Corrective Action Plans

Finding 398038 (2023-001)

Material Weakness 2023

WA

Subrecipient Monitoring Questioned Costs Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Riverside School District No. 416 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of ...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Riverside School District No. 416 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with wage rate requirements. Name, address, and telephone of District contact person: Lisa Bjorklund, Business Manager Riverside School District No. 416 34515 N Newport Hwy Chattaroy, WA 99003-9734 Corrective action the auditee plans to take in response to the finding: In the future the district will comply with the federal prevailing wage requirements as part of our internal control process. Riverside will provide a weekly statement for all federal prevailing wage contracts; contracts will have all applicable Davis Bacon language in the contract prior to the start of any work. Riverside will comply with all applicable under Title 2 CFR Part 200, Title 29 CFR Section 3.3, and Title 29 CFR Section 5.5. Anticipated date to complete the corrective action: The corrective action will be in place as of May 20, 2024.

View Audit 306759

Finding 398036 (2023-001)

Significant Deficiency 2023

City of San Benito

TX

Questioned Costs Reporting Significant Deficiency

Performance Reporting Federal Program: American Relief Plan Act (ARPA) ALN 21.027 Federal Agency: U.S. Department of Treasury Federal Award Year: 2021 Type of Finding: Significant Deficiency in Internal Control over Compliance and Noncompliance Individual Responsible: Stephanie Sarrionandia, Finance...

Performance Reporting Federal Program: American Relief Plan Act (ARPA) ALN 21.027 Federal Agency: U.S. Department of Treasury Federal Award Year: 2021 Type of Finding: Significant Deficiency in Internal Control over Compliance and Noncompliance Individual Responsible: Stephanie Sarrionandia, Finance Director The City of San Benito has identified turnover in the finance department and city administration staff as the root cause of failure to submit reports on time, due to a lack of sufficient staff members with access to the system for report submission. Corrective Actions:  Designated Access: During the 2024 Fiscal Year, the City ensured that at least three employees were designated to have access to the required information and system for report submission. Additionally, the City maintained a roster of designated employees which ensured coverage during staff transitions.  Cross-Training Program: During the 2024 Fiscal Year, the City implemented a comprehensive cross-training program to ensure all designated employees had a thorough understanding of reporting guidelines and procedures. Additionally, the City documented standard operating procedures for report submission and ensured they were readily available to all designated staff members.  Designated Responsibility: During the 2024 Fiscal Year, the City designated specific individuals to be responsible of overseeing report submission deadlines to ensure compliance. Additionally, the City established clear communication channels for reporting deadlines and responsibilities to designated staff members. By following this plan, the City of San Benito has addressed the issue of delayed report submissions and ensured smoother operations despite turnover in staff. Date corrective action plan was implemented: October 01, 2023.

View Audit 306747

Finding 398028 (2023-002)

Material Weakness 2023

Washington Community School District

IA

Internal Control / Segregation of Duties

The District will continue to work at identifying procedures that will result in the separating of duties listed so that an individual does not have sole control over the listed areas.

View Audit 306744

Finding 398025 (2023-001)

Material Weakness 2023

Southside School District No. 42

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Paul Wieneke, Southside School District 161 SE Collier Rd Shelton, WA 98584 (360) 426-8437 Corrective ac...

Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Paul Wieneke, Southside School District 161 SE Collier Rd Shelton, WA 98584 (360) 426-8437 Corrective action the auditee plans to take in response to the finding: When engaging in any future state or federally funded capital project, the district will implement further internal controls to ensure compliance with all prevailing wage requirements. The district will keep a record of communication with the contractor, noting the date and time that weekly prevailing wages are monitored and are confirmed as accurate. The district will provide additional training to ensure staff overseeing compliance with federal programs are aware of all applicable requirements. Anticipated date to complete the corrective action: May 6, 2024

View Audit 306722

Finding 398022 (2023-002)

Significant Deficiency 2023

Pine Bluff School District

AR

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties

Response: The District concurs with this finding. District Management understands the importance of following approved policies and ensuring any incentive pay meets the approved guidelines within such policies.

View Audit 306717 Questioned Costs: $1

Finding 398022 (2023-002)

Significant Deficiency 2023

Pine Bluff School District

AR

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties

The District will follow the recommendation of Arkansas Legislative Audit and contact the Arkansas Division of Elementary and Secondary Education for guidance regarding this matter and implement proper controls over program expenditures.

View Audit 306717 Questioned Costs: $1

Finding 398022 (2023-002)

Significant Deficiency 2023

Pine Bluff School District

AR

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties

Corrective Action Taken: Corrective action has been implemented to ensure the District maintains proper controls over program expenditures. The Director of Federal Programs reviews and approves all

View Audit 306717 Questioned Costs: $1

Finding 397986 (2023-009)

Material Weakness 2023

Boys and Girls Club of Dane County, Inc.

WI

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

Recommendation: Additional procedures should be designed, implemented, and documented for allowable costs to ensure documentation of review and approval of allowable costs to be charged to the federal award. The accounting system configurations should be modified to require segregation of duties for...

Recommendation: Additional procedures should be designed, implemented, and documented for allowable costs to ensure documentation of review and approval of allowable costs to be charged to the federal award. The accounting system configurations should be modified to require segregation of duties for all transactions. For journal entries, a documented review and approval should be performed by a finance committee member on a monthly basis. Ac􀆟on Taken: BGCDC has received instructions on how to configure the Accounts Payable module to incorporate the proper approval process. We are in the process of making that update. In addition, for any journal entries made the by CFO, a monthly list will go to the Finance Committee for review. The CFO tries to not make journal entries, but with limited Finance staff and a large workload, this is often inevitable. The logical approvals would come from Finance Committee. The contact person responsible for corrective action is Wendi Speed, CFO. The anticipated completion date is June 30, 2025.

View Audit 306700

Finding 397977 (2023-006)

Material Weakness 2023

State of South Dakota

SD

Special Tests & Provisions Questioned Costs Eligibility

Finding 2023-006: Material Weakness in Internal Control over Compliance - Special Tests and Provisions ...

Finding 2023-006: Material Weakness in Internal Control over Compliance - Special Tests and Provisions Corrective Action Plan: I. The DLR RA Management Analyst will prepare and submit all ETA Reports (Preparer). a. The Management Analyst will initially enter all data into the report and ensure its initial accuracy. b. The Management Analyst will also be responsible for addressing any warning message(s) or error message(s) that are generated by the reporting system. c. Once the data has been entered and all warning and error messages have been addressed, the Management Analyst will notify the DLR RA Senior Internal Auditor that the ETA Report is complete and ready for their review. 2. The DLR RA Senior Internal Auditor will Review and Sign Off on all ETA reports (Reviewer) a. The Senior Auditor will review the completed report to ensure its accuracy. b. If an issue is found during the review, it will be researched and corrected. c. Once the Senior Internal Auditor has verified all data elements within the report are correct, they will email the Management Analyst signing off on the data presented and give approval for the Management Analyst to submit the final report. 3. The Management Analyst submits the final report. 4. Once submitted, the Management Analyst will print the submitted copy of the final report to PDF. 5. Once in PDF form, the Management Analyst will add the following notes: a. Prepared By: [Name] b. Date and Time c. Reviewed By: [Name] d. Date and Time 6. With the "Prepared/Reviewed Note" added, it is now considered the "Finalized Report." 7. The Management Analyst will save an electronic copy of the Finalized Report along with copies of any supporting documentation and any email communications between the "Preparer" and the "Reviewer" to the QA records to be retained according to DLR Record Retention policies. 8. All RA Staff can access all finalized reports through the RA MS SharePoint site. Contact Person: Pauline Heier, Director, Reemployment Assistance Anticipated Completion Date: No anticipated completion date was listed in the separately issued audit report.

View Audit 306685

Finding 397976 (2023-005)

Material Weakness 2023

State of South Dakota

SD

Questioned Costs Material Weakness Reporting

Finding 2023-005: Material Weakness in Internal Control over Compliance - Reporting ...

Finding 2023-005: Material Weakness in Internal Control over Compliance - Reporting Corrective Action Plan: I. The DLR RA Management Analyst will prepare and submit all ETA Reports (Preparer). a. The Management Analyst will initially enter all data into the report and ensure its initial accuracy. b. The Management Analyst will also be responsible for addressing any warning message(s) or error message(s) that are generated by the reporting system. c. Once the data has been entered and all warning and error messages have been addressed, the Management Analyst will notify the DLR RA Senior Internal Auditor that the ETA Report is complete and ready for their review. 2. The DLR RA Senior Internal Auditor will Review and Sign Off on all ETA reports (Reviewer) a. The Senior Auditor will review the completed report to ensure its accuracy. b. If an issue is found during the review, it will be researched and corrected. c. Once the Senior Internal Auditor has verified all data elements within the report are correct, they will email the Management Analyst signing off on the data presented and give approval for the Management Analyst to submit the final report. 3. The Management Analyst submits the final report. 4. Once submitted, the Management Analyst will print the submitted copy of the final report to PDF. 5. Once in PDF form, the Management Analyst will add the following notes: a. Prepared By: [Name] b. Date and Time c. Reviewed By: [Name] d. Date and Time 6. With the "Prepared/Reviewed Note" added, it is now considered the "Finalized Report." 7. The Management Analyst will save an electronic copy of the Finalized Report along with copies of any supporting documentation and any email communications between the "Preparer" and the "Reviewer" to the QA records to be retained according to DLR Record Retention policies. 8. All RA Staff can access all finalized reports through the RA MS SharePoint site. Contact Person: Pauline Heier, Director, Reemployment Assistance Anticipated Completion Date: No anticipated completion date was listed in the separately issued audit report.

View Audit 306685

Finding 397975 (2023-004)

Material Weakness 2023

State of South Dakota

SD

Internal Control / Segregation of Duties Questioned Costs Material Weakness

Finding No. 2023-004: Inadequate Controls over the Payment of Claims ...

Finding No. 2023-004: Inadequate Controls over the Payment of Claims Corrective Action Plan: The claim initiation duties have been separated from the claim approval responsibilities. When a claim is initiated in FACIS, that request can only be approved by someone with permissions to review and approve claims on the case. Reviewing and approving authorizations on the FACIS system can only be issued to an individual on CPS staff who does not have claim entry responsibilities. Payment is generated only after approval is completed. During the period audited, the FACIS system did not save information about which staff member had approved the claim. This left no record to verify the name and date for claim approvals. Contact Person: Jason Simmons, Chief Financial Officer, Department of Social Services Anticipated Completion Date: In state fiscal year 2024, FACIS was updated to fully document this information for later retrieval and review, essentially the implementation of this corrective action plan prior to the completion of DLA's audit; therefore, this finding has been corrected.

View Audit 306685

Finding 397972 (2023-002)

Significant Deficiency 2023

Memphis Area Legal Services, Inc.

TN

Internal Control / Segregation of Duties

MALS will update SOPs to ensure that time sheets are timely reviewed and approved by the relevant Managing Attorney/Supervisor in the Kemps Timekeeping Software. At a bi-weekly minimum, each Managing Attorney/Supervisor will send to the Director of Finance and Grant Compliance or the COO, an email r...

MALS will update SOPs to ensure that time sheets are timely reviewed and approved by the relevant Managing Attorney/Supervisor in the Kemps Timekeeping Software. At a bi-weekly minimum, each Managing Attorney/Supervisor will send to the Director of Finance and Grant Compliance or the COO, an email regarding the accuracy of the Kemps Timekeeping, confirming that the Managing Attorney/Supervisor has reviewed and approved the Time entered into the System.

View Audit 306682

Finding 397968 (2023-002)

Material Weakness 2023

The Harry and Jeanette Weinberg Terrace, Inc.

MD

HUD Housing Programs Questioned Costs Cash Management

Project Legal Name: The Harry and Jeanette Weinberg Terrace, INC HUD Project No.: 502-EE015 Audit Firm: CohnReznick Period covered by the audit: Year end June 2023 Corrective Action Plan prepared by: Name: Shantay Hall Position: HUD Compliance Specialist Telephone Number: 571-307-6571 The following ...

Project Legal Name: The Harry and Jeanette Weinberg Terrace, INC HUD Project No.: 502-EE015 Audit Firm: CohnReznick Period covered by the audit: Year end June 2023 Corrective Action Plan prepared by: Name: Shantay Hall Position: HUD Compliance Specialist Telephone Number: 571-307-6571 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding # 2023‐002; Section 202 Supportive Housing for the Elderly, Assistance Listing 14.157 a. Recommendation: Management should establish internal controls and procedures to ensure that excess residual receipts reserve funds are remitted timely. b. Action(s) Taken or Planned on the Finding The inspection was conducted under previous management. The Franklin Johnston Group took over July 1st, 2023. When the Franklin Johnston group took over, we were unable to get in contact with HUD for months to receive Confirmation wiring instructions. HUD requires Residual receipts to be remitted and deposited no later than the termination/renewal date. The Franklin Johnston group just received confirmation wiring instructions as of January 2024. Funds of $2,794.00 are now paid as of January of 2024. The Franklin Johnston Group will ensure that moving forward all residual receipts are to be remitted and expedited in a timely matter.

View Audit 306676

Finding 397955 (2023-001)

Significant Deficiency 2023

Youthbuild Lake County, INC

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

There has been changes in our fiscal department that will allow YBLC, Inc to be on time with compliance

View Audit 306666

Finding 397950 (2023-002)

Significant Deficiency 2023

City of South Haven

MN

Internal Control / Segregation of Duties

Segregation of Duties. Name of Contact Person: Melissa Stenson, City Clerk. Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing so...

Segregation of Duties. Name of Contact Person: Melissa Stenson, City Clerk. Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls. Proposed Completion Date: The City Council will implement the above procedures immediately.

View Audit 306665

Finding 397947 (2023-002)

Significant Deficiency 2023

Cla Homes I, Corp.

VA

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

2023-02 Special Test and Provisions - Replacement Reserve Federal agency: US Department of Housing and Urban Development AL number: 14.181, Supportive Housing for Persons with Disabilities Federal Award year: July 1, 2022, through June 30, 2023 Condition: The required $400 monthly deposit to the rep...

2023-02 Special Test and Provisions - Replacement Reserve Federal agency: US Department of Housing and Urban Development AL number: 14.181, Supportive Housing for Persons with Disabilities Federal Award year: July 1, 2022, through June 30, 2023 Condition: The required $400 monthly deposit to the replacement reserve account was not transferred monthly from January 2022 through August 2022. A catch-up transfer occurred in September 2022 to rectify the deficiency. Responsible persons: Susan Keenan, Executive Director and Monica Duggal, Project Manager Actions Taken: Corrective action has been taken, a catch-up transfer occurred on September 19, 2022, to rectify the deficiency and the Entity is up to date on its monthly deposits.

View Audit 306659

Finding 397877 (2023-001)

Material Weakness 2023

Accord

MN

Internal Control / Segregation of Duties Eligibility Questioned Costs § 200.303

Compliance and Controls over Compliance – Eligibility Home Investment Partnership Program, AL# 14.239 Material Weakness Accord did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual performing...

Compliance and Controls over Compliance – Eligibility Home Investment Partnership Program, AL# 14.239 Material Weakness Accord did not have controls in place to ensure that eligibility criteria and rent calculations were being reviewed and/or approved by someone other than the individual performing the initial determination or annual reexamination. Actions Taken or Planned: Management agrees with this finding. As of December 31, 2023, the Organization has sold all properties financed by HOME funds. Contact Persons: Robert Pickering, Chief Financial Officer

View Audit 306612

Finding 397866 (2023-001)

Material Weakness 2023

Msad #27

ME

Questioned Costs Special Tests & Provisions Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN (Concerning Audit Finding 2023-001) Contact Person Responsible for Corrective Action: Lucie Tabor, Director of Finance Corrective Action: The Maine School Administrative District 27 will take the following actions to address finding 2023-001: As a Federal response to COVID-19,...

CORRECTIVE ACTION PLAN (Concerning Audit Finding 2023-001) Contact Person Responsible for Corrective Action: Lucie Tabor, Director of Finance Corrective Action: The Maine School Administrative District 27 will take the following actions to address finding 2023-001: As a Federal response to COVID-19, the Federal and State Governments provided grants to school districts to address the COVID-19 pandemic response for Schools. The CARES and ESSER Grants were initially distributed with a very short timeline on spending, initially by the end on December 2020, then subsequently extended to March 31 st and then extended beyond with additional Grants provided (ESSER I, 2 and ESSER ARP). This made for a very confusing and intense period to spend, track and coordinate spending and projects across three School Districts that the Valley Unified Education Service Center oversees. Also, the initial Grant that was provided to school Districts (CARES/ESSER I) were done so without clear directives from the Department of Education as to whether these were State Funds or Federal Funds . We were well under way with Committing and spending the funds before it was communicated that the initial funds were State funds (CARES), but subsequent ones were Federal Funds. By then, most of our projects were well under way and/or had been committed and we were now dealing with COVID-19 illnesses, remote school days, school shutdowns and delays/difficulties getting our products and contractors to pro vi de their services on the timeline we needed for the grants. These grants ran concurrently with one another and panned four Fiscal Years: 2020-21 , 2021-2022, 2022-2023 and 2023-2024. It is very rare that we have the opportunity to use Federal funds to address building or renovation projects for our school districts , so we have had no experience with the David Bacon prevailing wage requirement prior to these Federal fund , and therefore, this was not something on our radar at the time. Most of the Federal funding grants that we are used to (ESEA and Special Education) are spent on wages and purchases of materials and equipment, not projects of the scope that we were able to provide using ESSER Grant Funds. For any future projects requiring contractors, we will ensure that MSAD 27 provides the Davis Bacon requirement for prevailing wage rates including the information with the Request for Proposals or Bids (if applicable) and also with the contracts for the service once awarded. We will then ensure that the prevailing wage rates app licable to the contractor were paid to the workers (if applicable) prior to us paying the invoice to the contractor. Anticipated Compl etion Date: August 31 , 2024 to develop the policy and procedure for future Request for Propo als/ Bids that require the Davis Bacon prevailing wage rates.

View Audit 306609 Questioned Costs: $1

Finding 397858 (2023-001)

Significant Deficiency 2023

City of Weslaco

TX

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.328

The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed Implementation date: September 30, 2024

View Audit 306592

Finding 397721 (2023-002)

Significant Deficiency 2023

Breakthrough Phase Iii, Inc.

TN

HUD Housing Programs Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Breakthrough Phase III, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from...

CORRECTIVE ACTION PLAN Breakthrough Phase III, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS — FINANCIAL STATEMENT AUDIT None FINDINGS — FEDERAL AWARD PROGRAMS AUDITS FINDING N0. 2023-002: Ineffective operation of internal controls by management Management conducted recertifications of the Project’ 5 tenants; however, cannot locate any tenant ﬁles for the fiscal year under audit. Criteria: According to HUD Handbook 4350.3, owners must conduct a recertification of family income and composition at least annually by the tenant’s recertification anniversary date. Owners then must recompute the tenants’ rents and assistance payments, if applicable, based on the information gathered. Owners must also keep all tenant ﬁle and recertiﬁcation documentation as required by HUD. Cause of Condition: Management did not have systems in place to ensure tenant ﬁles and recertiﬁcation documentation were kept in accordance with HUD requirements. Recommendation: Auditor recommends management review HUD Handbook 4350.3 and put proper internal controls in place to ensure tenant ﬁles are in compliance with HUD and kept in accordance with HUD requirements. Action Taken: Personnel at Breakthrough Corporation that are handling the operations of the Project have gone through HUD—related training and are working diligently to get the tenant files up to date and in accordance with HUD compliance.

View Audit 306573

Finding 397719 (2023-002)

Significant Deficiency 2023

Breakthrough Phase Ii, Inc.

TN

HUD Housing Programs Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Breakthrough Phase II, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from...

CORRECTIVE ACTION PLAN Breakthrough Phase II, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS — FINANCIAL STATEMENT AUDIT None FINDINGS — FEDERAL AWARD PROGRAMS AUDITS FINDING N0. 2023-002: Ineffective operation of internal controls by management Management conducted recertifications of the Project’ 5 tenants; however, cannot locate any tenant ﬁles for the fiscal year under audit. Criteria: According to HUD Handbook 4350.3, owners must conduct a recertification of family income and composition at least annually by the tenant’s recertification anniversary date. Owners then must recompute the tenants’ rents and assistance payments, if applicable, based on the information gathered. Owners must also keep all tenant ﬁle and recertiﬁcation documentation as required by HUD. Cause of Condition: Management did not have systems in place to ensure tenant ﬁles and recertiﬁcation documentation were kept in accordance with HUD requirements. Recommendation: Auditor recommends management review HUD Handbook 4350.3 and put proper internal controls in place to ensure tenant ﬁles are in compliance with HUD and kept in accordance with HUD requirements. Action Taken: Personnel at Breakthrough Corporation that are handling the operations of the Project have gone through HUD—related training and are working diligently to get the tenant files up to date and in accordance with HUD compliance.

View Audit 306572

Finding 397717 (2023-002)

Significant Deficiency 2023

Breakthrough Phase I, Inc.

TN

HUD Housing Programs Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Breakthrough Phase I, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from ...

CORRECTIVE ACTION PLAN Breakthrough Phase I, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2022 —June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS — FINANCIAL STATEMENT AUDIT None FINDINGS — FEDERAL AWARD PROGRAMS AUDITS FINDING N0. 2023-002: Ineffective operation of internal controls by management Management conducted recertifications of the Project’ 5 tenants; however, cannot locate any tenant ﬁles for the fiscal year under audit. Criteria: According to HUD Handbook 4350.3, owners must conduct a recertification of family income and composition at least annually by the tenant’s recertification anniversary date. Owners then must recompute the tenants’ rents and assistance payments, if applicable, based on the information gathered. Owners must also keep all tenant ﬁle and recertiﬁcation documentation as required by HUD. Cause of Condition: Management did not have systems in place to ensure tenant ﬁles and recertiﬁcation documentation were kept in accordance with HUD requirements. Recommendation: Auditor recommends management review HUD Handbook 4350.3 and put proper internal controls in place to ensure tenant ﬁles are in compliance with HUD and kept in accordance with HUD requirements. Action Taken: Personnel at Breakthrough Corporation that are handling the operations of the Project have gone through HUD—related training and are working diligently to get the tenant files up to date and in accordance with HUD compliance.

View Audit 306570

Finding 397692 (2023-002)

Significant Deficiency 2023

Roof Above, Inc.

NC

Subrecipient Monitoring Reporting Significant Deficiency

Corrective Action Plan Significant Deficiency - Reporting Finding 2023-002 Roof Above will develop a policy for formal documentation of review of required reports prior to submission. Contact person responsible for corrective action: Kaedon Grinnell, Chief Program Officer Anticipated completion d...

Corrective Action Plan Significant Deficiency - Reporting Finding 2023-002 Roof Above will develop a policy for formal documentation of review of required reports prior to submission. Contact person responsible for corrective action: Kaedon Grinnell, Chief Program Officer Anticipated completion date: September 30, 2024

View Audit 306553

Finding 397578 (2023-082)

Material Weakness 2023

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Material Weakness Reporting

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it performed procedures to safeguard against unnecessary utilization of care and services for the Medicaid program. Questioned Costs: Assistance Listing # 93.775 93....

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it performed procedures to safeguard against unnecessary utilization of care and services for the Medicaid program. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Authority does not concur with the auditor’s conclusion that it needs to update the state plan to include all methods and procedures used to safeguard against unnecessary utilization of care and services. The Authority has received written guidance from the Centers for Medicare & Medicaid Services (CMS) that it does not need to individually list the methods and procedures but rather complete the template document in the state plan and select from a list of applicable methods. CMS approved this portion of the state plan effective July 1, 2023. The Authority has adequate internal controls to ensure compliance with utilization control requirements and partially concurs with the auditor’s recommendation related to implementing and monitoring a statewide surveillance and utilization control program. The Authority recently updated the Fraud and Detection System (FADS) and is in the process of updating policies and procedures related to FADS operation and the statewide surveillance and utilization control program. The FADS system triggers alerts and judgmental sampling is used by staff to assess risk and determine follow-up procedures. The system is in its early implementation phase and the Authority is still in the process of establishing written criteria. The conditions noted in this finding were previously reported in findings 2022-061, 2021-050, 2020-047, 2020-048, 2019-052, 2019-053, and 2018-047. Completion Date: Estimated December 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

View Audit 306534

Finding 397577 (2023-081)

Material Weakness 2023

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Special Tests & Provisions Internal Control / Segregation of Duties

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it periodically audited cost report data for rate setting, hospital billings, and other financial and statistical records for inpatient hospital services. Questioned Cos...

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with requirements to ensure it periodically audited cost report data for rate setting, hospital billings, and other financial and statistical records for inpatient hospital services. Questioned Costs: Assistance Listing # 93.775 93.777 93.777 COVID-19 93.778 93.778 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Health Care Authority partially concurs with the audit finding. The Authority does not audit inpatient hospital cost reports because it is not a federal requirement. The Authority has updated the Washington Administrative Code and its State Plan to align with federal regulations. The Authority partially concurs with the auditor’s assertion that it does not audit hospital and financial and statistical records. The Authority contracts for audits of Disproportionate Share Hospitals which includes roughly half of the hospitals in Washington. These audits include other financial and statistical records and meet this requirement. The auditor was provided information regarding these audits. The Authority will develop a desk audit process to review the financial statements of Washington hospitals, as necessary, and will create policies and procedures related to this process. The Authority does not concur with the auditor’s conclusion that it does not audit hospital billings or have methodology, policies, or procedures related to these audits. The Authority conducts utilization review and payment integrity audits of inpatient hospitals on an ongoing basis, which includes verification of billed charges. This information is well-documented and was provided to the auditor during the audit. The Authority will continue to formally document its internal controls over this compliance area. The conditions noted in this finding were previously reported in findings 2022-060, 2021-051, and 2020-049. Completion Date: Estimated October 2024 Agency Contact: Kari Summerour, CPA External Audit Compliance Manager PO Box 45502 Olympia, WA 98504-5502 (360) 725-9586 Kari.Summerour@hca.wa.gov

View Audit 306534

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