Corrective Action Plans

Finding 1153506 (2024-001)

Material Weakness 2024

TN

Questioned Costs Eligibility Subrecipient Monitoring

Planned Corrective Action: Current policy and procedure in place will be followed. The grant accountant and food compliance officer will review Summer Food Service Program sites and reimbursements prior to the completion of the SFSP program period each year.

View Audit 366736 Questioned Costs: $1

Finding 1153461 (2024-002)

Material Weakness 2024

Thomas University, Inc.

GA

Questioned Costs Student Financial Aid Eligibility

Responsible Official’s Response and Corrective Action Planned: We agree with the finding and recommendations. Thomas University has upgraded its student information system from CAMS to Jenzabar. The Financial Aid module Jenzabar Financial Aid has been configured by the Director of Financial Aid with...

Responsible Official’s Response and Corrective Action Planned: We agree with the finding and recommendations. Thomas University has upgraded its student information system from CAMS to Jenzabar. The Financial Aid module Jenzabar Financial Aid has been configured by the Director of Financial Aid with a group process to identify enrollment level changes. This process is programmed to adjust the student scheduled Pell to reflect the updated Pell amount based on the Pell table. This process will reduce the Pell amount if the hours adjust down even when the Pell has already disbursed. This process will also increase the Pell when the hours increase. This process is on a scheduler that runs daily. Planned Implementation Date of Corrective Action: This process was created and implemented 10/01/2024. Person Responsible for Corrective Action: Derek Haskins, Director of Financial Aid

View Audit 366719 Questioned Costs: $1

Finding 1153455 (2024-001)

Material Weakness 2024

Bladenboro Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Bladenboro Housing Authority Corrective Action Plan For the Year Ended December 31, 2024 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2024-001 Name of Contact Person: Becky Tatum Interim Director Corrective Action: Manageme...

Bladenboro Housing Authority Corrective Action Plan For the Year Ended December 31, 2024 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2024-001 Name of Contact Person: Becky Tatum Interim Director Corrective Action: Management will implement proper internal control procedures for the Public and Indian Housing program eligibility requirements. Proposed Completion Date: Immediately

View Audit 366705

Finding 1153453 (2024-002)

Material Weakness 2024

Shawnee Christian Healthcare Center, Inc.

KY

Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking

The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throu...

The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patent accounts have been adjusted properly.

View Audit 366700

Finding 1153386 (2024-004)

Material Weakness 2024

Afghan Cultural Society of Mn

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that ACS review all participant files to ensure proper documentation is retained supporting the eligibility of a...

Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that ACS review all participant files to ensure proper documentation is retained supporting the eligibility of applicants. We noted that there is currently a process in place to review files to ensure that only eligible participants are being served, but we recommend that a process is implemented and documented to ensure that there is proper review and approval of all applicants prior to the individual receiving services and that this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This will be grant dependent as many of the grant's ACS has the grantors retain the documentation and do a secondary review of eligibility. The Self-Help grant is a grant that is direct to the organization, and two people will review and document on the participation form they have reviewed the eligibility of the participants. Name(s) of the contact person(s) responsible for corrective action: Nasreen Sajady Planned completion date for corrective action plan: This will begin September 2025 and continue for the remainder of the programs needing a secondary review.

View Audit 366598

Finding 1153297 (2024-001)

Material Weakness 2024

Dunn Housing Authority

NC

Eligibility HUD Housing Programs Reporting

Corrective Action Plan Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2024-001 Name of Contact Person: Felicia Chester, Executive Director Corrective Action: We will implement proper internal control procedures for the Public...

Corrective Action Plan Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2024-001 Name of Contact Person: Felicia Chester, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program elegibility requirements. Mangement has established a checklist for applications and will establish checklists for move-ins and move-outs. Proposed Completion Date: Immediately

View Audit 366512

Finding 1152932 (2024-002)

Material Weakness 2024

Springfield Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Eligibility

FINDING 2024-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency 11 SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2024 FYE audit report. In 2024, the Springfi...

FINDING 2024-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency 11 SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2024 FYE audit report. In 2024, the Springfield Housing Authority Housing Choice Voucher program delineated the following positions to undertake income and rent calculations: one (1) Special Programs Coordinator, four (4) HCV Specialists and one (1) Program Integrity Specialist. Of those six (6) employees, only one had a tenure longer than 12 months. Due to continuing post COVID-19 turnover and lack of qualified workers in the local workforce, the SHA experienced a higher than usual turnover rate in the HCV positions that conduct rent calculations during the majority of FY2024. The Springfield Housing Authority hired third party consultants to assist with annual recertifications in the 3rd Quarter of 2023 that continued through December 31, 2024. The primary function of the Program Integrity Specialist position is to audit and quality control tenant files and rent calculations conducted by HCV Specialists. The HCV Director and/or HCV Manager is responsible for reviewing 3% of recertifications audited by the Program Integrity Specialist position as an additional quality control measure. This error rate was directly attributable to the unprecedented turnover rate of HCV Specialists during the 2024 fiscal year. The Director of HCV, HCV Manager, HCV Specialists, HCV Special Programs Coordinator and Program Integrity Specialist were provided additional internal and external training opportunities in HCV rent calculations and program integrity in June 2025. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Specialist will conduct reviews of 100% of annual and interim recertifications for HCV program participants by December 31, 2025. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the HCV Specialists, monthly. • The HCV Director and/or Manager will review 10% of the recertifications audited by the Program Integrity Specialist as an additional quality control measure by December 31, 2025. • Any newly hired HCV Director, HCV Manager, HCV Specialists and Program Integrity Specialist will be provided with additional external training opportunities in Housing Choice Voucher program income and rent calculations and program integrity within sixty (60) days of employment. • The HCV Director and/or Manager will re-review the files identified with errors during the independent audit and resolve the errors in accordance with the SHA Administrative Plan and HUD rules and regulations by December 31, 2025. Person Responsible: Melissa Huffstedtler Anticipated Completion Date: December 31, 2025

View Audit 366267

Finding 1152931 (2024-001)

Material Weakness 2024

Springfield Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Eligibility

FINDING 2024-001 "Public Housing Tenant Files - Eligibility- Internal Control Over Tenant Files Non-Compliance and Significant Deficiency" SHA RESPONSE • The Springfield Housing Authority acknowledges the five (5) errors as delineated in the full 2024 FYE audit report. The auditors pulled files from...

FINDING 2024-001 "Public Housing Tenant Files - Eligibility- Internal Control Over Tenant Files Non-Compliance and Significant Deficiency" SHA RESPONSE • The Springfield Housing Authority acknowledges the five (5) errors as delineated in the full 2024 FYE audit report. The auditors pulled files from two points in time through the fiscal year. It was noted that the identified errors were from the second half of the fiscal year tenant actions (July- December) when the Springfield Housing Authority experienced a staffing shortage in both the Program Integrity and Asset Manager functions of the Public Housing program. The majority of identified errors were found in instances where the public housing operations was short staffed in five positions (2 Asset Managers, 1 Program Integrity Specialist, 1 Occupancy Specialist and 1 Inspector). Staffing stabilization at the first half of the fiscal year gave way to a higher than usual turnover rate in the positions that conduct rent calculations, file audits and inspections during the latter part of FY2024. The primary function of the Program Integrity Specialist position is to audit and quality control tenant files and rent calculations conducted by Occupancy Specialists. The Asset Managers are responsible for reviewing 3% of recertifications audited by the Program Integrity Specialist position as an additional quality control measure. The Asset Managers, Occupancy Specialists and Program Integrity Specialists were provided additional internal and external training opportunities in low rent public housing rent calculations and program integrity in June 2025. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Specialist will conduct reviews of 100% of annual and interim recertifications for public housing tenants by December 31, 2025. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the Occupancy Specialists, monthly. • The Asset Manager(s) will review 10% of the recertifications audited by the Program Integrity Specialist as an additional quality control measure by December 31, 2025. • Any newly hired Asset Managers, Occupancy Specialists and Program Integrity Specialists will be provided with additional external training opportunities in low rent public housing rent calculations and program integrity within sixty (60) days of employment. • The Asset Managers will re-review the files identified with errors during the independent audit and resolve the errors in accordance with the SHA Admissions and Continued Occupancy Plan and HUD rules and regulations by December 31, 2025. Person Responsible: Melissa Huffstedtler, Deputy Director Anticipated Completion Date: December 31, 2025

View Audit 366267

Finding 1152927 (2024-001)

Material Weakness 2024

Stoddard County Public Health Center

MO

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

Name of Contact Person: Ben Godwin, Director. Recommendation: We recommend the Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify all...

Name of Contact Person: Ben Godwin, Director. Recommendation: We recommend the Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Proposed Completion Date: Immediately.

View Audit 366253

Finding 1152893 (2024-004)

Material Weakness 2024

Vinton County

OH

Eligibility School Nutrition Programs Matching / Level of Effort / Earmarking § 200.303

The Board of Health WIC personnel will implement additional control practices for the review and approval for WIC eligibility for participants. In addition, WIC personnel will ensure all supporting documentation has been obtained in order to determine participant eligibility.

View Audit 366220

Finding 576312 (2024-002)

Material Weakness 2024

Yakama Nation Housing Authority

WA

Allowable Costs / Cost Principles Eligibility HUD Housing Programs § 200.303

Persons responsible for this corrective action plan: Phylistine Alexander, Housing Manager and Jana Kent, Executive Director Corrective Action Plan: YNHA will work with the NwONAP Grant Evaluation Director to evaluate our current tenant file documentation and eligibility determination process an...

Persons responsible for this corrective action plan: Phylistine Alexander, Housing Manager and Jana Kent, Executive Director Corrective Action Plan: YNHA will work with the NwONAP Grant Evaluation Director to evaluate our current tenant file documentation and eligibility determination process and will implement recommendations from HUD. Estimated Completion Date: December 31, 2025

View Audit 366187

Finding 576160 (2024-002)

Significant Deficiency 2024

Heart of Kansas Family Health Care, Inc.

KS

Eligibility

Heart of Kansas will retrain all personnel to ensure they are adhering to the Sliding fee Scale Policy. Debby Popplereiter, patient Accounts Director, and Blanca Salas, patient intake coordinator, will start randomly selecting 5 patients a month and reviewing whether the policy was followed and the ...

Heart of Kansas will retrain all personnel to ensure they are adhering to the Sliding fee Scale Policy. Debby Popplereiter, patient Accounts Director, and Blanca Salas, patient intake coordinator, will start randomly selecting 5 patients a month and reviewing whether the policy was followed and the sliding fees selected correctly. Freddy Gunn, CFO, will review results with Debby to determine if further education and/or training will be needed. We will begin this process immediately.

View Audit 366075

Finding 576112 (2024-003)

Material Weakness 2024

Gooding Senior Housing Association INC

ID

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2024-003 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...

Finding 2024-003 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: Management has requested that the auditor propose certain year-end adjustments to bring the financial statements into conformity with Generally Accepted Accounting Principles (GAAP). For example, cash to accrual adjustments, depreciation calculations and adjustments, adjustments to debt and interest expense, interest subsidy adjustments, etc. Management Response: Management has evaluated the risk that a material misstatement might occur and not be detected in the financial statements. Management believes that the risk of material misstatement is not significant for the following reasons: 1. The entries are standard entries required to be made each year. If an entry was not made it would be obvious in the financial statements. A calculation error that would be material to the financial statements would also be obvious. 2. Management reviews and approves both the proposed adjusting journal entries and the financial statements prior to release. Based upon management’s consideration of the risk of material misstatement, management believes the costs of hiring, training, and monitoring part-time accounting personnel far exceed any potential benefits from implementing additional controls. Status: In progress Anticipated Completion Date: Estimated 2025

View Audit 366031

Finding 576110 (2024-001)

None 2024

Gooding Senior Housing Association INC

ID

Reporting Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.512

Finding 2024-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...

Finding 2024-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025

View Audit 366031

Finding 576081 (2024-002)

None 2024

Legal Services Nyc and Constituent Corporations

NY

Eligibility

The Director of Grants and Contracts for Queens Legal Services has spoken to the supervisor for the paralegals responsible for the errors in these cases, who has spoken to the paralegals. The Compliance Officer is working with LSNYC's LegalServer Support IT specialist to see if the platform can be ...

The Director of Grants and Contracts for Queens Legal Services has spoken to the supervisor for the paralegals responsible for the errors in these cases, who has spoken to the paralegals. The Compliance Officer is working with LSNYC's LegalServer Support IT specialist to see if the platform can be customized so that LSC Eligibility Overrides can only be used to go from Yes to No (as is necessary when we have open a duplicate case for a client, since only one case can be LSC eligible), which is the only acceptable way for LSC Eligibility Overrides to work. The Compliance Officer will work with the Citywide Director of Intake to develop written materials that (1) remind intake staff to exclude primary residences from Asset totals, which has always been and will continue to be part of financial eligibility training; (2) remind intake staff that an Asset Override may only be made with the written approval of a supervisor (who will review to make sure that the assets legitimately exceed the asset ceiling) documented in the case file; and (3) explain to intake staff the appropriate use of each of the override fields - income overrides, asset overrides, and LSC Eligibility overrides.

View Audit 365979

Finding 576080 (2024-001)

None 2024

Legal Services Nyc and Constituent Corporations

NY

Eligibility

The Compliance Officer met with the Grants and Contracts team from Manhattan Legal Services about the income ineligible case and discussed systems for ensuring that supervisors review the monthly compliance cleanup reports and make the identified corrections as instructed. They will reiterate to al...

The Compliance Officer met with the Grants and Contracts team from Manhattan Legal Services about the income ineligible case and discussed systems for ensuring that supervisors review the monthly compliance cleanup reports and make the identified corrections as instructed. They will reiterate to all staff that the LSC income eligibility category in our case management system, LegalServer, is unrelated to income eligibility criteria for individual contracts and that while LSNYC may represent a client who is not LSC income eligible using funds for which that is permissible, those cases must be marked as LSC income ineligible. The intake paralegal responsible for the erroneous override will get remedial instructions on removing such overrides rather than leaving them in place. Additionally, the Compliance Officer has been meeting with staff in other boroughs who distribute monthly cleanup reports to evaluate their practices for ensuring corrections are made in response to the reports. The Compliance Officer and Citywide Director of Intake Services will continue to train on how the LSC income eligibility criteria are to be applied, and that No should be selected for LSC income eligibility even when a client is income eligible under other funders’ contracts. The Director of Grants and Contracts for Queens Legal Services has spoken to the attorney and supervisor responsible for the incorrect LSC Eligibility Override Note in the asset-ineligible case. The Compliance Officer is working with LSNYC's LegalServer Support IT specialist to see if the platform can be customized so that LSC Eligibility Overrides can only be used to go from Yes to No (as is necessary when we have open a duplicate case for a client, since only one case can be LSC eligible), which is the only acceptable way for LSC Eligibility Overrides to work. The Compliance Officer and the Citywide Director of Intake will continue to train staff on the LSC asset eligibility criteria and stress that although we can accept clients whose assets exceed the LSC asset ceiling, no one should be selected for Asset and LSC eligibility for those cases.

View Audit 365979

Finding 576033 (2024-002)

Significant Deficiency 2024

Public Housing Authority of Butte

MT

HUD Housing Programs Eligibility Reporting

2024‐002 HUD Required Reporting HUD regulations and federal requirements mandate timely submission of the Unaudited Financial Assessment Subsystem for Public Housing Agencies (FASSPHA). During the audit, it was noted that the Authority did not meet the prescribed deadlines for submitting the unaudit...

2024‐002 HUD Required Reporting HUD regulations and federal requirements mandate timely submission of the Unaudited Financial Assessment Subsystem for Public Housing Agencies (FASSPHA). During the audit, it was noted that the Authority did not meet the prescribed deadlines for submitting the unaudited FASSPHA to federal agencies. The Public Housing Authority of Butte has contracted with BDO to prepare and submit the unaudited FASSPH. BDO prepared and submitted the unaudited FASSPH for fiscal year ending 2024. Going forward BDO will continue to assist the Public Housing Authority of Butte with preparing and submitting the unaudited financial reports. The Public Housing Authority of Butte has hired a Deputy Executive Director who will be able to closely monitor HUD deadlines and reporting requirements.

View Audit 365924

Finding 576029 (2024-002)

Significant Deficiency 2024

Pomona Community Health Center Dba Parktree Community Health Center

CA

Special Tests & Provisions Eligibility Significant Deficiency

2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents ...

2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents are retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on document retention policies in relation to the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review of current patient sliding fee applications to ensure all required documents are maintained and retained for the appropriate length of time as per PCHC Board of Director approved policies. Weekly audits verifying supporting documents for the sliding fee applications are conducted under the supervision of management, and improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025

View Audit 365919

Finding 575882 (2024-003)

Material Weakness 2024

Buckeye Local School District

OH

Eligibility School Nutrition Programs Matching / Level of Effort / Earmarking § 200.303

The District beginning in FY 2025 became part of the Community Eligibility Program allowing for all students to receive free lunch and breakfast. As such, the District is not using Pay Schools to determine eligibility.

View Audit 365847

Finding 575820 (2024-001)

Significant Deficiency 2024

Genesis Nonprofit Housing Corporation

MI

Eligibility HUD Housing Programs Significant Deficiency

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.

View Audit 365801

Finding 575802 (2024-001)

Material Weakness 2024

Mary Lee Community

TX

Eligibility HUD Housing Programs Reporting

Recommendation: The Cornerstone and Legacy projects were disposed of by sale and contribution, respectively, and all HOME-related loans and related compliance requirements were assumed by Foundation Communities (an unrelated nonprofit organization) or one of its affiliates during May 2024. Therefore...

Recommendation: The Cornerstone and Legacy projects were disposed of by sale and contribution, respectively, and all HOME-related loans and related compliance requirements were assumed by Foundation Communities (an unrelated nonprofit organization) or one of its affiliates during May 2024. Therefore, we have no recommendation for this finding. Action taken: Management agrees with the finding. No action is needed.

View Audit 365790

Finding 575774 (2024-002)

Material Weakness 2024

North Valley Caring Services

CA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302

Management concurs with the finding and will revise procedures to ensure detailed, timely recording of USDA Foods distributions. Staff will receive training on documentation requirements, and management will implement periodic compliance reviews. These corrective actions are expected to be complet...

Management concurs with the finding and will revise procedures to ensure detailed, timely recording of USDA Foods distributions. Staff will receive training on documentation requirements, and management will implement periodic compliance reviews. These corrective actions are expected to be completed by March 1, 2025.

View Audit 365739

Finding 575773 (2024-001)

Material Weakness 2024

North Valley Caring Services

CA

Subrecipient Monitoring Eligibility

Management concurs with the finding. NVCS was followed guidance received from the pass‐through entity but did not fully implement the required proxy documentation format. Management will revise procedures to ensure that the “Volunteer Proxy: [Name]” designation is clearly included where applicable...

Management concurs with the finding. NVCS was followed guidance received from the pass‐through entity but did not fully implement the required proxy documentation format. Management will revise procedures to ensure that the “Volunteer Proxy: [Name]” designation is clearly included where applicable and will provide training to distribution staff. Internal monitoring will be implemented to ensure future compliance. The corrective action is expected to be fully implemented by March 1, 2025.

View Audit 365739

Finding 575769 (2024-002)

Material Weakness 2024

Catherine's Health Center

MI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a ...

Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.

View Audit 365733

Finding 575726 (2024-001)

Significant Deficiency 2024

Parkview Services

WA

Eligibility Procurement, Suspension & Debarment Reporting

Management does not agree with this finding. Parkview Services disputes this finding and maintains that no corrective action is necessary. All tenants met eligibility requirements prior to move-in, and there was no risk of non-compliance with funding agreements. Eligibility was verified in each case...

Management does not agree with this finding. Parkview Services disputes this finding and maintains that no corrective action is necessary. All tenants met eligibility requirements prior to move-in, and there was no risk of non-compliance with funding agreements. Eligibility was verified in each case through DDA referral packets from the supported living service provider or email communications with the DDA case manager. These contain protected personal and health information and are therefore not retained in landlord files. The funding agreements require that DDA provide referrals for the project but do not prescribe the format or timing of specific documents placed in the tenant file. While Parkview has an internal practice of obtaining a “referral letter” for each file, the absence or later dating of this letter in the cited cases reflects procedural deviations due to extenuating circumstances, not a failure to verify eligibility. Standard practices, including a move-in checklist and file review, were in place, and Parkview remained fully compliant with contractual requirements

View Audit 365724

Corrective Action Plans

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