EIN: 621043517
UEI: VEXDBMVR2PM7
Audited by: Watkins Uiberall, PLLC
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on August 28, 2025. 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 February 28, 2026 (191 days ago).
What is a management decision? →Lack of Documented Review and Approval of Costs Charged Corrective Action: Although current management was not involved during the audit period, the Organization recognizes the importance of documented expenditure review under Uniform Guidance. A formal procedure is being developed that will require all grant-related expenditures to be reviewed and initialed or electronically approved by authorized personnel. The policy will require documentation that clearly demonstrates both the allowability of the cost and its alignment with approved program activities. These procedures will be implemented and tested beginning with FY26 expenditures.
Show full finding ▾Hide full finding ▴Lack of Documented Review and Approval of Costs Charged Corrective Action: Although current management was not involved during the audit period, the Organization recognizes the importance of documented expenditure review under Uniform Guidance. A formal procedure is being developed that will require all grant-related expenditures to be reviewed and initialed or electronically approved by authorized personnel. The policy will require documentation that clearly demonstrates both the allowability of the cost and its alignment with approved program activities. These procedures will be implemented and tested beginning with FY26 expenditures.
Corrective Action: Although current management was not involved during the audit period, the Organization recognizes the importance of documented expenditure review under Uniform Guidance. A formal procedure is being developed that will require all grant-related expenditures to be reviewed and initialed or electronically approved by authorized personnel. The policy will require documentation that clearly demonstrates both the allowability of the cost and its alignment with approved program activities. These procedures will be implemented and tested beginning with FY26 expenditures.
2022-001
Lack of Documentation of Payroll Allocations and Pay Rate Approvals Corrective Action: The Organization lacked adequate timekeeping and pay rate documentation controls during FY23, and no current management or staff were present at the time. As of FY26, the Organization has begun implementing new payroll oversight processes. Going forward, timecards will be required for any employee whose time is allocated to multiple functions or funding sources. Management will also require documentation of payroll approvals (e.g., signed letters or memos) for all employees and will store these documents in both hard copy and electronic format. Payroll allocation methodologies will be reassessed at least every three years using a representative time study.
Show full finding ▾Hide full finding ▴Lack of Documentation of Payroll Allocations and Pay Rate Approvals Corrective Action: The Organization lacked adequate timekeeping and pay rate documentation controls during FY23, and no current management or staff were present at the time. As of FY26, the Organization has begun implementing new payroll oversight processes. Going forward, timecards will be required for any employee whose time is allocated to multiple functions or funding sources. Management will also require documentation of payroll approvals (e.g., signed letters or memos) for all employees and will store these documents in both hard copy and electronic format. Payroll allocation methodologies will be reassessed at least every three years using a representative time study.
Corrective Action: The Organization lacked adequate timekeeping and pay rate documentation controls during FY23, and no current management or staff were present at the time. As of FY26, the Organization has begun implementing new payroll oversight processes. Going forward, timecards will be required for any employee whose time is allocated to multiple functions or funding sources. Management will also require documentation of payroll approvals (e.g., signed letters or memos) for all employees and will store these documents in both hard copy and electronic format. Payroll allocation methodologies will be reassessed at least every three years using a representative time study.
2023-009 – Lack of Documented Allocation Methodologies for Costs Charged to Federal Awards Corrective Action: This finding is a continuation of a prior year deficiency related to the lack of formal allocation methodologies. Management is currently drafting a cost allocation policy that includes specific guidance on how to allocate shared costs (e.g., rent, insurance, software) across programs, management & general, and fundraising functions. The new policy will include acceptable bases such as square footage, staff headcount, or usage logs and will be reviewed annually. All allocations will be supported by schedules retained with the audit documentation.
Show full finding ▾Hide full finding ▴2023-009 – Lack of Documented Allocation Methodologies for Costs Charged to Federal Awards Corrective Action: This finding is a continuation of a prior year deficiency related to the lack of formal allocation methodologies. Management is currently drafting a cost allocation policy that includes specific guidance on how to allocate shared costs (e.g., rent, insurance, software) across programs, management & general, and fundraising functions. The new policy will include acceptable bases such as square footage, staff headcount, or usage logs and will be reviewed annually. All allocations will be supported by schedules retained with the audit documentation.
Corrective Action: This finding is a continuation of a prior year deficiency related to the lack of formal allocation methodologies. Management is currently drafting a cost allocation policy that includes specific guidance on how to allocate shared costs (e.g., rent, insurance, software) across programs, management & general, and fundraising functions. The new policy will include acceptable bases such as square footage, staff headcount, or usage logs and will be reviewed annually. All allocations will be supported by schedules retained with the audit documentation.
2022-002
FAC accepted this audit on February 26, 2024 — management decision was due August 26, 2024.
Expenditures allocated to federal awards were not based on rational and consistent allocation methodologies. Criteria: Expenditures charged to federal award programs should be reasonable and necessary. Those costs that are allocated should include documentation of the specific allocation methodologies used.Cause: The Organization obtained their first federal funding as a result of the COVID-19 pandemic. The Organization did not have an internal control system in place to meet the criteria required under the more robust internal control framework provided by the Uniform Guidance. As a result, even though audited allocated expenses appeared reasonable, a documented methodology was not in writing. Effect: Of the expenditures tested, most were initially allocated within the general ledger under a different methodology than was eventually expensed under the federal grant awards. Additionally, audit time and bookkeeping time was incurred to reconcile between the two allocation methodologies, and, in most cases, there was no documentation of the eventual allocation methodology. Many of the allocations reviewed relied on oral assertions of expenditures applicable to different Organization functions and federal award programs. In addition, although the allocations charged to the grants appeared to be consistent within a range, the initial assessment appeared to be based on budgetary concerns rather the use. Recommendation: Indirect costs, such as overhead and other split expenses, should be based on a written allocation methodology. For example, overhead expenses such as rent and utilities could be based on the square footage occupied by employees that provide services to specific Organization functions. Other expenses such as the purchase of supplies should be charged directly to the function or program utilizing the supplies or over rational basis of use if utilized under many functions or programs. Employee time should be allocated specifically based on the hours in the date spent towards achieving the goals of the Organization’s functions or programs. As a further recommendation, the Organization should obtain training to gain a full understanding of the internal control requirements under the Uniform Guidance internal control framework. Management’s Response: See management’s corrective action plan.
Show full finding ▾Hide full finding ▴Inadequate Controls Over Expenditure Allocations Condition: Expenditures allocated to federal awards were not based on rational and consistent allocation methodologies. Criteria: Expenditures charged to federal award programs should be reasonable and necessary. Those costs that are allocated should include documentation of the specific allocation methodologies used.Cause: The Organization obtained their first federal funding as a result of the COVID-19 pandemic. The Organization did not have an internal control system in place to meet the criteria required under the more robust internal control framework provided by the Uniform Guidance. As a result, even though audited allocated expenses appeared reasonable, a documented methodology was not in writing. Effect: Of the expenditures tested, most were initially allocated within the general ledger under a different methodology than was eventually expensed under the federal grant awards. Additionally, audit time and bookkeeping time was incurred to reconcile between the two allocation methodologies, and, in most cases, there was no documentation of the eventual allocation methodology. Many of the allocations reviewed relied on oral assertions of expenditures applicable to different Organization functions and federal award programs. In addition, although the allocations charged to the grants appeared to be consistent within a range, the initial assessment appeared to be based on budgetary concerns rather the use. Recommendation: Indirect costs, such as overhead and other split expenses, should be based on a written allocation methodology. For example, overhead expenses such as rent and utilities could be based on the square footage occupied by employees that provide services to specific Organization functions. Other expenses such as the purchase of supplies should be charged directly to the function or program utilizing the supplies or over rational basis of use if utilized under many functions or programs. Employee time should be allocated specifically based on the hours in the date spent towards achieving the goals of the Organization’s functions or programs. As a further recommendation, the Organization should obtain training to gain a full understanding of the internal control requirements under the Uniform Guidance internal control framework. Management’s Response: See management’s corrective action plan.
Corrective Action: Although we had a control process in place at that time, it was not sufficient to meet the standard of the single audit. We have improved our Internal Controls since the start of the audit. In addition to the annual budget process, non-recurring expenses must be pre-approved by the CEO or Director Finance and Administration prior to purchasing. Monthly transactions that are auto debited from the credit card or bank account, for example health insurance, telephone, internet, etc. are processed in accordance with our budget and pre-approved by the CEO and Director of Finance and Administration. Those transactions are still reviewed monthly. Below is a section from our current Internal Control document. Disbursements For non-routine purchases, expenses must be pre-approved by the CEO or DOFA. The CEO, Directors or Executive Assistant (EA) will initiate the purchase. Due to very few non-routine purchases, LM currently does not use a purchase order system. The EA opens the mail and will give all the invoices to the Director of Finance and Administration (DOFA) to be coded and reviewed against the grant and/or budget. After coding the invoices, the DOFA gives the payable invoices to the Staff Accountant (SA). The Directors are responsible for stamping and coding all their payable invoices, comparing them against their budgets to ensure coding is correct and placing the stamped and coded payables in the appropriate area for the SA. Weekly the SA will review all the stamped and coded payables from all the Directors with the DOFA for review and approval of the various budgets. Then the DOFA will review the AP invoices with the CEO for his final approval and signature. Once payables are approved by the CEO, the SA will update the AP log in SharePoint and scan the signed/approved AP invoices to CBIZ for posting to QuickBooks. Credit Cards: Currently, the CEO, DOPO, DVM, and EA have credit cards. All expenses must be pre-approved by the CEO or DOFA. Recurring payments such as utilities, software, and telephone are done via credit card. Many office supplies and program supplies are paid via credit card. Also, many times last minute expenses are paid via credit cards. The credit card has an aggregate $10,000 limit. The CEO has an aggregate $15,000 limit. The Directors, EA and CEO should print credit card receipts, stamp and code expenses on the receipt and these receipts are to be placed daily in the Finance CC folder in the copy room. The SA will review the receipts and coding, then weekly review the CC receipts with the DOFA against the various budgets. Once reviewed and approved by the DOFA, the SA will add to the CC log on SharePoint. CBIZ will update QB monthly directly from the CC Log which includes allocation coding.
Expenditures allocated to federal awards were not based on rational and consistent allocation methodologies. Criteria: Expenditures charged to federal award programs should be reasonable and necessary. Those costs that are allocated should include documentation of the specific allocation methodologies used.Cause: The Organization obtained their first federal funding as a result of the COVID-19 pandemic. The Organization did not have an internal control system in place to meet the criteria required under the more robust internal control framework provided by the Uniform Guidance. As a result, even though audited allocated expenses appeared reasonable, a documented methodology was not in writing. Effect: Of the expenditures tested, most were initially allocated within the general ledger under a different methodology than was eventually expensed under the federal grant awards. Additionally, audit time and bookkeeping time was incurred to reconcile between the two allocation methodologies, and, in most cases, there was no documentation of the eventual allocation methodology. Many of the allocations reviewed relied on oral assertions of expenditures applicable to different Organization functions and federal award programs. In addition, although the allocations charged to the grants appeared to be consistent within a range, the initial assessment appeared to be based on budgetary concerns rather the use. Recommendation: Indirect costs, such as overhead and other split expenses, should be based on a written allocation methodology. For example, overhead expenses such as rent and utilities could be based on the square footage occupied by employees that provide services to specific Organization functions. Other expenses such as the purchase of supplies should be charged directly to the function or program utilizing the supplies or over rational basis of use if utilized under many functions or programs. Employee time should be allocated specifically based on the hours in the date spent towards achieving the goals of the Organization’s functions or programs. As a further recommendation, the Organization should obtain training to gain a full understanding of the internal control requirements under the Uniform Guidance internal control framework. Management’s Response: See management’s corrective action plan.
Show full finding ▾Hide full finding ▴Inadequate Controls Over Expenditure Allocations Condition: Expenditures allocated to federal awards were not based on rational and consistent allocation methodologies. Criteria: Expenditures charged to federal award programs should be reasonable and necessary. Those costs that are allocated should include documentation of the specific allocation methodologies used.Cause: The Organization obtained their first federal funding as a result of the COVID-19 pandemic. The Organization did not have an internal control system in place to meet the criteria required under the more robust internal control framework provided by the Uniform Guidance. As a result, even though audited allocated expenses appeared reasonable, a documented methodology was not in writing. Effect: Of the expenditures tested, most were initially allocated within the general ledger under a different methodology than was eventually expensed under the federal grant awards. Additionally, audit time and bookkeeping time was incurred to reconcile between the two allocation methodologies, and, in most cases, there was no documentation of the eventual allocation methodology. Many of the allocations reviewed relied on oral assertions of expenditures applicable to different Organization functions and federal award programs. In addition, although the allocations charged to the grants appeared to be consistent within a range, the initial assessment appeared to be based on budgetary concerns rather the use. Recommendation: Indirect costs, such as overhead and other split expenses, should be based on a written allocation methodology. For example, overhead expenses such as rent and utilities could be based on the square footage occupied by employees that provide services to specific Organization functions. Other expenses such as the purchase of supplies should be charged directly to the function or program utilizing the supplies or over rational basis of use if utilized under many functions or programs. Employee time should be allocated specifically based on the hours in the date spent towards achieving the goals of the Organization’s functions or programs. As a further recommendation, the Organization should obtain training to gain a full understanding of the internal control requirements under the Uniform Guidance internal control framework. Management’s Response: See management’s corrective action plan.
Corrective Action: Although we had a control process in place at that time, it was not sufficient to meet the standard of the single audit. We have improved our Internal Controls since the start of the audit. We have been using CBIZ, a CPA Firm, for our third-party accounting since June of 2023. Prior to expenditures being sent to CBIZ for posting to QuickBooks, the expenditures are reviewed by 4 staff members: the Director who initiated the purchase and adds the allocations codes to the invoice/bill/receipt, the Staff Accountant, the Director of Finance and Administration and the CEO for final approval who also initials the expenditure. Once the expenditure is approved, it is then added to our AP Log and/or CC log by our Staff Accountant and then the approved expenditures are scanned to CBIZ for posting to QuickBooks by one of their staff members. A manager with CBIZ will review it again when completing our monthly financials for accuracy. Once CBIZ posts our expenditures and deposits, they note on our SharePoint and OneDrive AP, CC logs and Weekly Income Reports that the work has been posted in QuickBooks. Due to the requirements of our current Grants, we have increased our internal controls, budget overviews and Director’s responsibilities to manage their events and expenses and code allocations per the budget so if reallocation of any kind is needed, it can be revised before it goes to the CPA. In addition, there is a 2nd review of the Grant Invoice and expenditure documentation by the Director and Finance and Administration and the CEO before the invoice is submitted to the Grant Administrator for reimbursement.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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