Corrective Action Plans

Finding 554735 (2024-021)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Reporting Significant Deficiency

2024-021 Oregon Department of Human Services Obtain accurate information from the ONE application Management Response: We agree with this recommendation. ODHS will continue to monitor and review the ACF-199 and ACF-209 prior to submission. The review will include a sample of JOBS eligible individual...

2024-021 Oregon Department of Human Services Obtain accurate information from the ONE application Management Response: We agree with this recommendation. ODHS will continue to monitor and review the ACF-199 and ACF-209 prior to submission. The review will include a sample of JOBS eligible individuals who do not have countable work activities in the ACF reports, to confirm that their TRACS personal development plan (PDP) accurately reflects engagement and activities in which the individual is engaged. Additionally, ODHS will implement a tracking system to ensure the review of reports is clearly documented. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE Maintenance & Operations agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. Anticipated Completion Date: December 31, 2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353343

Finding 554733 (2024-029)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Period of Performance Reporting

2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case m...

2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case management system is well-documented and current. This issue was initially identified during the statewide single audit for the period ended June 30, 2023. In response to the prior year’s finding, the agency created a new case-note category for documenting client employment start date and wages at exit. Compliance with this new control is then verified as part of our pre-closure case file review process. The agency will continue to provide training to staff on the use of this case note category to ensure we are consistently documenting the start date of employment in the primary occupation and the hourly wage at exit. Anticipated Completion Date: July 1, 2025 Contact person: Angel Hale, Director of Vocational Rehabilitation Services

View Audit 353343

Finding 554732 (2024-028)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Period of Performance Reporting

2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to ...

2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We will update internal controls related to this matter. Anticipated Completion Date: September 30, 2024 Contact Person: Bryan Campbell, Vocational Rehabilitation Operations Manager

View Audit 353343

Finding 554731 (2024-043)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Internal Control / Segregation of Duties § 200.303

2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include cal...

2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include calculation of days when a veteran may be absent for purposes other than receiving hospital care. In addition to strengthening procedures, the controller will review the reconciliation each month. Anticipated Completion Date: June 30, 2025 Contact person: Nicole Dolan, Budget and Fiscal Manager

View Audit 353343

Finding 554718 (2024-002)

Significant Deficiency 2024

Tri-County Senior Citizens and Housing, Inc.

CO

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development ...

Finding 2024-002: Lower Income Housing Assistance Program - Section 8 New Construction and Substantial Rehabilitation Assistance Listing Number: 14.182 U.S. Department of Housing and Urban Development (Repeat of Finding 2023-002 and 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: At this time, we do not have an administrative assistant/Activities Coordinator. Administrator works closely with the bookkeeper. Administrator and Executive Director will schedule every third recertification for review. Executive Director does review of the financial statements on a monthly basis when they are emailed over just before Policy Board meetings. During audit last year, we understood that reporting and eligibility did not have to happen at each interval but a review by another party in office every few re-certifications, as well as reviewing cash management. If there are any questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.

View Audit 353337

Finding 554630 (2024-002)

Significant Deficiency 2024

Independence Square Housing Corporation, Inc.

CA

HUD Housing Programs Eligibility Significant Deficiency § 200.303

Corrective action plan - management response: The organization to update policies and procedures, over completing tenant certification and re-certification, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Marsha...

Corrective action plan - management response: The organization to update policies and procedures, over completing tenant certification and re-certification, to include review by a management agent or acting management agent. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date for corrective action plan: March 2025

View Audit 353292

Finding 554629 (2024-001)

Significant Deficiency 2024

Independence Square Housing Corporation, Inc.

CA

HUD Housing Programs Eligibility Significant Deficiency § 200.303

Corrective action plan - management response: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date...

Corrective action plan - management response: Management to update income limits in Onesite to reflect HUD income limits applicable as of the tenant’s application date. Name(s) of the contact person(s) responsible for corrective action: Marsha Larkin Marani, Project Manager Planned completion date for corrective action plan: March 2025 (as Income Thresholds become available annually by HUD)

View Audit 353292

Finding 554611 (2024-017)

Significant Deficiency 2024

State of Oregon

OR

Special Tests & Provisions Eligibility Significant Deficiency § 200.303

2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in...

2024-017 Oregon Department of Human Services/Oregon Health Authority Strengthen internal controls over the ONE system Management Response: We agree with this recommendation. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE M&O agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. In addition, the agency will request reports that will allow reconciliation of transactions between ONE and the mainframe system. Anticipated Completion Date: December 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285

Finding 554610 (2024-016)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Eligibility Special Tests & Provisions

2024-016 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations Management Response: We agree with this recommendation. OHA – Medicaid (Todd Howard) - At the next Provider Enrollment meeting on April 17, 2025, we wi...

2024-016 Oregon Department of Human Services/Oregon Health Authority Improve documentation for provider eligibility determinations and revalidations Management Response: We agree with this recommendation. OHA – Medicaid (Todd Howard) - At the next Provider Enrollment meeting on April 17, 2025, we will conduct an additional training on the ownership and disclosure form, in particular the requirement around the managing employee disclosure. We will also work with our CCO contract administrator, unit lead worker and staff that process the annual CCO ownership disclosure forms to ensure all disclosures and attachments are obtained. ODHS-Aging & People with Disabilities (Jennifer Stallsworth) The Office of Aging and People with Disabilities is committed to ensuring the Provider Enrollment Agreements and I-9 forms are on accurate and records are stored and retained properly. Corrective Actions Taken & In Progress • Improved Provider Enrollment & Renewal Forms – On or before March 31, all new and renewing providers will have the option to complete the Provider Enrollment Application and Agreement (PEAA), I-9, W-4 (federal and state), and HCW Guide Agreement Form through DocuSign and submit them electronically through email, which will assist in the accuracy of forms completion and mitigate human errors in completing forms. • Local Office Verification Step – An Action Request (AR) transmittal will require local offices to verify that a properly completed I-9 is on file during provider renewal process. • Training & Resources – We will develop a Quick Resource Guide (QRG) with clear instructions and visual examples to help staff verify employment documents accurately and store them appropriately. • Quality Assurance Enhancements – The Provider Relations Unit (PRU) will implement a Quality Assurance check for I-9 forms during provider enrollment and renewal process. • E-Verify – The department is developing a proposal with an implementation plan using the Department of Homeland Security’s E-Verify+ system as an electronic verification tool for employment eligibility. We will seek leadership approval by July 1, 2025, with a plan to implement by March 31, 2026. Resolution of Questioned Costs The department has obtained the missing I-9 documentation and will not reimburse the federal agency for the questioned costs. We are confident these measures will ensure full compliance and improve the accuracy and efficiency of our provider enrollment process. Anticipated Completion Date: March 31, 2026 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285 Questioned Costs: $1

Finding 554607 (2024-013)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Significant Deficiency Internal Control / Segregation of Duties

2024-013 Oregon Health Authority Improve documentation and controls over client eligibility Management Response: We agree with this recommendation. A specific case was discovered where the state failed to obtain a signature from an SSI individual. Due to the individual’s SSI status and being continu...

2024-013 Oregon Health Authority Improve documentation and controls over client eligibility Management Response: We agree with this recommendation. A specific case was discovered where the state failed to obtain a signature from an SSI individual. Due to the individual’s SSI status and being continuously on benefits, the ONE system attempts to passively approve renewals without requiring worker interaction, leading to potential gaps where signatures are not on file for cases that converted into the new system in 2020 and 2021. The operation lapse occurred because the SSI individual converted into the new system on continuous benefits going through passive renewal processes that do not require direct worker interaction. The State of Oregon is working with the local branch to obtain a verbal signature from the identified individual. Additionally, the State conducted a thorough review of current policies and procedures related to passive renewals for SSI individuals to ensure compliance with federal requirements. • Call center software recordings and verbal signatures has been updated as recently as February 2025 providing staff with clear direction on how to capture the verbal signatures and which recordings to play. • Establishing DOR/Filing Date Eligibility Guide was updated as recently as March 13, 2025, including a chart itemizing the signature types (electronic and paper forms), programs that accept each type, and the corresponding option to select in ONE • Rights and Responsibilities Eligibility Guide was enhanced on Oct. 7, 2024 to add detailed directions to staff on how to capture the signature in ONE, when rights and responsibilities are not issued automatically, the appropriate Rights and Responsibilities to provide for each program and where to find a current signature record on file. • Finally, the Case Action Eligibility Guide has been updated to include specific guidance and examples of when it's appropriate to extend processing timeframes for RFI's. Anticipated Completion Date: May 1, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

View Audit 353285

Finding 554597 (2024-027)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Student Financial Aid Eligibility

2024-027 Oregon Department of Human Services Strengthen controls around background checks Management Response: Child Welfare has robust business processes that support the accurate and timely completion of fingerprint-based background checks. These include an OR-Kids provider record that ensures all...

2024-027 Oregon Department of Human Services Strengthen controls around background checks Management Response: Child Welfare has robust business processes that support the accurate and timely completion of fingerprint-based background checks. These include an OR-Kids provider record that ensures all required elements are completed prior to issuing a full certificate of approval, including management approval. Additionally, Title IV-E eligibility business processes require the verification of finger-print based background checks through review of the original documentation (1011f). The Foster Care Program completes regular quality assurance reviews in all districts as an ongoing effort to identify issues and ensure compliance. Any issues identified during reviews are discussed with local managers and staff to coordinate corrections and identify solutions and/or training needs. Program analysis of this error has determined the issue to be an isolated event of human error. Foster Care Program and Federal Policy and Resources will collaborate to ensure the error case is corrected and provide documentation to demonstrate those corrections. Anticipated Completion Date: April 30, 2025. Contact Persons: Megan Brazo-Erickson, Federal Policy and Resources, Donna Haney, Foster Care Program

View Audit 353285 Questioned Costs: $1

Finding 554595 (2024-026)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Eligibility Significant Deficiency

2024-026 Oregon Department of Human Services Ensure refugee status is verified and documented and income information is updated timely Management Response: The Refugee Program agrees with the findings. The Refugee Program has previously identified the need for additional training and has been taking...

2024-026 Oregon Department of Human Services Ensure refugee status is verified and documented and income information is updated timely Management Response: The Refugee Program agrees with the findings. The Refugee Program has previously identified the need for additional training and has been taking steps to address this issue. The Refugee Program has already conducted a comprehensive statewide training on Refugee Cash and Refugee Medical Assistance eligibility in January 2025. The training materials and recording are available for staff and leadership to access. The Refugee Program will continue providing training to individual branches and districts upon request. The Refugee Program offers monthly Analyst Hour calls to provide policy and program updates, address questions and troubleshoot complicated cases. To ensure better compliance, the Refugee Program will also focus on the recommended topics in the next three Analyst Hour calls. The Quality Assurance monthly reviews of Refugee Cash cases have resumed in March 2025. These reviews include all the items listed in the audit recommendations, which provides an additional layer for quality and accuracy check. In addition, the Refugee Program will discuss the recommended topics with service delivery statewide in ongoing meetings regarding eligibility and engagement. Anticipated completion date: June 30, 2025 Contact Person: Amra Biberić, Refugee program manager

View Audit 353285 Questioned Costs: $1

Finding 554592 (2024-024)

Significant Deficiency 2024

State of Oregon

OR

Special Tests & Provisions Eligibility Significant Deficiency

2024-024 Oregon Department of Human Services Improve controls relating to client non-cooperation with child support requirements Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. TANF poli...

2024-024 Oregon Department of Human Services Improve controls relating to client non-cooperation with child support requirements Management Response: We agree with this recommendation. Department management acknowledges the finding and has already initiated actions to address the concerns. TANF policy is developing a self-paced training on how to correctly process child support tasks. The training will be available to staff on the internal policy resource page, and communications will be sent advertising the training. ODHS will also continue to review a report of tasks that were marked as complete without a change in cooperation status in ONE and follow up with staff as necessary. In addition, the self- sufficiency training unit is in the process is developing a new family coach eligibility training in ONE which will include training on processing child support tasks that come through ONE. Anticipated Completion Date: 12/31/2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353285

Finding 554590 (2024-022)

Significant Deficiency 2024

State of Oregon

OR

Questioned Costs Special Tests & Provisions Eligibility § 200.303

2024-022 Oregon Department of Human Services Improve controls to ensure eligibility criteria are met Management Response: We agree with this recommendation. Beginning in April 2025 the Quality Control (QC) manager will have oversight of the process and be included in the emails between the QC lead a...

2024-022 Oregon Department of Human Services Improve controls to ensure eligibility criteria are met Management Response: We agree with this recommendation. Beginning in April 2025 the Quality Control (QC) manager will have oversight of the process and be included in the emails between the QC lead and administration concerning the error packets being sent to the branch for corrective action by the 15th of each month. The QC manager will check on the 16th of each month to ensure the task was completed. Department management acknowledges the finding and has already initiated actions to address the concerns. The State of Oregon has implemented a structured approach to address this concern. Since January 2025, the Oregon Eligibility Partnership (OEP) has updated and developed six eligibility guides aimed at improving, understanding, and execution of processes related to TANF enrollment, including asset pursuit and IEVS checks. These guides are now available as part of the training curriculum for eligibility workers. Additionally, the "Verification Take Time for Training" (TT4T) module, which was last presented in October 2022, will be reviewed by the OEP to assess potential gaps or outdated information. Any necessary updates will be incorporated by July 2025 to ensure comprehensive training is available to all eligibility workers. Finally, OEP will continue to monitor the effectiveness of the updated training materials and guides through ongoing reviews, feedback collection from eligibility workers, and periodic review and refreshing of the materials. Anticipated Completion Date: December 31, 2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353285 Questioned Costs: $1

Finding 554589 (2024-021)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Reporting Significant Deficiency

2024-021 Oregon Department of Human Services Obtain accurate information from the ONE application Management Response: We agree with this recommendation. ODHS will continue to monitor and review the ACF-199 and ACF-209 prior to submission. The review will include a sample of JOBS eligible individual...

2024-021 Oregon Department of Human Services Obtain accurate information from the ONE application Management Response: We agree with this recommendation. ODHS will continue to monitor and review the ACF-199 and ACF-209 prior to submission. The review will include a sample of JOBS eligible individuals who do not have countable work activities in the ACF reports, to confirm that their TRACS personal development plan (PDP) accurately reflects engagement and activities in which the individual is engaged. Additionally, ODHS will implement a tracking system to ensure the review of reports is clearly documented. ODHS will continue to work with our vendor to secure a SOC 2 Type II audit of our processes and oversight of the ONE system in 2025. Additionally, ODHS will work on amending the ONE Maintenance & Operations agreement with Deloitte for them to obtain a scoped SOC 2 Type II audit related to their work within the ONE system. ODHS would expect to negotiate this additional audit requirement in 2025 with the first audit then happening in 2026. Anticipated Completion Date: December 31, 2025 Contact Person: Eva Ruiz, TANF program manager

View Audit 353285

Finding 554587 (2024-029)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Period of Performance Reporting

2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case m...

2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case management system is well-documented and current. This issue was initially identified during the statewide single audit for the period ended June 30, 2023. In response to the prior year’s finding, the agency created a new case-note category for documenting client employment start date and wages at exit. Compliance with this new control is then verified as part of our pre-closure case file review process. The agency will continue to provide training to staff on the use of this case note category to ensure we are consistently documenting the start date of employment in the primary occupation and the hourly wage at exit. Anticipated Completion Date: July 1, 2025 Contact person: Angel Hale, Director of Vocational Rehabilitation Services

View Audit 353285

Finding 554586 (2024-028)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Period of Performance Reporting

2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to ...

2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We will update internal controls related to this matter. Anticipated Completion Date: September 30, 2024 Contact Person: Bryan Campbell, Vocational Rehabilitation Operations Manager

View Audit 353285

Finding 554585 (2024-043)

Significant Deficiency 2024

State of Oregon

OR

Eligibility Internal Control / Segregation of Duties § 200.303

2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include cal...

2024-043 Department of Veterans' Affairs Encourage accuracy of per diem recalculations Management Response: ODVA agrees with this recommendation Reconciliation/recalculation procedures have been updated to fully align with regulations as established by 38 CFR 51.40. These procedures will include calculation of days when a veteran may be absent for purposes other than receiving hospital care. In addition to strengthening procedures, the controller will review the reconciliation each month. Anticipated Completion Date: June 30, 2025 Contact person: Nicole Dolan, Budget and Fiscal Manager

View Audit 353285

Finding 554518 (2024-002)

Material Weakness 2024

Bassett Creek Senior Housing 092-Ee037

MN

Eligibility HUD Housing Programs Material Weakness

Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant fil...

Corrective Action: The Organization agrees with the finding. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Management is working with the new property managers to ensure they have procedures in place to document and maintain tenant files in accordance with HUD and will have routine internal audits of tenant files to ensure compliance with HUD regulations. For properties not transitioning to new property management, management believes the reduced volume of properties at one property manager will reduce staff turnover and more efficiently provide the proper training to existing staff to improve compliance with tenant files. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO

View Audit 353189

Finding 554517 (2024-001)

Material Weakness 2024

Bassett Creek Senior Housing 092-Ee037

MN

HUD Housing Programs Eligibility Material Weakness

Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications...

Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, management has assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications and hired a team of additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications. Currently, management plans to transition 50% of its real estate portfolio to new property management in 2025. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2025. Name of contact person: Jennifer Anderson, Interim CFO

View Audit 353189

Finding 554380 (2024-001)

Significant Deficiency 2024

Housing Authority of the City of Brinkley

AR

HUD Housing Programs Eligibility

Housing Authority of the City of Brinkley respectfully submits the following corrective action plan for the year ended June 30, 2024. Responsible Official: Robert Pearson, Executive Director Name and address of independent public accounting firm: Miller & Rose, PA 1309 East Race Searcy, AR 721...

Housing Authority of the City of Brinkley respectfully submits the following corrective action plan for the year ended June 30, 2024. Responsible Official: Robert Pearson, Executive Director Name and address of independent public accounting firm: Miller & Rose, PA 1309 East Race Searcy, AR 72143 Audit period: Year ended June 30, 2024 Oversight Agency: U.S. Department of Housing and Urban Development The findings from the June 30, 2024, audit are discussed below. The findings are numbered to correspond to the auditing findings disclosed in the Schedule of Findings and Questioned Costs. 2024-001 Eligibility Federal Program: Public and Indian Housing, Federal Assistance Listing Number 14.850 Condition and Criteria: The Authority’s purpose for existence is to provide decent, safe, and affordable housing for low-income families. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent to be paid by the family. HUD regulations prescribe the content of these family files. These requirements consist of the following: a. As a condition of admission or continued occupancy, the tenant and other family members are required to provide necessary information, documentation, and releases for the PHA to verify income eligibility. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. e. Re-examine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary. Population and Items Tested: We selected seventeen public housing tenant files for testing. One file did not contain an annual re-examination. The file indicates a re-examination for September 1, 2022. The next re-examination was conducted on September 1, 2024. One file indicated the tenant should have been charged $399. The tenant was charged $387. Auditor’s Recommendation: All re-examinations should be completed on an annual basis and the required documents should be signed by the tenant. All rent amounts should be updated to make sure they agree with the computed rent. Planned corrective actions: We will comply with the auditor’s recommendation. Estimated Completion Date: June 30, 2025.

View Audit 353046

Finding 554369 (2024-001)

Significant Deficiency 2024

Monte Vista Community Center Housing Authority, Inc.

CO

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding 2024-001: Rural Rental Housing Loans Assistance Listing Number: 10.415 U.S. Department of Agriculture Compliance Requirement: Eligibility Type of Finding: Internal Control Over Compliance (significant deficiency) Recommendation: The organ...

Finding 2024-001: Rural Rental Housing Loans Assistance Listing Number: 10.415 U.S. Department of Agriculture Compliance Requirement: Eligibility Type of Finding: Internal Control Over Compliance (significant deficiency) Recommendation: The organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The organization should consider assessing and realigning the duties and responsibilities of the Executive Director and Alamosa Site Manager to provide for a review process of tenant eligibility determinations. Action Taken: I have hired office personnel in the Monte Vista office. The procedures will be established to adequately segregate the duties. In the Alamosa office, either I or Priscilla Schimpf will be assisting Laura with adequately segregating the duties in that office. The process will become effective March 1, 2025. If there are questions regarding this plan, please call the responsible party at (719) 852-5505. Sincerely yours, Corinna Garcia Executive Director Monte Vista Community Center Housing Authority, Inc.

View Audit 352994

Finding 554344 (2024-001)

Material Weakness 2024

Lebanon City School District

OH

Eligibility School Nutrition Programs Matching / Level of Effort / Earmarking

The School District will implement monitoring control procedures to review software system eligibility determinations to ensure compliance with federal income guidelines.

View Audit 352954

Finding 554321 (2024-001)

Material Weakness 2024

Tcb Pedestal Gardens LLC

MA

HUD Housing Programs Eligibility Material Weakness

Finding 2024-001 - Eligibility - Material Weakness Recommendation: We recommend that management reviews its internal controls over obtaining and maintaining tenant file documentation to ensure compliance with eligibility requirements. Management should establish procedures and monitor compliance wit...

Finding 2024-001 - Eligibility - Material Weakness Recommendation: We recommend that management reviews its internal controls over obtaining and maintaining tenant file documentation to ensure compliance with eligibility requirements. Management should establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by federal regulations. Action Taken: Management is aware of the finding and condition that allowed for the noncompliance. Management noted that the property was sold subsequent to period end and that they have informed the new owner of the potential tenant file issues.

View Audit 352915

Finding 553977 (2024-004)

Material Weakness 2024

Desert Aids Project, Inc.

CA

Questioned Costs Special Tests & Provisions Eligibility

Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Special Tests and Provision – Material Weakness in Internal Control over Compliance and Noncompliance Finding Summary Health centers must prepare and apply a sliding f...

Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Special Tests and Provision – Material Weakness in Internal Control over Compliance and Noncompliance Finding Summary Health centers must prepare and apply a sliding fee discount schedule (Sliding Fee Discounts) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Internal controls in place did not ensure that the sliding fee discount was not given until all income verification was obtained. Or in cases where the sliding fee discount was given pending income verification, the income verification was not completed which resulted in sliding fee discounts being given without adequate support. Responsible Individuals Nedy Terrazas, Assoc COO, Simon Bahta, EPIC EHR Mgr and Briana Renner, CFO Status Management of DAP Health, Inc. has policies and procedures in place which require the completion of the income verification and obtaining the necessary information for the sliding fee discount prior to a sliding fee discount being given. However, with the acquisition of the new clinics, the policies and procedures already in place were not being followed appropriately at all clinics. Management has had staff complete additional training and provided education to explain why the sliding fee discounts cannot be given until a completed file, including income verification support, is obtained. Anticipated Completion Date June 30, 2025

View Audit 352630 Questioned Costs: $1

Corrective Action Plans

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