Corrective Action Plans

Finding 575276 (2023-005)

Significant Deficiency 2023

ND

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

Corrective Action Plan: ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future. Person(s) Responsible: Alv...

Corrective Action Plan: ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future. Person(s) Responsible: Alvonne Penola, Treatment Program Director Estimated Completion Date: Effective immediately

View Audit 365312

Finding 575273 (2023-004)

Material Weakness 2023

Standing Rock Sioux Tribe

ND

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Corrective Action Plan: ALN 93.575 and 93.596 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 and 93.596 (Provider files): In July 2025, the Program hired a Compliance ...

Corrective Action Plan: ALN 93.575 and 93.596 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 and 93.596 (Provider files): In July 2025, the Program hired a Compliance Specialist to review provider files for compliance. In addition, the Program hired an employee to assist with the demanding workload. ALN 93.568 (participant files): the identified items of non-compliance was a direct result of program personnel turnover, including the Director. The Director position was vacant for the entire fiscal year. The Program is now fully staffed and working on ensuring that all intake items are clearly documented/retained in the participant files. Person(s) Responsible: Jackie Brownotter, Child Care Assistance Program Director, Deanne Bear Catches, LIHEAP Director Estimated Completion Date: ALN 93.575 and 93.596 (CPR Certifications): October 2024, ALN 93.575 and93.596 (Provider files): Effective immediately ALN 93.568 (participant files): effectively immediately

View Audit 365312

Finding 573743 (2023-016)

Significant Deficiency 2023

Caswell County

NC

Allowable Costs / Cost Principles Questioned Costs Eligibility

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-016 Inaccurate Resource Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervis...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-016 Inaccurate Resource Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. Transfer of Asset policy and procedures will be reviewed with applicable caseworkers. TOA evaluation and clear documentation of Transfers and Resolutions must be documented. Help Desk tickets should be submitted timely if information or functionality is not working properly. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. May 1, 2024 Section III - Federal Award Findings and Question Costs (continued) 141

View Audit 364406

Finding 573742 (2023-015)

Significant Deficiency 2023

Caswell County

NC

Questioned Costs Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-015 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-015 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Section III - Federal Award Findings and Question Costs (continued) April 11, 2024 Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. CW must address all Household income and have clear documentation of request or findings. Training targeted to address error trend of Documentation of Vehicles and Rebuttals. Training targeted to address error trend of evaluation of 1/3 reduction. Information requested from OST to properly enter 1/3 reduction in NCFAST obtained. Training targeted for applicable staff to address Transfer of Asset requirements and how to address and clearly document transfers. Help Desk tickets should be submitted timely if information or functionality is not working properly. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 140

View Audit 364406

Finding 573741 (2023-014)

Significant Deficiency 2023

Caswell County

NC

Questioned Costs Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-014 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Super...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-014 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Section III - Federal Award Findings and Question Costs (continued) A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include accurate household members, online verifications, documented sources and verifications of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. May 1, 2024 139

View Audit 364406

Finding 573740 (2023-013)

Significant Deficiency 2023

Caswell County

NC

Questioned Costs Eligibility Significant Deficiency

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-012 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: December 2025 Finding: 20...

CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-012 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: December 2025 Finding: 2023-013 IV-D Non-Cooperation Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor At the time the determinations under audit were completed this was a requirement. However, under current policy referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). Please see Administrative Letter 13/23 Due to CCU referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). 5/1/2024 Caseworkers will adhere to Continuous Coverage Unwinding (CCU) Period Policy. As noted in the response to Findings 2023-001 and 2023-006, County finance staff is diligently working to improve the timeliness of transaction processing and anticipates timely completion of the FY25 audit which will resolve this finding. Melissa Miller, Interim Finance Officer Section III - Federal Award Findings and Question Costs 138

View Audit 364406

Finding 573739 (2023-002)

Significant Deficiency 2023

Housing Authority of the City of Pueblo

CO

Questioned Costs Eligibility Significant Deficiency

Finding 2023-002 U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: For 5 participant files, the recertification / move-in checklists were not signed by Authority staff. Res...

Finding 2023-002 U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: For 5 participant files, the recertification / move-in checklists were not signed by Authority staff. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: In addition to accounting, we also had newer staff members in the compliance department after a leadership transition with the department manager. We have conducted thorough training and discussions to help identify solutions moving forward. We will establish internal controls to ensure that all recertification/move-in checklists are signed by Authority Staff. We will work with the department manager to ensure that the control processes are being followed. Anticipated Completion Date: January 2024

View Audit 364403

Finding 573738 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of Pueblo

CO

Allowable Costs / Cost Principles HUD Housing Programs Questioned Costs

U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Nonco...

U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The Authority was not able to locate 1 of the 61 participant files selected for audit testing. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: During 2023, the Housing Choice Voucher Department moved physical locations from the 10th Floor of 1414 Santa Fe to 201 S Victoria. Also, during this time, all of the historical paper files were being scanned for digital storage. During this time, paperwork for one of the participants re-certification and inspection were misplaced and not able to be located during audit fieldwork. We do not anticipate this issue in the future since there will not be another office move, and all recertification paperwork moving forward is being scanned and attached in our software Anticipate Completion Date: January 2024

View Audit 364403

Finding 572978 (2023-001)

Significant Deficiency 2023

Park Shore East Cooperative

IL

Internal Control / Segregation of Duties Questioned Costs Eligibility

Finding No. 2023-01: Tenant income is to be reconciled to reports run by the Enterprise Income Verification system (EIV) Recommendation: Management should use the EIV system properly to verify tenant employment and income during recertifications and calculate subsidy payments correctly. Action Taken...

Finding No. 2023-01: Tenant income is to be reconciled to reports run by the Enterprise Income Verification system (EIV) Recommendation: Management should use the EIV system properly to verify tenant employment and income during recertifications and calculate subsidy payments correctly. Action Taken or Planned: Management is conducting proper reconciliation between EIV system and tenant declared income at recertification. Responsible Person: Monique Brown, Manager Completion Date: May 31, 2023

View Audit 363827 Questioned Costs: $1

Finding 572566 (2023-005)

Significant Deficiency 2023

Cherokee Boys Club, Inc.

NC

Questioned Costs Eligibility

Finding 2023-005: Significant Deficiency - Eligibility Condition: The Club was unable to locate the initial program application documentation for one individual selected for testing. Corrective Action: The Club agrees with this finding and will establish a process for storing all past and present ...

Finding 2023-005: Significant Deficiency - Eligibility Condition: The Club was unable to locate the initial program application documentation for one individual selected for testing. Corrective Action: The Club agrees with this finding and will establish a process for storing all past and present student and staff files in a secure location to maintain all necessary applications and other documents related to enrollment and eligibility. Person Responsible For Corrective Action: Leslie McEntire, Childcare Manager Anticipated Completion Date: June 30, 2025

View Audit 363709

Finding 572326 (2023-059)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Special Tests & Provisions Eligibility Material Weakness

VIEWS OF RESPONSIBLE OFFICIALS ADSEF developed a collaborative agreement with ASUME to ensure the digital processing of referrals containing information about the absent parent. IMPLEMENTATION DATE August 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by i...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF developed a collaborative agreement with ASUME to ensure the digital processing of referrals containing information about the absent parent. IMPLEMENTATION DATE August 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572325 (2023-058)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Special Tests & Provisions Eligibility Material Weakness

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. Through its Office of Technology and Information, ADSEF used to send the BENDEX list to the regional offices. This proc...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. Through its Office of Technology and Information, ADSEF used to send the BENDEX list to the regional offices. This process was discontinued as of November 2022, when the collaborative agreement with Social Security expired. The SWICA list continues to be processed monthly across all the regions covered by ADSEF. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572318 (2023-053)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

VIEWS OF RESPONSIBLE OFFICIALS Draft and approve eligibility criteria in accordance with federal reporting requirements. Implement monthly reconciliations between TANF and internal records. Establish a report review committee with designated personnel. It’s important to note that administrative expe...

VIEWS OF RESPONSIBLE OFFICIALS Draft and approve eligibility criteria in accordance with federal reporting requirements. Implement monthly reconciliations between TANF and internal records. Establish a report review committee with designated personnel. It’s important to note that administrative expenses are listed under Letter F of the Family Preservation program. Other expenses that could be considered administrative under different letters—such as materials, payroll, etc.—are related to direct services, since the employees being paid under these accounts are social workers and the materials are used for activities that are part of the direct service. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)

View Audit 363366

Finding 572256 (2023-040)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Eligibility Material Weakness § 200.334 § 200.337

VIEWS OF RESPONSIBLE OFFICIALS As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. For this Digitalization project we have available matching funds of approximately 7 million dollars. IMPLEM...

VIEWS OF RESPONSIBLE OFFICIALS As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. For this Digitalization project we have available matching funds of approximately 7 million dollars. IMPLEMENTATION DATE Awaiting System Implementation RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572255 (2023-039)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Eligibility Material Weakness § 200.303

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym) continue

View Audit 363366

Finding 572253 (2023-038)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Eligibility Material Weakness § 200.303

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. Anexes: • Comunicación Límite de tiempo de Beneficios Categoría C • Comunicación sobre periodo de certificación Categoría C, próximos a cumplir los 60 meses. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572249 (2023-037)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Questioned Costs Allowable Costs / Cost Principles Eligibility

VIEWS OF RESPONSIBLE OFFICIALS Establish a peer or supervisory review process for a percentage of eligibility determinations prior to final approval and implement a common error log to identify areas requiring further training or adjustment of procedures. IMPLEMENTATION DATE During Fiscal Year 2025-...

VIEWS OF RESPONSIBLE OFFICIALS Establish a peer or supervisory review process for a percentage of eligibility determinations prior to final approval and implement a common error log to identify areas requiring further training or adjustment of procedures. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Sidnia Vélez, Child Care Program Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)

View Audit 363366 Questioned Costs: $1

Finding 572248 (2023-036)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Eligibility Material Weakness § 200.303

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572246 (2023-035)

Material Weakness 2023

Commonwealth of Puerto Rico - Department of the Family

PR

Subrecipient Monitoring Cash Management Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305

VIEWS OF RESPONSIBLE OFFICIALS Based on the audit report submitted, it is recommended that the Cash Management Section Procedures Manual be amended, and that the segregation of employee duties be identified. To this end, work has begun on reading and amending the Manual. It will be updated consideri...

VIEWS OF RESPONSIBLE OFFICIALS Based on the audit report submitted, it is recommended that the Cash Management Section Procedures Manual be amended, and that the segregation of employee duties be identified. To this end, work has begun on reading and amending the Manual. It will be updated considering both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

View Audit 363366

Finding 572213 (2023-002)

Material Weakness 2023

Galveston County Health District

TX

Eligibility Internal Control / Segregation of Duties

Planned Corrective Action: We have reviewed all billing codes and overrides and research ways to automate controls to apply sliding fee discounts consistently. The error was primarily due to COVID test cost CPT 87635 that was covered by the grants which was wet to ignore the slide. After the grants ...

Planned Corrective Action: We have reviewed all billing codes and overrides and research ways to automate controls to apply sliding fee discounts consistently. The error was primarily due to COVID test cost CPT 87635 that was covered by the grants which was wet to ignore the slide. After the grants were closed no one managed this properly as the full charge was being charged to the patient. We performed internal reviews of billing for compliance. Reports were run identifying these patients and we applied the appropriate discount that was applied on a sliding discount at the time of service. NexGen is set to apply sliding fee discounts automatically based on file maintenance setting and patient chart setting. All CPT Codes that are set to slide fees are exempt under special programs and are being managed at the beginning and ending of these programs. Name of Contact Person: Ruth Cable, CFO and Lane Baker, COO Anticipated completion date: September 30, 2025 Managements Response: The District has reviewed the Independent Auditor’s recommendation. The District’s leadership is committed to developing processes to ensure all compliance requirements are met.

View Audit 363352

Finding 572057 (2023-003)

Significant Deficiency 2023

Waikiki Health

HI

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directl...

Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directly with the Director of Clinical Operations, Kei Wee, to conduct a comprehensive review of the Center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and definition of family size. The Clinical Operations Director, Kei Wee, will develop and implement a step-by-step standard operating procedure (SOP) for staff to consistently assess and apply sliding fee discounts. The SOP will include clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director, Kei Wee's management team, will conduct monthly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to management for corrective follow-up and provide training for registration/front-desk staff and billing personnel on the updated policy and procedures as needed.

View Audit 363175

Finding 571785 (2023-003)

Significant Deficiency 2023

Aim Institute

NE

Eligibility Questioned Costs

We will develop a checklist to ensure all documentation and eligibility requirements are met. We will review monthly with the teams to validate all documentation. During this review we will also make sure that all program directors are trained on the proper documentation and eligibility requirements...

We will develop a checklist to ensure all documentation and eligibility requirements are met. We will review monthly with the teams to validate all documentation. During this review we will also make sure that all program directors are trained on the proper documentation and eligibility requirements. Reasonable completion date: 06/30/25 Responsible Party: Erin Lasiter, VP Programs/Operations

View Audit 362806

Finding 571387 (2023-001)

None 2023

Tri-County Housing, Inc. Dba Total Concept & Subsidiaries

CO

Questioned Costs Subrecipient Monitoring Eligibility § 200.512

Oversight Agency for Audit Tri-County Housing, Inc. dba Total Concept & Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2023. Name of independent accounting firm: Haynie & Company Audit Period: January 1, 2023 through December 31, 2023. The ...

Oversight Agency for Audit Tri-County Housing, Inc. dba Total Concept & Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2023. Name of independent accounting firm: Haynie & Company Audit Period: January 1, 2023 through December 31, 2023. The finding from the December 31, 2023 Schedule of Findings and Questioned Costs is discussed below. Finding 2023-1 Comments of the finding and recommendation: Management agrees with the finding. Action taken: We will assign the Executive Director to oversee all federal reporting deadlines and implement a centralized compliance calendar with automated reminders. Internal policies will be updated to require a formal review of reporting documents at least 45 days prior to submission deadlines. Additionally, relevant staff will receive training on Uniform Guidance requirements, and quarterly compliance meetings will be held to monitor progress. These actions are intended to ensure timely and accurate future submissions in accordance with federal regulations. If the oversight agency has questions regarding this plan, please email Steven Cordova, executive director of Tri-County Housing, Inc. dba Total Concept & Subsidiaries at scordova@totalconcept.net. Sincerely yours, Tri-County Housing, Inc. dba Total Concept & Subsidiaries

View Audit 362321

Finding 571355 (2023-005)

Significant Deficiency 2023

Reach Community Development, Inc.

OR

Eligibility Special Tests & Provisions Significant Deficiency

Finding No. 2023-005 CDBG Entitlement Grants Cluster Federal Assistance Listing Number #14.218 Uniform Guidance Compliance Requirement Code: N- Special Tests and Provisions Criteria Tenant lease files are required to be maintained and tenant eligibility determined in accordance with the Clark Count...

Finding No. 2023-005 CDBG Entitlement Grants Cluster Federal Assistance Listing Number #14.218 Uniform Guidance Compliance Requirement Code: N- Special Tests and Provisions Criteria Tenant lease files are required to be maintained and tenant eligibility determined in accordance with the Clark County Community Services CDBG Procedures Manual and grant documents. Condition In connection with our lease file review we noted two instances of seven tenants tested where management was unable to locate tenant files. Cause Management’s policies with respect to eligibility and the maintenance of tenant lease files in accordance with Compliance in Clark County Community Services CDBG Procedures Manual and grant documents were not consistently followed. Effect or Potential Effect This could result in units being rented to ineligible tenants. Questioned Costs: N/A. Context In connection with the procedures applied to our CDBG units testing, two of the seven tenants tested did have lease files available. Repeat Finding: No Recommendation Management should establish procedures and monitor compliance with those procedures to ensure that correct income verification procedures are performed timely, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of Clark County Community Services CDBG Procedures Manual and grant documents. Views of Responsible Officials The Compliance Specialist discovered missing files at a property while pulling files for the audit. The Compliance team worked to contact residents and rebuild the files with the missing documents. Compliance management investigated and determined the cause of the missing documents was due to a prior site manager not scanning and filing the appropriate documents, along with high staff turnover during this time. The Compliance team is finalizing a new procedure, in addition to the existing, to audit Yardi Voyager for uploaded completed files after move-in and recertification: the goal of this is to catch missing files and documents timely and hold site teams accountable for following the required procedures.

View Audit 362297

Finding 571353 (2023-003)

Significant Deficiency 2023

Reach Community Development, Inc.

OR

Eligibility Questioned Costs HUD Housing Programs

Finding No. 2023-003 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Uniform Guidance Compliance Requirement Code: E-Eligibility Criteria Each owner must comply with the requirements set forth in 24 CFR Part 92 regulations as outlined in the "Compliance in HOME Re...

Finding No. 2023-003 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Uniform Guidance Compliance Requirement Code: E-Eligibility Criteria Each owner must comply with the requirements set forth in 24 CFR Part 92 regulations as outlined in the "Compliance in HOME Rental Projects: A Guide for Property Owners" published by HUD which requires the property to maintain the contracted number of HOME units as well as the designated splits in bedroom size and High Home/Low Home unit ratios. Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. Cause Management’s policies with respect to maintaining the number and split of contracted HOME units were not consistently followed. Effect or Potential Effect The procedures for determining and maintaining the correct HOME units within the property were not applied. This could result in ineligible tenants occupying HOME designated units. Questioned Costs: Not applicable. Context In connection with the procedures applied to our HOME units testing, one of the five properties tested did not meet the contracted HOME units size portfolio (there should be four 3-bedroom units (there are 5); and there should be three 4-bedroom units (there are 2)). Repeat Finding: Yes - Finding 2022-003 Recommendation Management should follow procedures in place to ensure consistent application and adherence to the requirements in accordance with the “Compliance in HOME Rental Projects: A Guide for Property Owners” published by HUD. Views of Responsible Officials A unit will be re-classified the next time there is a vacant unit of the corresponding size/type.

View Audit 362297

Corrective Action Plans

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