Corrective Action Plans

Finding 575669 (2024-004)

Significant Deficiency 2024

IN

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identif...

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. As a result, three of the sixty transactions tested did not include sufficient documentation to support eligibility determinations, representing instances of noncompliance with the eligibility requirements under the federal program. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.

View Audit 365678 Questioned Costs: $1

Finding 575668 (2024-003)

Material Weakness 2024

Indiana Diaper Bank, Inc.

IN

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.403

Finding 2024-03 Insufficient Documentation of Other Direct Expenses Condition: During testing of direct costs charged to the federal program, the Organization did not maintain sufficient documentation to fully support all expenditures claimed. In one instance, a receipt supporting a claimed expense...

Finding 2024-03 Insufficient Documentation of Other Direct Expenses Condition: During testing of direct costs charged to the federal program, the Organization did not maintain sufficient documentation to fully support all expenditures claimed. In one instance, a receipt supporting a claimed expense was missing. In three additional cases, although the expenditures were generally supported, the documentation did not clearly reflect how the amounts allocated to the major federal program were determined. While these issues were isolated and the known and likely questioned costs were immaterial, the lack of complete documentation represents noncompliance with federal requirements for allowable costs. Corrective Actions Taken or Planned: The Organization will develop written guidelines specifying the required supporting documentation for each type of direct expense. Set up vendors in QuickBooks. We will hire and train Finance Manager to manage and track revenue and expenses, QuickBooks, grant reporting etc. All receipts and expenses will be scanned in and kept electronically. The Organization will provide training on documentation requirements, proper record submission, and compliance expectations.

View Audit 365678 Questioned Costs: $1

Finding 575666 (2024-001)

Material Weakness 2024

Indiana Diaper Bank, Inc.

IN

Material Weakness Reporting Equipment & Real Property Management

Finding 2024-01 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in multiple material audit adjustments across key financial statement accounts, including inventory, accounts payable,...

Finding 2024-01 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in multiple material audit adjustments across key financial statement accounts, including inventory, accounts payable, fixed assets, deferred revenue, and related activity accounts. These adjustments were proposed by the auditors and subsequently recorded by management to fairly present the financial statements in accordance with generally accepted accounting principles. The extent and materiality of the adjustments indicate that the Organization's existing closing procedures were insufficient to identify and correct errors prior to the audit. Corrective Actions Taken or Planned: The Organization will develop a financial close calendar with clear deadlines. We will create a standard operating procedure for account reconciliations, journal entries, and financial reporting with assignments to specifics staff. The Organization will implement a review and sign-off process for financial reports at board meetings. The Organization plans on hiring a part-time finance manager to help us with documentation and reporting.

View Audit 365678

Finding 575659 (2024-004)

Material Weakness 2024

City of Dell Rapids

SD

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318 § 200.326

Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The City does not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individ...

Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The City does not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Finance Officer Corrective Action Plan: The City will establish controls to follow all applicable procurement requirements under Uniform Guidance and applicable CFR sections. Anticipated Completion Date: December 31, 2025

View Audit 365664

Finding 575658 (2024-003)

Material Weakness 2024

City of Dell Rapids

SD

Internal Control / Segregation of Duties Material Weakness Reporting

Reporting Material Noncompliance and Material Weakness in Internal Control over Compliance Finding Summary: The annual project and expenditure report submitted for the year ended December 31, 2024 for Federal Financial Assistance Listing No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recover...

Reporting Material Noncompliance and Material Weakness in Internal Control over Compliance Finding Summary: The annual project and expenditure report submitted for the year ended December 31, 2024 for Federal Financial Assistance Listing No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds, had amounts reported that did not agree to the general ledger of the City. Responsible Individuals: Finance Officer Corrective Action Plan: The City will establish controls to follow all applicable reporting requirements under Uniform Guidance and applicable CFR sections. Anticipated Completion Date: December 31, 2025

View Audit 365664

Finding 575657 (2024-003)

Material Weakness 2024

City of Cherry Hills Village

CO

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

Federal Progarm Name: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (CSLFRF Progarm) - Assistance Listing No. 21.027 Recommendation: We recommend that the Annual Report be approved by someone other than preparer prior to submission. Explanation of disagreement with audit finding: Ther...

Federal Progarm Name: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (CSLFRF Progarm) - Assistance Listing No. 21.027 Recommendation: We recommend that the Annual Report be approved by someone other than preparer prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken is response to finding: The City will create and enact financial reporting procedures that outlines how to handle reporting for funding such as ARPA to ensure that these reports are being reviewed and approved before submission in the future. Name of the contact person responsible for corrective action: Kelly Newman, Director of Finance and Administration. Planned completion date for corrective action plan: December 31, 2025.

View Audit 365663

Finding 575645 (2024-001)

Significant Deficiency 2024

Boat People Sos, INC

VA

Internal Control / Segregation of Duties

Accounting staff will be trained to record monthly lease expenses according to their lease schedules and cash payments. These accounts will be reviewed quarterly, including year end and signed off by a qualified accountant. Management will create a tracking sheet to monitor the renewal, terminatio...

Accounting staff will be trained to record monthly lease expenses according to their lease schedules and cash payments. These accounts will be reviewed quarterly, including year end and signed off by a qualified accountant. Management will create a tracking sheet to monitor the renewal, termination, expiration dates, and review of their schedules. It will be reviewed quarterly by COO and finance department. Branch manager is required to update COO for any changes related to lease. A copy of the lease along with all other relevant items will be sent to finance department either by COO or branch manager.

View Audit 365650

Finding 575640 (2024-001)

Significant Deficiency 2024

Pro Bono Resource Center of Maryland, Inc.

MD

Questioned Costs Reporting Significant Deficiency § 200.62

Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. ...

Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. Name of Contact Person: Amy M Smitherman, amy.smitherman@gmail.com, 646-240-3185 Projected Completion Date: 9/15/2025

View Audit 365647 Questioned Costs: $1

Finding 575638 (2024-001)

Significant Deficiency 2024

Housing Authority of the County of Santa Barbara

CA

Questioned Costs Special Tests & Provisions HUD Housing Programs

Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standa...

Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least biennially to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussion with management, there was a failed inspection that did not pass reinspection within 30 days without penalty. Context: There were approximately six hundred ninety four (694) failed inspections during the audit period. Of a sample size of twenty-five (25) failed inspections, one (1) unit did not pass reinspection within 30 days. HAP was not abated nor was the tenant transferred. Known Questioned Costs: $5,322 Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor and will make the necessary changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement). Sanford Riggs, Director of Operations, is responsible for implementing this corrective action by December 31, 2025

View Audit 365643 Questioned Costs: $1

Finding 575634 (2024-001)

Significant Deficiency 2024

Franklin County Government

IL

Internal Control / Segregation of Duties

Franklin County will work to document current procedures and redevelop internal control procedures as appropriate for the management of federal funds.

View Audit 365604

Finding 575582 (2024-002)

Material Weakness 2024

City of East Chicago

IN

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.328

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur ...

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: To ensure proper implementation of the policies and procedures in place related to SLFRF reporting, in the future, no submittal of reports will be approved without the City Controller and a Senior Staff Accountant reviewing and approving the P&E reports. This will ensure policies and procedures are followed and possibly added to, if needed, to ensure compliance over SLFRF reporting. Anticipated Completion Date: Corrective action is now in effect as of August 18, 2025.

View Audit 365567

Finding 575579 (2024-004)

Significant Deficiency 2024

Survivor Advocacy Outreach Program

OH

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

The policy for SAOP was updated to include proper approvals for related to Federal program. This policy was to be approved by the Board of Directors by August 31, 2025

View Audit 365566

Finding 575545 (2024-004)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Bank Depository Agreements Recommendation: Obtain depository agreements for all bank accounts as required by HUD. Response/Action Taken: we are working directly with our banking institutions to ensure that all accounts holding HUD funds have the required depository agreements. As of August 2025, ...

Bank Depository Agreements Recommendation: Obtain depository agreements for all bank accounts as required by HUD. Response/Action Taken: we are working directly with our banking institutions to ensure that all accounts holding HUD funds have the required depository agreements. As of August 2025, two of the three existing accounts have updated agreements, and the final agreement is currently under legal review and anticipated for completion by the end of Q3 2024. Context from Prior Audit Findings (FY23) The 2023 audit included findings related to documentaion gaps in areas such as Reasonable Rent, Utility Allowance Schedules, Waiting List procedures, and Housing Quality Standards enforcement. HALC took corrective actions in 2024 to address each of these deficiencies. The recurring nature of some 2024 findings indicates an ongoing effort to build stronger internal controls, rather than unresolved issues form the prior year. If the U.S. Department of Housing and Urban Development has questions regardin this plan, please contact Karen Rockwell at 541-265-5326.

View Audit 365535

Finding 575544 (2024-003)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Special Tests & Provisions Eligibility

Tenant Filing Documentation Processes Recommendation: Implement processes to ensure that all required documentation is properly maintained for every tenant. Response/Action Taken: HALC has standardized the documentation process through updated SOPs and training modules. All staff are now required ...

Tenant Filing Documentation Processes Recommendation: Implement processes to ensure that all required documentation is properly maintained for every tenant. Response/Action Taken: HALC has standardized the documentation process through updated SOPs and training modules. All staff are now required to follow a uniform documentation checklist during intake and recertification. Additionally, file reviews are conducted quarterly by supervisors to ensure compliance and identify any gaps in documentation.

View Audit 365535

Finding 575543 (2024-002)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Special Tests & Provisions Reporting

HUD-50058 Listing Review Process Recommendation: Implement a higher-level review of the HUD-50058 forms submitted to the PIC system. Response/Action Taken: To enhance quality control and data integrity, HALC has introduced a supervisory review of HUD-50058 forms before submission to PIC. A new sec...

HUD-50058 Listing Review Process Recommendation: Implement a higher-level review of the HUD-50058 forms submitted to the PIC system. Response/Action Taken: To enhance quality control and data integrity, HALC has introduced a supervisory review of HUD-50058 forms before submission to PIC. A new second-level review process was developed in Q2 2025, and designated staff now review the forms for accuracy and completeness weekly. We are also coodinationg periodic refresher trainings for housing specialists to stay aligned with HUD requirements.

View Audit 365535

Finding 575542 (2024-001)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Tenant Reasonable Rent Files Documentation Recommendation: Implement internal controls to ensure tenant reasonable rent files are maintained with adequate documentation. Response/Action Taken: The Authority acknowledges the importance of maintaining complete and accurate reasonable rent documenti...

Tenant Reasonable Rent Files Documentation Recommendation: Implement internal controls to ensure tenant reasonable rent files are maintained with adequate documentation. Response/Action Taken: The Authority acknowledges the importance of maintaining complete and accurate reasonable rent documention. We have instituted an internal file review checklist and implemented bi-monthly audits of tenant files to verify compliance. Staff have been restrained on HUD documentation standards, new file retention protocols are in place to ensure all supporting documents are consistently captured and stored electronically.

View Audit 365535

Finding 575513 (2024-001)

Significant Deficiency 2024

Northern Oswego County Health Services, Inc. Dba Connextcare

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

Federal Assistance Listing Numbers: 93.224 and 93.527 2024.001 Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review it was determined that a single CDT code within ConnextCare’s practic...

Federal Assistance Listing Numbers: 93.224 and 93.527 2024.001 Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review it was determined that a single CDT code within ConnextCare’s practice management system was not set-up with the proper procedure class and was omitted from the Sliding Fee Program maintenance schedule. The procedure class was corrected in the system. ConnextCare has audited all CDT codes and has determined that there were no other instances. Additionally, ConnextCare audit all D0274 charges back to January 1st, 2024, and determine there were no other occurrences. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Tracy Wimmer, CFO at (315) 298-6569 ext. 2020. Sincerely yours, Tracy Wimmer Chief Financial Officer

View Audit 365508

Finding 575509 (2024-004)

Material Weakness 2024

Town of Marblehead

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance was not verified for three covered transactions. Corrective Action Plan: The Town will implement the following: • Have the Grant Coordinator review and understand compliance with the Town’s Federal Grant Awards Policy. • Have the Grant Coordinator in...

Condition: Suspension and debarment compliance was not verified for three covered transactions. Corrective Action Plan: The Town will implement the following: • Have the Grant Coordinator review and understand compliance with the Town’s Federal Grant Awards Policy. • Have the Grant Coordinator in conjunction with the compliance accountant develop a standard reporting checklist to be used by all staff preparing or reviewing Federal project submissions. • Implement a two-level review process requiring: o Department-level preparation with supporting documentation. o Grant Coordinator final review and approval before submission of Federal reports. • Require quarterly reconciliations between project expenditures and Federal reporting to ensure accuracy. Anticipated Completion Dates: o By September 30, 2025: Grant Coordinator training completed, and checklist distributed. o Ongoing: Reports will be reviewed and certified quarterly by the Grant Coordinator prior to submission. Contact Information: Donna Cotterell, Grant Coordinator

View Audit 365493

Finding 575508 (2024-003)

Significant Deficiency 2024

Town of Marblehead

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.328

Condition: As of the March 31, 2024, reporting date, the Town reported project amounts voted by the Select Board as obligated rather than purchases, contracts and agreements that met the Federal criteria of an obligation. Corrective Action Plan: Misinterpretation of Federal reporting requirements r...

Condition: As of the March 31, 2024, reporting date, the Town reported project amounts voted by the Select Board as obligated rather than purchases, contracts and agreements that met the Federal criteria of an obligation. Corrective Action Plan: Misinterpretation of Federal reporting requirements regarding the definition of an obligation. Reliance on local budgetary approvals (Select Board votes) rather than federally defined contractual commitments. Lack of documented procedures for distinguishing between appropriations/votes and obligations in Federal reporting. This was primarily due to the many changes by the US Treasury on ARPA Federal Reporting. The Select Board did obligate funds for the Town to hire a compliance accountant as an administrative service which is allowable under ARPA to ensure compliance. In addition, the Town hired a full-time grants coordinator to oversee the grants. All future reports will reflect only qualifying obligations supported by contracts, purchase orders, or agreements. Anticipated Completion Dates: o Completed in 2025: Correction of prior misreporting and adoption of revised obligation reporting practice. o By September 30, 2025: Grant Coordinator additional training and issuance of updated reporting checklist. o Ongoing: Federal obligation reports prepared quarterly, reviewed by the Grant Coordinator prior to submission. Quarterly compliance checks will be performed by the Grant Coordinator to confirm obligations are federally compliant. Contact Information: Donna Cotterell, Grant Coordinator

View Audit 365493

Finding 575507 (2024-003)

Significant Deficiency 2024

Avivo

MN

Cash Management Reporting Significant Deficiency § 200.303

Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend the entity evaluate its procedures and implement an additional control to ensure reports are submitted timely and reviewed prior to submission. Exp...

Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend the entity evaluate its procedures and implement an additional control to ensure reports are submitted timely and reviewed prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Avivo will implement an enhanced internal review process to ensure timely report submission and accuracy prior to submission. This will include assigning dedicated personnel to track submission deadlines and conducting pre-submission reviews for completeness and accuracy. Name(s) of the contact person(s) responsible for corrective action: Heidi Kammer-Hodge & Kristen Bewley. Planned completion date for corrective action plan: December 2025.

View Audit 365488

Finding 575491 (2024-002)

Significant Deficiency 2024

Avivo

MN

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no...

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to 2023-2024, we only had one primary HUD contract that we were solely responsible for spending and contract timelines. With the addition of three more COC grants, with different, yet close together end dates, we needed to develop a more formalized process to ensure all expenses are billed to the correct contract for the correct dates. Avivo will implement oversight check-in meetings at least one month prior to each contract end and at least one more before final grant submissions. This meeting will include program leadership, RAA, Director of Housing Compliance, and our Contracts Accountant who oversees eLOCCS pulls. We will discuss all final expenditures and any upcoming expenses that may near the end of the grant term, including staff expenditures like mileage reimbursement. We will create an oversight document that highlights all areas to consider and breaks down roles and responsibilities to drive these meetings ongoingly. Accounting and program leadership will closely monitor spending via Papersave, credit card submission and through Paycom falls within the correct payment periods. Additionally, the RAA and Program Managers in the last quarter of the grant cycle, will meet monthly to work to resolve any outstanding rent balances and oversee any staff reimbursement or other charges that may need to be accounted for. Name(s) of the contact person(s) responsible for corrective action: Courtney Knoll & Lyssa Westling. Planned completion date for corrective action plan: December 2025

View Audit 365488 Questioned Costs: $1

Finding 575475 (2024-001)

Significant Deficiency 2024

Avivo

MN

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to document rental rate checks are occurring prior to entering into rental contract. Explanation of disagreement with audit finding: T...

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to document rental rate checks are occurring prior to entering into rental contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In March 2024, Avivo created a Rental Assistance Administrator (RAA) role to oversee all rental administration processes for our subsidy housing programs, including paperwork and compliance. The role developed over 2024 and was reviewed and reclassified from purely administrative to leadership and compliance in March 2025, after a year of development. With the new role, we have shifted responsibility off managers for final approval of documentation and have them focusing solely on programming and service provision. The RAA has created standardization across programs, ensures high levels of compliance, ensures no payments are sent without full, accurate documentation and helps to identify common errors early on and areas for training or support. To ensure the most accurate and complete paperwork is uploaded to our electronic health record, we are now submitting all subsidy paperwork through the electronic health system for review and approval. This solidified our process and eliminated managers creating their own processes. Switching to all approvals being electronic ensures that the most accurate and complete paperwork is available and in one place. RAA also approves and processes all rental payments from the service side and if paperwork is not approved, no payments will be released. Program Leadership, RAA and Director of Housing Operations meet bimonthly to review the program manual and policies overall to ensure most accurate policies and practices are reflected. We also updated our checklist cover sheets for all subsidy paperwork changes to reflect the changes from paper to electronic health record and have made several pieces of the subsidy paperwork process available to be completed electronically. In regards to rent reasonableness specifically, Program Leadership, RAA and Director of Housing Operations are planning two work sessions in late August and September, to review policies, current paperwork requirements and to plan additional training and supports for frontline staff to ensure full understanding of rent reasonableness and overall best practices. As part of this, we will review current paperwork and see if there are improvements that could be made, including making documentation fully electronic. We will also be looking at timelines around paperwork submission and sending out payments. Once it is determined what actions are the best solutions, managers will present changes and retrain on rent reasonableness and any other compliance improvements in team meetings in October 2025. Name(s) of the contact person(s) responsible for corrective action: Courtney Knoll, Program Director Planned completion date for corrective action plan: October 2025

View Audit 365488

Finding 575471 (2024-003)

Material Weakness 2024

Lutheran Social Services of Central Ohio

OH

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring

Condition: During the year, the Organization did not have appropriate review procedures and controls in place related to cash management and reporting over federal programs Planned Corrective Action: Finance has recent changes in leadership roles and with the change in leadership, has put into plac...

Condition: During the year, the Organization did not have appropriate review procedures and controls in place related to cash management and reporting over federal programs Planned Corrective Action: Finance has recent changes in leadership roles and with the change in leadership, has put into place improvements in oversight of cash management and reporting. LSS has a philosophy of continuous improvement and with the current management LSS will ensure that all guidelines and requirements for cash management and reporting for federal programs are met. Contact person responsible for corrective action: Julie Fratianne, CFO Anticipated Completion Date: September 30, 2025

View Audit 365486

Finding 575408 (2024-002)

Material Weakness 2024

Town of Wilbraham, Ma

MA

Internal Control / Segregation of Duties Material Weakness Reporting § 200.329

There is no corrective action. The $124,579 spent in FY24 were for un-reimbursed prior year Covid-19 CARES expenses. The Town believes the inclusion of these expenses is required to accurately show the total federal ARPA expenditures.

View Audit 365457

Finding 575396 (2024-001)

Material Weakness 2024

City of New Albany

OH

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.1 § 200.303

FINDING 2024-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The City submitted four P&E reports during the audit period; however, the controls in place were not effective to prevent, or detect and correct, errors. As a result, errors...

FINDING 2024-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The City submitted four P&E reports during the audit period; however, the controls in place were not effective to prevent, or detect and correct, errors. As a result, errors in reporting were identified. The current period and cumulative expenditures reported consisted of the amounts expended by the beneficiaries who were awarded funds from the City, rather than total amounts expended to the beneficiaries, resulting in current period expenditures and cumulative expenditures being incorrectly reported on all four reports as follows:  Quarterly Report: October 1, 2023 to December 31, 2023 Current period expenditures were overstated by $666,417. Cumulative expenditures were understated by $964,879.  Quarterly Report: January 1, 2024 to March 31, 2024 Current period expenditures were overstated by $860,312. Cumulative expenditures were understated by $104,567.  Quarterly Report: April 1, 2024 to June 30, 2024 Current period expenditures were overstated by $104,567. Contact Person Responsible for Corrective Action: Linda Moeller Contact Phone Number and Email Address: 812-948-5333 and lmoeller@cityofnewalbany.com Views of Responsible Officials and Explanation and Reasons for Disagreement:  We concur with the finding.  However, the issue and non-compliance deals with the interpretation of the federal rules regarding the appropriate amounts to report and when to report them by subrecipients of the monies.  The non-compliance is not related to policies or controls not being effective to prevent, detect or correct errors. In fact, the reporting system initially implemented by the City and put in the federal reports provided the actual expenditures for those periods by recipients of the grants.  However, the City does agree that after full examination and review of the federal rules the initial full amount of funds provided to the subrecipients should have been reported in full versus the actual expenditures during the periods. Description of Corrective Action Plan:  Current period and cumulative expenditures reported will consist of the amounts advanced to subrecipients. Anticipated Completion Date:  The City has already made this correction in its Quarterly Report July 1, 2024 to September 30, 2024.

View Audit 365446

Corrective Action Plans

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