §200.403 requires that costs charged to federal awards be allowable, allocable, and adequately documented. Costs must be directly associated with the benefiting program. Government Auditing Standards require that entities design and implement internal controls to provide reasonable assurance that transactions are properly recorded and compliance with applicable requirements is achieved. Conditions Found The Organization did not record expenditures directly to specific federal awards or grant programs at the time costs were incurred. Instead, expenditures were recorded in classes of accounts and subsequently allocated to funding sources in aggregate based on available revenue. This methodology does not ensure that expenditures are accurately identified with the benefiting federal award. Cause The condition appears to be the result of inadequate internal controls over grant accounting, including: • Lack of a formalized process for tracking expenditures by individual grant • Limitations in the accounting system and heavily reliance on supporting schedules outside of the accounting function • Insufficient training and oversight related to grant compliance requirements Effect As a result, the Organization is at risk of: • Noncompliance with Uniform Guidance cost principles and reporting requirements • Misstatement of expenditures by grant program • Inability to demonstrate that costs charged to federal awards are allowable, allocable, and properly supported • Potential questioned costs or repayment of federal funds • Inaccuracy of federal reporting Context This issue was identified through testing of expenditures across multiple federal programs and was determined to be pervasive in nature. The control deficiency impacts all major federal programs and financial reporting processes related to grant activity. Repeat Finding No Questioned Costs The Organization’s expenditures are similar amongst all programs and grants. At the onset of the audit, expenditures were not coded and reconciled to each grant individually; however, the Organization was able to identify, code and update the general ledger to properly identify the major program expenditures. We were able to determine there are no questioned costs. Recommendation We recommend that the Organization strengthen its internal controls over grant accounting by: • Implementing procedures to code expenditures directly to specific grants at the time of entry • Enhancing the chart of accounts to allow for tracking by funding source • Reducing the use of manual spreadsheets that allow for human error • Proper review and approval of grant allocations to ensure proper grant reporting • Providing training to accounting personnel on Uniform Guidance requirements for cost allowability and allocability Views of Responsible Officials See attached corrective action plan.
Show full finding ▾Hide full finding ▴Finding No.: 2025-001 Criteria Pursuant to 2 CFR §200.302(b)(3), nonfederal entities must maintain financial management systems that provide for the identification of all federal awards received and expended, including accurate, current, and complete disclosure of expenditures by federal award. Further, 2 CFR §200.403 requires that costs charged to federal awards be allowable, allocable, and adequately documented. Costs must be directly associated with the benefiting program. Government Auditing Standards require that entities design and implement internal controls to provide reasonable assurance that transactions are properly recorded and compliance with applicable requirements is achieved. Conditions Found The Organization did not record expenditures directly to specific federal awards or grant programs at the time costs were incurred. Instead, expenditures were recorded in classes of accounts and subsequently allocated to funding sources in aggregate based on available revenue. This methodology does not ensure that expenditures are accurately identified with the benefiting federal award. Cause The condition appears to be the result of inadequate internal controls over grant accounting, including: • Lack of a formalized process for tracking expenditures by individual grant • Limitations in the accounting system and heavily reliance on supporting schedules outside of the accounting function • Insufficient training and oversight related to grant compliance requirements Effect As a result, the Organization is at risk of: • Noncompliance with Uniform Guidance cost principles and reporting requirements • Misstatement of expenditures by grant program • Inability to demonstrate that costs charged to federal awards are allowable, allocable, and properly supported • Potential questioned costs or repayment of federal funds • Inaccuracy of federal reporting Context This issue was identified through testing of expenditures across multiple federal programs and was determined to be pervasive in nature. The control deficiency impacts all major federal programs and financial reporting processes related to grant activity. Repeat Finding No Questioned Costs The Organization’s expenditures are similar amongst all programs and grants. At the onset of the audit, expenditures were not coded and reconciled to each grant individually; however, the Organization was able to identify, code and update the general ledger to properly identify the major program expenditures. We were able to determine there are no questioned costs. Recommendation We recommend that the Organization strengthen its internal controls over grant accounting by: • Implementing procedures to code expenditures directly to specific grants at the time of entry • Enhancing the chart of accounts to allow for tracking by funding source • Reducing the use of manual spreadsheets that allow for human error • Proper review and approval of grant allocations to ensure proper grant reporting • Providing training to accounting personnel on Uniform Guidance requirements for cost allowability and allocability Views of Responsible Officials See attached corrective action plan.
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures for the specific grants will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding No.: 2025-002 Criteria In order for an Organization’s system of internal controls to function properly, it is essential that there be clear definitions of job responsibilities. Assignment of responsibilities should include the appropriate segregation of duties in order to ensure proper control. Also, personnel within the Organization should be cross-trained to ensure that in the event that an employee leaves the Organization, there would be another employee prepared to take on the responsibilities. Such responsibilities should be formally documented in a policies and procedures manual. Conditions Found During audit procedures, it was noted that the Organization had trouble producing internal control procedure documents for the period under audit. The Organization also relies heavily on a third party to produce quarterly and annual reporting. Cause The Organization lacks updated and proper documentation around policies and procedures and lacks formal review of third party information. Effect The SEFA and financial statements could be inaccurately presented. Context This issue was identified during our audit procedures and was noted across multiple areas. Repeat Finding Yes. Reported as Finding No. 2024-003. Questioned Costs None Recommendation We recommend an internal control procedure document be maintained and regularly updated to reflect the current procedures, policies, roles and responsibilities in place. In addition, there should be formal documented review and approval by someone in the Organization of the work produced by the third party to ensure any errors or omissions in financial information are caught. Views of Responsible Officials See attached corrective action plan.
Show full finding ▾Hide full finding ▴Finding No.: 2025-002 Criteria In order for an Organization’s system of internal controls to function properly, it is essential that there be clear definitions of job responsibilities. Assignment of responsibilities should include the appropriate segregation of duties in order to ensure proper control. Also, personnel within the Organization should be cross-trained to ensure that in the event that an employee leaves the Organization, there would be another employee prepared to take on the responsibilities. Such responsibilities should be formally documented in a policies and procedures manual. Conditions Found During audit procedures, it was noted that the Organization had trouble producing internal control procedure documents for the period under audit. The Organization also relies heavily on a third party to produce quarterly and annual reporting. Cause The Organization lacks updated and proper documentation around policies and procedures and lacks formal review of third party information. Effect The SEFA and financial statements could be inaccurately presented. Context This issue was identified during our audit procedures and was noted across multiple areas. Repeat Finding Yes. Reported as Finding No. 2024-003. Questioned Costs None Recommendation We recommend an internal control procedure document be maintained and regularly updated to reflect the current procedures, policies, roles and responsibilities in place. In addition, there should be formal documented review and approval by someone in the Organization of the work produced by the third party to ensure any errors or omissions in financial information are caught. Views of Responsible Officials See attached corrective action plan.
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. 1. The Organization will update and maintain a formal policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
2024-003
Finding No.: 2025-003 Federal Agency: Aging Cluster (93.044, 93.045, 93.053) and Medicaid Cluster (93.778) Criteria Pursuant to 2 CFR §200.302(b)(3), nonfederal entities must maintain financial management systems that provide for the identification of all federal awards received and expended, including accurate, current, and complete disclosure of expenditures by federal award. Further, 2 CFR §200.403 requires that costs charged to federal awards be allowable, allocable, and adequately documented. Costs must be directly associated with the benefiting program. Government Auditing Standards require that entities design and implement internal controls to provide reasonable assurance that transactions are properly recorded and compliance with applicable requirements is achieved. Conditions Found The Organization did not consistently record expenditures directly to specific federal awards or grant revenue at the time costs were incurred. Instead, expenditures were recorded in general accounts and subsequently allocated to funding sources in aggregate based on available grant revenue. This methodology does not ensure that expenditures are accurately identified with the benefiting federal award. Cause The condition appears to be the result of inadequate internal controls over grant accounting, including: • Lack of a formalized process for tracking expenditures by individual grant • Limitations in the accounting system and heavily reliance on supporting schedules outside of the accounting function • Insufficient training and oversight related to grant compliance requirements Effect As a result, the Organization is at risk of: • Noncompliance with Uniform Guidance cost principles and reporting requirements • Misstatement of expenditures by grant program • Inability to demonstrate that costs charged to federal awards are allowable, allocable, and properly supported • Potential questioned costs or repayment of federal funds • Inaccuracy of federal reporting Questioned Costs The lack of coding by invoice level to each grant raises concern that expenditures listed on the SEFA may not meet stated grant allowability and allocable requirements. The Organization’s expenditures are similar amongst all programs and grants. At the onset of the audit, expenditures were not coded and reconciled to each grant individually; however, the Organization was able to identify, code and update the general ledger to properly identify the major program expenditures. We were able to determine there are no questioned costs. Context This issue was identified through testing of expenditures across multiple federal programs and was determined to be pervasive in nature. The control deficiency impacts all major federal programs and financial reporting processes related to grant activity. Repeat Finding No Recommendation We recommend that the Organization strengthen its internal controls over grant accounting by: • Implementing procedures to code expenditures directly to specific grants at the time of entry • Enhancing the chart of accounts to allow for tracking by funding source • Reducing the use of manual spreadsheets that allow for human error • Proper review and approval of grant allocations to ensure proper grant reporting • Providing training to accounting personnel on Uniform Guidance requirements for cost allowability and allocability Views of Responsible Officials See attached corrective action plan.
Show full finding ▾Hide full finding ▴Finding No.: 2025-003 Federal Agency: Aging Cluster (93.044, 93.045, 93.053) and Medicaid Cluster (93.778) Criteria Pursuant to 2 CFR §200.302(b)(3), nonfederal entities must maintain financial management systems that provide for the identification of all federal awards received and expended, including accurate, current, and complete disclosure of expenditures by federal award. Further, 2 CFR §200.403 requires that costs charged to federal awards be allowable, allocable, and adequately documented. Costs must be directly associated with the benefiting program. Government Auditing Standards require that entities design and implement internal controls to provide reasonable assurance that transactions are properly recorded and compliance with applicable requirements is achieved. Conditions Found The Organization did not consistently record expenditures directly to specific federal awards or grant revenue at the time costs were incurred. Instead, expenditures were recorded in general accounts and subsequently allocated to funding sources in aggregate based on available grant revenue. This methodology does not ensure that expenditures are accurately identified with the benefiting federal award. Cause The condition appears to be the result of inadequate internal controls over grant accounting, including: • Lack of a formalized process for tracking expenditures by individual grant • Limitations in the accounting system and heavily reliance on supporting schedules outside of the accounting function • Insufficient training and oversight related to grant compliance requirements Effect As a result, the Organization is at risk of: • Noncompliance with Uniform Guidance cost principles and reporting requirements • Misstatement of expenditures by grant program • Inability to demonstrate that costs charged to federal awards are allowable, allocable, and properly supported • Potential questioned costs or repayment of federal funds • Inaccuracy of federal reporting Questioned Costs The lack of coding by invoice level to each grant raises concern that expenditures listed on the SEFA may not meet stated grant allowability and allocable requirements. The Organization’s expenditures are similar amongst all programs and grants. At the onset of the audit, expenditures were not coded and reconciled to each grant individually; however, the Organization was able to identify, code and update the general ledger to properly identify the major program expenditures. We were able to determine there are no questioned costs. Context This issue was identified through testing of expenditures across multiple federal programs and was determined to be pervasive in nature. The control deficiency impacts all major federal programs and financial reporting processes related to grant activity. Repeat Finding No Recommendation We recommend that the Organization strengthen its internal controls over grant accounting by: • Implementing procedures to code expenditures directly to specific grants at the time of entry • Enhancing the chart of accounts to allow for tracking by funding source • Reducing the use of manual spreadsheets that allow for human error • Proper review and approval of grant allocations to ensure proper grant reporting • Providing training to accounting personnel on Uniform Guidance requirements for cost allowability and allocability Views of Responsible Officials See attached corrective action plan.
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding No.: 2025-004 Federal Agency: Medicaid Cluster (93.778) Criteria Under 2 CFR §200.510(b), nonfederal entities that expend federal awards are required to prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the entity’s financial statements. The SEFA must: • Include total federal expenditures for each federal program • Identify each federal program by Assistance Listing Number (ALN) • Include the name of the federal agency and pass-through entity, where applicable • Include pass-through identifying numbers • Disclose significant accounting policies used in preparing the SEFA • Reconcile, or be traceable, to the underlying accounting records Additionally, Government Auditing Standards require that internal controls over financial reporting and compliance be designed and implemented to ensure accurate reporting. Conditions Found The Organization did not prepare a complete and accurate SEFA for the year ended September 30, 2025. Certain federal expenditures were initially omitted from the SEFA. As a result, the SEFA required adjustment which resulted in a second major program for testing once the Organization corrected its SEFA. Cause The condition appears to be the result of inadequate internal controls over the identification, tracking, and reporting of federal awards. Specifically: • Lack of a formal process to identify all federal funding sources • Insufficient review controls over SEFA preparation • Limited understanding of SEFA reporting requirements under Uniform Guidance Effect The incomplete SEFA increases the risk that: • Federal expenditures may be understated or misstated • Major program determination could be impacted • Required disclosures under Uniform Guidance may not be met • Users of the financial statements may rely on inaccurate information Questioned Costs The Organization’s expenditures are similar amongst all programs and grants. At the onset of the audit, expenditures were not coded and reconciled to each grant individually; however, the Organization was able to identify, code and update the general ledger to properly identify the major program expenditures. We were able to determine there are no questioned costs. Context The SEFA omitted approximately $347,000 in federal expenditures in their SEFA provided during audit planning procedures, representing approximately 18% of total federal expenditures. Repeat Finding No Recommendation We recommend that the Organization strengthen internal controls over SEFA preparation and completeness by: • Implementing a comprehensive process to identify all federal awards, including pass-through funding • Maintaining a centralized listing of federal grants with ALNs and award information • Ensuring expenditures are tracked by federal program throughout the year • Performing a detailed review and reconciliation of the SEFA to the general ledger prior to issuance • Providing training to personnel responsible for SEFA preparation on Uniform Guidance requirements Views of Responsible Officials See attached corrective action plan.
Show full finding ▾Hide full finding ▴Finding No.: 2025-004 Federal Agency: Medicaid Cluster (93.778) Criteria Under 2 CFR §200.510(b), nonfederal entities that expend federal awards are required to prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the entity’s financial statements. The SEFA must: • Include total federal expenditures for each federal program • Identify each federal program by Assistance Listing Number (ALN) • Include the name of the federal agency and pass-through entity, where applicable • Include pass-through identifying numbers • Disclose significant accounting policies used in preparing the SEFA • Reconcile, or be traceable, to the underlying accounting records Additionally, Government Auditing Standards require that internal controls over financial reporting and compliance be designed and implemented to ensure accurate reporting. Conditions Found The Organization did not prepare a complete and accurate SEFA for the year ended September 30, 2025. Certain federal expenditures were initially omitted from the SEFA. As a result, the SEFA required adjustment which resulted in a second major program for testing once the Organization corrected its SEFA. Cause The condition appears to be the result of inadequate internal controls over the identification, tracking, and reporting of federal awards. Specifically: • Lack of a formal process to identify all federal funding sources • Insufficient review controls over SEFA preparation • Limited understanding of SEFA reporting requirements under Uniform Guidance Effect The incomplete SEFA increases the risk that: • Federal expenditures may be understated or misstated • Major program determination could be impacted • Required disclosures under Uniform Guidance may not be met • Users of the financial statements may rely on inaccurate information Questioned Costs The Organization’s expenditures are similar amongst all programs and grants. At the onset of the audit, expenditures were not coded and reconciled to each grant individually; however, the Organization was able to identify, code and update the general ledger to properly identify the major program expenditures. We were able to determine there are no questioned costs. Context The SEFA omitted approximately $347,000 in federal expenditures in their SEFA provided during audit planning procedures, representing approximately 18% of total federal expenditures. Repeat Finding No Recommendation We recommend that the Organization strengthen internal controls over SEFA preparation and completeness by: • Implementing a comprehensive process to identify all federal awards, including pass-through funding • Maintaining a centralized listing of federal grants with ALNs and award information • Ensuring expenditures are tracked by federal program throughout the year • Performing a detailed review and reconciliation of the SEFA to the general ledger prior to issuance • Providing training to personnel responsible for SEFA preparation on Uniform Guidance requirements Views of Responsible Officials See attached corrective action plan.
Finding Reference Number: 2025-04 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Organization acknowledges the importance of preparing a complete and accurate Schedule of Expenditures of Federal Awards (SEFA) in accordance with Uniform Guidance requirements. Management will strengthen internal controls over the identification, tracking, reconciliation, review, and reporting of federal awards to ensure all federal expenditures are properly captured and rep01ted in future periods. 1. Develop and implement a fom1al year-end SEFA preparation checklist that identifies all required information, including federal agency, pass-through entity, Assistance Listing Number, program name, award amount, expenditures, and any amounts passed through to subrecipients 2. Review all revenue sources, grant agreements, reimbursement activity, and general ledger accounts at least quarterly lo identify any federal awards that must be included on the SEFA. 3. Perform a documented reconciliation of SEFA expenditures to the general ledger and supporting grant records before the SEFA is submitted for audit. 4. The SEFA will be prepared by the third party outside accountant and reviewed by the Finance Director to ensure that all federal awards are accurately reported. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding No.: 2025-005 Federal Agency: Aging Cluster (93.044, 93.045, 93.053) and Medicaid Cluster (93.778) Criteria In order for an Organization’s system of internal controls to function properly, it is essential that there be clear definitions of job responsibilities. Assignment of responsibilities should include the appropriate segregation of duties in order to ensure proper control. Also, personnel within the Organization should be cross-trained to ensure that in the event that an employee leaves the Organization, there would be another employee prepared to take on the responsibilities. Such responsibilities should be formally documented in a policies and procedures manual. Conditions Found During audit procedures, it was noted that the Organization had trouble producing internal control procedure documents that had been updated for the period under audit. The Organization also relies heavily on a third party to produce quarterly and annual reporting. Cause The Organization lacks updated and proper documentation around policies and procedures and lacks formal review of third party information. Effect The SEFA and financial statements could be inaccurately presented. Context This issue was identified during our audit procedures and was noted across multiple areas. Repeat Finding Yes. Reported as Finding No. 2024-003. Questioned Costs None. Recommendation We recommend a document be maintained and regularly updated to reflect the current procedures, policies, roles and responsibilities in place. In addition, there should be formal documented review and approval by someone in the Organization of the work produced by the third party to ensure any errors or omissions in financial information are caught. Views of Responsible Officials See attached corrective action plan
Show full finding ▾Hide full finding ▴Finding No.: 2025-005 Federal Agency: Aging Cluster (93.044, 93.045, 93.053) and Medicaid Cluster (93.778) Criteria In order for an Organization’s system of internal controls to function properly, it is essential that there be clear definitions of job responsibilities. Assignment of responsibilities should include the appropriate segregation of duties in order to ensure proper control. Also, personnel within the Organization should be cross-trained to ensure that in the event that an employee leaves the Organization, there would be another employee prepared to take on the responsibilities. Such responsibilities should be formally documented in a policies and procedures manual. Conditions Found During audit procedures, it was noted that the Organization had trouble producing internal control procedure documents that had been updated for the period under audit. The Organization also relies heavily on a third party to produce quarterly and annual reporting. Cause The Organization lacks updated and proper documentation around policies and procedures and lacks formal review of third party information. Effect The SEFA and financial statements could be inaccurately presented. Context This issue was identified during our audit procedures and was noted across multiple areas. Repeat Finding Yes. Reported as Finding No. 2024-003. Questioned Costs None. Recommendation We recommend a document be maintained and regularly updated to reflect the current procedures, policies, roles and responsibilities in place. In addition, there should be formal documented review and approval by someone in the Organization of the work produced by the third party to ensure any errors or omissions in financial information are caught. Views of Responsible Officials See attached corrective action plan
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. l. The Organization will update and maintain a fom1al policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
2024-003
FAC accepted this audit on May 20, 2025 — management decision was due November 20, 2025.
Finding No.: 2024-001 Criteria A fundamental concept of a strong payroll control environment is the proper approval and retention of employee wage rates and contracts. Documentation should be retained for all pay rate changes noting the date of change and the approval for the change. Conditions Found During our audit, we noted two employees who lacked appropriate pay rate support for their wage rates in effect for the year ended September 30, 2024. Cause The Organization is not adhering to their review and approval process and retention of pay rate support. Effect The SEFA and financial statements could be inaccurately presented. Recommendation We recommend the Organization adhere to their established review and approval process over pay rate support and proper retention of such information. Views of Responsible Officials Management agrees with this recommendation and will implement an annual review and approval process effective for the fiscal 2025 reporting period.
Show full finding ▾Hide full finding ▴Finding No.: 2024-001 Criteria A fundamental concept of a strong payroll control environment is the proper approval and retention of employee wage rates and contracts. Documentation should be retained for all pay rate changes noting the date of change and the approval for the change. Conditions Found During our audit, we noted two employees who lacked appropriate pay rate support for their wage rates in effect for the year ended September 30, 2024. Cause The Organization is not adhering to their review and approval process and retention of pay rate support. Effect The SEFA and financial statements could be inaccurately presented. Recommendation We recommend the Organization adhere to their established review and approval process over pay rate support and proper retention of such information. Views of Responsible Officials Management agrees with this recommendation and will implement an annual review and approval process effective for the fiscal 2025 reporting period.
Finding Reference Number: 2024-001 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director will review personnel files for all raises to ensure that the required documentation supports the raise amount approved by the Executive Director. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: May 31, 2025
Finding No.: 2024-002 Criteria The Organization has established the control requiring all expenditures above $2,000 requiring dual signature. Conditions Found During our audit, we noted one check which lacked the required dual signature. Cause The Organization is not adhering to their established controls around expenditures. Effect The SEFA and financial statements could be inaccurately presented. Recommendation We recommend the Organization adhere to their established control around dual signatures for all disbursements above their stated threshold. Views of Responsible Officials Management agrees with this recommendation and will implement a review and approval process effective for the fiscal 2025 reporting period.
Show full finding ▾Hide full finding ▴Finding No.: 2024-002 Criteria The Organization has established the control requiring all expenditures above $2,000 requiring dual signature. Conditions Found During our audit, we noted one check which lacked the required dual signature. Cause The Organization is not adhering to their established controls around expenditures. Effect The SEFA and financial statements could be inaccurately presented. Recommendation We recommend the Organization adhere to their established control around dual signatures for all disbursements above their stated threshold. Views of Responsible Officials Management agrees with this recommendation and will implement a review and approval process effective for the fiscal 2025 reporting period.
Finding Reference Number: 2024-002 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director reviewed the internal controls requiring all expenditures above $2,000 requiring dual signatures with the Office Administrator. If the Office Administrator is not in the office when checks are to be mailed, the staff mailing checks will refer to the procedures filed in the front office prior to processing checks. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: March 28, 2025
Finding No.: 2024-003 Criteria In order for an Organization’s system of internal controls to function properly, it is essential that there be clear definitions of job responsibilities. Assignment of responsibilities should include the appropriate segregation of duties in order to ensure proper control. Also, personnel within the Organization should be cross-trained to ensure that in the event an employee leaves the Organization, there would be another employee prepared to take on the responsibilities. Such responsibilities should be formally documented in a policies and procedures manual. Conditions Found During audit procedures, it was noted that the Organization had trouble producing internal control procedure documents that had been updated for the period under audit. The Organization also relies heavily on a third party to produce quarterly and annual reporting. Cause The Organization lacks updated and proper documentation around policies and procedures and lacks formal review of third party information. Effect The SEFA and financial statements could be inaccurately presented. Recommendation We recommend a document be maintained and regularly updated to reflect the current procedures, policies, roles and responsibilities in place. In addition, there should be formal documented review and approval by someone in the Organization of the work produced by the third party to ensure any errors or omissions in financial information are caught. Views of Responsible Officials Management agrees with this recommendation and will implement a review and approval process effective for the fiscal 2025 reporting period.
Show full finding ▾Hide full finding ▴Finding No.: 2024-003 Criteria In order for an Organization’s system of internal controls to function properly, it is essential that there be clear definitions of job responsibilities. Assignment of responsibilities should include the appropriate segregation of duties in order to ensure proper control. Also, personnel within the Organization should be cross-trained to ensure that in the event an employee leaves the Organization, there would be another employee prepared to take on the responsibilities. Such responsibilities should be formally documented in a policies and procedures manual. Conditions Found During audit procedures, it was noted that the Organization had trouble producing internal control procedure documents that had been updated for the period under audit. The Organization also relies heavily on a third party to produce quarterly and annual reporting. Cause The Organization lacks updated and proper documentation around policies and procedures and lacks formal review of third party information. Effect The SEFA and financial statements could be inaccurately presented. Recommendation We recommend a document be maintained and regularly updated to reflect the current procedures, policies, roles and responsibilities in place. In addition, there should be formal documented review and approval by someone in the Organization of the work produced by the third party to ensure any errors or omissions in financial information are caught. Views of Responsible Officials Management agrees with this recommendation and will implement a review and approval process effective for the fiscal 2025 reporting period.
Finding Reference Number: 2024-003 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director and the Treasurer will review internal controls to ensure the proper segregation of duties. The Finance Director and the Executive Director will review job duties of the Finance Director and appropriate staff will be trained as back-up. We have a third party outside accountant that prepares quarterly and annual reporting. All reports are reviewed by the Executive Director, the Finance Director and the third-party accountant to ensure that the reports are accurate. After the initial review, the third-party accountant is present at the finance committee when the reports are presented. Name of Contact Person: Susan Dana, Finance Director Projected Completion Date: June 30, 2025
FAC accepted this audit on June 27, 2024 — management decision was due December 27, 2024.
FAC accepted this audit on June 28, 2023 — management decision was due December 28, 2023.
FAC accepted this audit on June 13, 2022 — management decision was due December 13, 2022.
FAC accepted this audit on May 4, 2021 — management decision was due November 4, 2021.
FAC accepted this audit on July 23, 2020 — management decision was due January 23, 2021.
FAC accepted this audit on July 1, 2019 — management decision was due January 1, 2020.
FAC accepted this audit on July 1, 2018 — management decision was due January 1, 2019.
FAC accepted this audit on April 19, 2017 — management decision was due October 19, 2017.
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