Corrective Action Plans

Finding 574452 (2024-002)

Significant Deficiency 2024

Indiana University Health, Inc. and Subsidiaries

IN

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees...

Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees to the program who were transferred internally. A correction was made to the April 2025 claim to adjust for the amount overclaimed. Indiana University Health strengthened claim review controls to ensure such changes go through additional review before claim submission. Contact Person(s) Responsible for Corrective Action: Christine Smith Completion Date: July 31, 2025

View Audit 364785

Finding 574451 (2024-001)

None 2024

Indiana University Health, Inc. and Subsidiaries

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...

Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A

View Audit 364785

Finding 574153 (2024-003)

Significant Deficiency 2024

Young Men's Christian Association of Montgomery, Inc.

AL

Allowable Costs / Cost Principles Eligibility § 200.303

Program: Summer Food Service Program CFDA: 10.559 Finding Type: Noncompliance / Significant Deficiency Issue: Two closed enrolled sites lacked documentation to support eligibility based on child enrollment. Management's Response: Response: Management recognizes the critical role of eligibility docum...

Program: Summer Food Service Program CFDA: 10.559 Finding Type: Noncompliance / Significant Deficiency Issue: Two closed enrolled sites lacked documentation to support eligibility based on child enrollment. Management's Response: Response: Management recognizes the critical role of eligibility documentation in maintaining compliance with SFSP regulations and ensuring program integrity. Corrective Action Taken: • The YMCA has implemented a formal monitoring protocol for all SFSP operating sites, including a pre-operational review checklist to verify eligibility documentation. • Site agreements now explicitly require submission of enrollment records and eligibility documentation prior to participation. Ongoing site monitoring includes periodic reviews to ensure continued compliance with eligibility requirements. Staff have been trained on 7 CER 225.6(c) and 2 CFR 200.303 to reinforce sponsor responsibilities. Responsible Individuals: Jeff Reynolds and Rachel Dumas Completion Date: Plan has been implemented as of the date of audit submission.

View Audit 364728

Finding 574119 (2024-001)

Significant Deficiency 2024

Brockton Housing Authority

MA

Questioned Costs HUD Housing Programs Eligibility

The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff ...

The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff primarily responsible for this function have left their positions in the last two years and have been replaced by staff new to the position. The Authority did increase quality control reviews due to the transition period. The finding does not identify a systemic issue rather it found various instances of noncompliance. Prior to the Audit the Authority scheduled a three-day onsite rent calculation training for all staff with Nan McKay inc that occurred the week of May 20, 2025. Finding 2024-001- Moving To Work Demonstration Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Authority will continue and enhance its training regimen for staff responsible for rent determination. Furthermore, the Authority has engaged the services of Edgemere Consulting. As part of this engagement Edgemere will conduct an independent quality control review of public housing and rental assistance files. From the information gathered from the file review Edgemere Consulting will develop specific training initiatives for the staff including enhanced quality control measures. Person Responsible: Bruna Campbell, Compliance officer Anticipated Completion Date: December 31, 2025 - Ongoing

View Audit 364699 Questioned Costs: $1

Finding 574080 (2024-002)

Significant Deficiency 2024

Chippewa County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Michelle Trulock, Financial Assistance Supervisor Corrective Action Planned: Cases where there was an income discrepancy have been reviewed and upd...

Finding Number: 2024-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Michelle Trulock, Financial Assistance Supervisor Corrective Action Planned: Cases where there was an income discrepancy have been reviewed and updated. Peacetime instructions used during COVID are no longer in place. MAXIS cases have reverted to pre-pandemic processing and will be reviewed and updated. Specific income calculations were reviewed with staff. Supervisor will promote annotation on documents for clarification, as well as clear and concise case noting. Desk reviews are completed periodically for review of income, assets and citizenship and all transfer in cases are reviewed for the like. Supervisor will request that each worker review citizenship (STAT/ MEMB/MEMI and imaging) at healthcare renewal month to ensure accuracy. Policy and procedure review for staff on reviewing forms for asset information. This also relates to the self-attestation of cash on the review forms. Anticipated Completion Date: On 06/03/2025, Supervisor met with staff to discuss the results of the audit and train and review policy and procedure on best practices for processing and maintenance of healthcare cases. This will be an ongoing agenda item at monthly unit meetings.

View Audit 364657

Finding 574053 (2024-004)

Significant Deficiency 2024

Easter Seals Serving Dc/md/va

MD

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.327

Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automate...

Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automated procurement approval process that allows us to set approval levels for each user and will reduce potential for errant approvals Ensure all new management staff receive and acknowledge the procurement policy

View Audit 364634

Finding 574019 (2024-002)

None 2024

Housing Initiatives, INC

WI

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rent...

2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rented to eligible low-income households. Complete and accurate income documentation is essential to demonstrate compliance with program eligibility requirements and long-term affordability commitments. Condition: During our review of 34 tenant files for HOME-funded rental units, we noted the following: • 6 files did not contain any income verification documentation • 1 file include income documentation, but it was incomplete and missing required supporting documentation Cause: These issues primarily occurred during a transition in property management. The change in personnel and processes led to a lapse in documentation and inconsistent application of income verification procedures. Effect: Without proper income verification, there is a risk that units may be rented to households that do not meet eligibility requirements. Additionally, the absence of documentation may hinder the Organization’s ability to demonstrate compliance during monitoring or audit reviews. Questioned Costs: Not applicable. Auditor’s Recommendation: We recommend that management strengthen internal controls over the income verification process by: • Implementing a standardized checklist for required documentation • Providing staff training on income verification procedures • Conducting supervisory reviews of all files prior to tenant approval, especially during periods of staff transition Auditee’s Response: Management agrees with the finding and has taken steps to address the issue. Four of the seven identified files have been updated with complete income documentation for 2025, and the remaining three are in process. Contact Person: Brad Hinkfuss Anticipated Completion: 9.30.2025

View Audit 364605

Finding 574010 (2024-001)

Significant Deficiency 2024

Community Housing Iii, Inc. Fir Grove Apartments

OR

HUD Housing Programs Eligibility

Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should...

Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that EIVs and recertifications are performed timely, inspections are completed, waitlists are being completed and followed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2024. As new staff are brought onboard training is provided and annual HUD training is completed by all staff. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance. Completion Date: June 30, 2025.

View Audit 364594

Finding 574004 (2024-001)

Significant Deficiency 2024

Community Housing Ii, Inc. the Maples II Apartments

OR

Eligibility HUD Housing Programs

Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management shoul...

Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that EIVs are performed timely, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2024. As new staff are brought onboard training is provided and annual HUD training is completed by all staff. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance. Completion Date: June 30, 2025.

View Audit 364592

Finding 574003 (2024-003)

Significant Deficiency 2024

Community Housing, Inc.

OR

HUD Housing Programs Special Tests & Provisions Eligibility

Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Home Investment Partnership Program Federal Assistance Listing: Number 14.239 Recommendation: Management should establish procedures and monitor c...

Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Home Investment Partnership Program Federal Assistance Listing: Number 14.239 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to ensure that HQS inspections are done in a timely manner. Staffing shortages at the property had an impact on the completion of HQS inspections in 2024. As new staff are brought onboard training is provided and management will continue to coordinate and provide assistance to on-site staff to ensure that the inspections are being completed and properties are in compliance.

View Audit 364591

Finding 573998 (2024-005)

Significant Deficiency 2024

Community Housing, Inc.

OR

Eligibility HUD Housing Programs

Federal Award Findings and Questioned Costs Item 2024-005 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish pro...

Federal Award Findings and Questioned Costs Item 2024-005 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: 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 HUD. Action Taken: REACH has policies in place to ensure that move out inspections are done in a timely manner. Staffing shortages at the property had an impact on the timeliness of the move out. As new staff are brought onboard training is provided and training is provided to on-site staff to ensure that the inspections are being completed and properties are in compliance. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance.

View Audit 364591

Finding 573995 (2024-001)

Significant Deficiency 2024

Community Housing, Inc.

OR

Eligibility HUD Housing Programs

Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish pro...

Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2024. As new staff are brought onboard training is provided and annual HUD training is completed by all staff. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance.

View Audit 364591

Finding 573792 (2024-003)

Significant Deficiency 2024

Catahoula Parish School Board

LA

Eligibility Internal Control / Segregation of Duties

Reference # and title: 2024-003 Controls and Compliance over Title I Targeting (Eligibility) Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Depar...

Reference # and title: 2024-003 Controls and Compliance over Title I Targeting (Eligibility) Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Department of Education Title I 84.010A 2024 Criteria or specific requirement: Title I, Part A of the Elementary and Secondary Education Act of 1965, as amended by Every Student Succeeds Act, requires eligibility to be determined based on the number of children ages 5 through 17 from low-income families. School Board management is required to review all total 118 Corrective Action Plan for Current Year Findings and Questioned Costs (Continued) For the Year Ended June 30, 2024 119 enrollment and low-income families’ data to ensure that the underlying data includes only students ages 5 through 17 and to certify that the eligibility calculations are complete and accurate. Condition found: Title I management completes and submits the Title I Targeting online to the Louisiana Department of Education (LDOE). The LDOE pre-populates the enrollment and number of low-income students in the Title I Targeting; however, these numbers are required to be reviewed and changed, if necessary, by the School Board. In reviewing the underlying data in determining eligibility for each school, it was noted that the School Board did not remove those students under age 5, which resulted in the ranking of schools to not be accurate. Corrective action planned: The School Board was unaware of the data file used needed to be reviewed; however, we will only include the accurate age band moving forward.

View Audit 364457

Finding 573782 (2024-001)

Significant Deficiency 2024

Commonwealth Institute of Funeral Service

TX

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #...

Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #003556 and G03556, Contract years: 05/05/21 – 12/31/26. Recommendation: Emphasize the importance of accurately reporting enrollment status. Planned corrective action: Management agrees with audit finding #2024-001. The Financial Aid Coordinator is responsible for reporting enrollment status changes, certifying enrollment every 60 days, and responding to NSLDS Roster files within 15 days, all through the NSLDSFAP website. To enhance the accuracy of these enrollment reports, the Institute is implementing a new double-check process. Henceforth, the Financial Aid Coordinator will print all enrollment status changes or enrollment report rosters prior to making any online updates or certifications. These printed reports will then be given to the Director of Operations for verification. Only after this verification will the Financial Aid Coordinator proceed with the necessary changes or certifications on the NSLDSFAP website. All printed reports will be retained by the Financial Aid Coordinator for documentation. Responsible officer: Cody Lopasky, President. Estimated completion date: June 1, 2025.

View Audit 364456

Finding 573725 (2024-001)

Material Weakness 2024

Alternatives to Hunger

WA

Subrecipient Monitoring Eligibility Material Weakness

The following represents Alternatives to Hunger dba Bellingham Food Bank’s corrective action plan for the items identified in the audit of the December 31, 2024 financial statements in accordance with 2 CFR 200.511(c): Section III – Federal Award Findings and Questioned Costs Finding 2024-001 – Elig...

The following represents Alternatives to Hunger dba Bellingham Food Bank’s corrective action plan for the items identified in the audit of the December 31, 2024 financial statements in accordance with 2 CFR 200.511(c): Section III – Federal Award Findings and Questioned Costs Finding 2024-001 – Eligibility – Material Weakness in Internal Controls Over Compliance and Material Non-Compliance Condition and Context: Alternatives to Hunger dba Bellingham Food Bank (the Organization) did not require intake forms be completed by recipients of food commodities at certain distribution centers to determine and document eligibility throughout the entire year. No other verification was performed to determine whether individuals were eligible before receiving food commodities. The Organization did not finish implementing its new eligibility verification process until mid-2024 and, as such, was not in compliance with these requirements for the full year. Planned Corrective Action: In mid-2024 the organization implemented procedures to collect client intake data at the largest program identified in testing and was following intake guidelines for all programs by the end of 2024. Responsible Division/Office and Individual: Mike Cohen, Executive Director Estimated Completion Date: 12/31/2024

View Audit 364383

Finding 573304 (2024-001)

Material Weakness 2024

Housing Authority of the City of Easton

PA

Questioned Costs HUD Housing Programs Eligibility

Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Tyler Martin, ...

Authority Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Tyler Martin, Executive Director, is responsible for implementing this corrective action by December 31, 2025.

View Audit 364098 Questioned Costs: $1

Finding 573208 (2024-008)

None 2024

League for the Blind & Disabled, Inc.

IN

Reporting Eligibility § 200.512

2024-008 Untimely Submission of Single Audit Reporting Package to the Federal Audit Clearinghouse Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A procedure to ensure timely submission of reports and audit documentation will be implemented.

View Audit 364023

Finding 573161 (2024-001)

Significant Deficiency 2024

Clear Path for Veterans New England, Inc.

MA

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

Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Clear Path for Veterans New England, Inc. is in the process of enhancing its internal controls over eligibility ...

Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Clear Path for Veterans New England, Inc. is in the process of enhancing its internal controls over eligibility to ensure that participants are recertified within the allowable time frame. Anticipated Completion Date September 2025

View Audit 363979

Finding 573160 (2024-002)

Significant Deficiency 2024

New Jersey City University

NJ

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

The finding resulted from a manual error. The University will evaluate the existing review process to ensure it operates with the level of precision necessary to detect such discrepancies. Additionally, targeted training will be provided to staff, where applicable, to reinforce proper review procedu...

The finding resulted from a manual error. The University will evaluate the existing review process to ensure it operates with the level of precision necessary to detect such discrepancies. Additionally, targeted training will be provided to staff, where applicable, to reinforce proper review procedures and reduce the risk of future manual errors.

View Audit 363978

Finding 573115 (2024-002)

Material Weakness 2024

Genesee County Youth Corporation

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties

2024 – 002 Lack of Segregation of Duties - Lack of Supervisory Review - Allow-ability of Expenses Charged to Grants The corrective action proposed for the above finding should be sufficient to account for any area of non-compliance in the evidence of supporting documentation for all disbursemen...

2024 – 002 Lack of Segregation of Duties - Lack of Supervisory Review - Allow-ability of Expenses Charged to Grants The corrective action proposed for the above finding should be sufficient to account for any area of non-compliance in the evidence of supporting documentation for all disbursements. Additionally, the Business Operations Manager and Executive Director will implement a systematic review of all grant awards, contracts, and develop an addendum document charting all allowable expenses within each funding stream that will be utilized by the team when to determine proper allocation of disbursements. This chart will provide a quick guide to monitor compliance and allow-ability of expenditures to each funder at the time a check request is submitted. Checks

View Audit 363925 Questioned Costs: $1

Finding 573041 (2024-002)

None 2024

Barrier Free Living Holding, Inc.

NY

Eligibility

Management will continue to accumulate proper supporting documentation to support the organization’s compliance with the eligibility compliance requirement and to provide such documentation, when legally possible. Responsible parties: Cynthia Amodeo, Chief Executive Officer Myra Ricard, Program Dire...

Management will continue to accumulate proper supporting documentation to support the organization’s compliance with the eligibility compliance requirement and to provide such documentation, when legally possible. Responsible parties: Cynthia Amodeo, Chief Executive Officer Myra Ricard, Program Director Anticipated Completion Date: Not Applicable as this is not correctable at this time due to New York State Executive Order 19-ADM-05; 19-OCFS-ADM-03.

View Audit 363923

Finding 573032 (2024-001)

Material Weakness 2024

Ncsc/usa Housing Development Corporation Two

FL

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University D...

Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement stronger internal controls over the administration of tenant eligibility and file maintenance, inclusive of more rigorous staff training, to ensure HUD regulations are followed timely and accurately. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting, tenant file maintenance, and monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO

View Audit 363899

Finding 573002 (2024-003)

Significant Deficiency 2024

Cedar Valley Services, Inc.

MN

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Subrecipient Monitoring

Formula Grants for Rural Areas – Assistance Listing No. 20.509 Recommendation: We recommend the Organization revise its suspension and debarment policy to include process for retaining timestamp of search performed. Explanation of disagreement with audit finding: There is no disagreement with the a...

Formula Grants for Rural Areas – Assistance Listing No. 20.509 Recommendation: We recommend the Organization revise its suspension and debarment policy to include process for retaining timestamp of search performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will take the steps necessary to properly document timing of suspension and debarment search performed. Names of the contact persons responsible for corrective action: Rich Pavek, Executive Director, and Kris Burkey, Finance Manager Planned completion date for corrective action plan: Ongoing

View Audit 363870

Finding 572963 (2024-001)

None 2024

Beacon Health System, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. S...

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of the WIC applicant’s proof of eligibility. Therefore, the auditors were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.

View Audit 363788

Finding 572627 (2024-003)

None 2024

Housing Authority of the City of Tampa, Florida

FL

HUD Housing Programs Eligibility Internal Control / Segregation of Duties

Action Taken: Management agrees with the finding noted above. It is the stated practice of the management of the Housing Authority of the City of Tampa to comply with all rules and regulations regarding its programs. Management feels this condition is more the result of errors than process. It is ma...

Action Taken: Management agrees with the finding noted above. It is the stated practice of the management of the Housing Authority of the City of Tampa to comply with all rules and regulations regarding its programs. Management feels this condition is more the result of errors than process. It is management's feeling that this resulted from staffing turnover, available administration funding and the sheer volume of files processed annually. There is a highly refined review and quality control process in place which will be re-evaluated and changed as needed. Staff, under the direction of the Director of Assisted Housing, remains dedicated to processing files as accurately is possible. We are hopeful to close this finding in the next fiscal audit. If the Department of Housing and Urban Development has questions regarding this plan, please contact Jerome Ryans, President/CEO at (813) 3419101 .

View Audit 363741

Corrective Action Plans

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