Corrective Action Plans

Finding 1155480 (2024-001)

Material Weakness 2024

PA

Subrecipient Monitoring Internal Control / Segregation of Duties Questioned Costs

Subrecipient Monitoring AL 93.778 Medical Assistance Program and DHS Medical Assistance Criteria: PA DHS compliance require the County to perform subrecipient monitoring procedures over MATP funding disbursed to the Program’s vendor. Condition: During the audit, it was noted that the County was not ...

Subrecipient Monitoring AL 93.778 Medical Assistance Program and DHS Medical Assistance Criteria: PA DHS compliance require the County to perform subrecipient monitoring procedures over MATP funding disbursed to the Program’s vendor. Condition: During the audit, it was noted that the County was not performing subrecipient monitoring over the Program’s vendor. Cause: The County does not have adequate controls in place or the expertise to ensure proper subrecipient monitoring procedures. Effect: The Program’s vendor may be using grant funding inappropriately. This is a repeat finding from the prior year – Finding 2023-001. Questioned Costs: The amount of questioned costs, if any, is undeterminable Recommendation: The County should implement internal control procedures that ensure the vendor is being properly monitored. Management Response: Management maintains that they do not have adequate controls or proper expertise to monitor the vendor. Management will contract a firm to provide oversight over the vendor. Anticipate Completion Date: Immediate

View Audit 367774

Finding 1155477 (2024-001)

Material Weakness 2024

Sullivan County

IN

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403 § 200.434

FINDING 2024-001 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed or Unallowed and Allowable Costs/Cost Principles. Audit Findings: Material Weakness, modified opinion. Contact Person Responsible for Corrective Action: Amy Scarbrough, Sullivan County Au...

FINDING 2024-001 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed or Unallowed and Allowable Costs/Cost Principles. Audit Findings: Material Weakness, modified opinion. Contact Person Responsible for Corrective Action: Amy Scarbrough, Sullivan County Auditor Contact Phone Number: (812) 268-4491 Email: ascarbrough@sullivancounty.in.gov Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We understand no allowable cost policy was ever implemented by the County Commissioners and County Council. County officials will work together to make such policy based on Federal Guidelines, which include guidelines that donations not allowable. Expenditures and documentation will be reviewed to verify that future federal funds are not used for donations. Completion Date: March 1, 2026

View Audit 367771 Questioned Costs: $1

Finding 1155471 (2024-002)

Material Weakness 2024

American Institute for Foreign Study Foundation, Inc.

CT

Questioned Costs Procurement, Suspension & Debarment Material Weakness § 200.318 § 200.326

Professional and Cultural Exchange Programs - Citizen Exchanges - Assistance Listing No. 19.415 Recommendation: We recommend that the Foundation review its procurement and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 through 200.326. Explanation of disagree...

Professional and Cultural Exchange Programs - Citizen Exchanges - Assistance Listing No. 19.415 Recommendation: We recommend that the Foundation review its procurement and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 through 200.326. Explanation of disagreement with audit finding: American Institute For Foreign Study Foundation, Inc. does not agree with the finding. During a visit by representatives of BEGA the existing procurement policy was shared with those representatives. They approved of it and did not recommend any changes. However, a compliant policy that complies with CFR sections 200.318 through 200.326 will be developed. Name of the contact person responsible for corrective action: James Mahoney, CFO Planned completion date for corrective action plan: August 31, 2025

View Audit 367754

Finding 1155452 (2024-013)

Material Weakness 2024

County of Allegheny, Pennsylvania

PA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Programs were instruCt'ed to update all current (:1t ﬁles to include the rent reasonableness studies and this should happen annually when the lease is reneWed or any time a client needs to move to. another unit. Providers are also now maintaining a rent reasonableness tracking sheet with all rent re...

Programs were instruCt'ed to update all current (:1t ﬁles to include the rent reasonableness studies and this should happen annually when the lease is reneWed or any time a client needs to move to. another unit. Providers are also now maintaining a rent reasonableness tracking sheet with all rent related inforrnation for units considered for the rent reasonableness analysis, Also, during each monthly invoice review, program staff lookrat each rent payment within each grant and ﬂag any rents that seem excessive and reacho‘ut to the provider with any :questidns:. If the rent is deemed too high. or ineligible, we will ask the provider to remove the amount from the invoice. We also have an updated, HUD approved, Rent Reasonableness policy, which has been provided to all housing providers.

View Audit 367739

Finding 1155451 (2024-012)

Material Weakness 2024

County of Allegheny, Pennsylvania

PA

Questioned Costs HUD Housing Programs Reporting

We review each invoice monthly as they are submitted. Most of the review is insuring the items being invoiced are eligible under HUD and making sure the amounts are added correctly. We will review more closely the match submitted. Match for HUD is now reported based on the entire funding and not by ...

We review each invoice monthly as they are submitted. Most of the review is insuring the items being invoiced are eligible under HUD and making sure the amounts are added correctly. We will review more closely the match submitted. Match for HUD is now reported based on the entire funding and not by individual grants. All match from all HUD programs is added together and submitted on one ﬁnal report at the end of each funding year. The requirement is 25% on all budget lines except for Leasing. However, if one program’s match is short of the 25% requirement, the overall CoC is responsible for the ﬁlll match, so additional DHS admin costs are used to represent the additional match needed. For our FY23-24 annual report to HUD, we submitted 32.94% in match for the overall ﬁmding. This amount did not include any additional HMIS (data system) costs, Allegheny Link (our coordinated entry system) costs or additional DHS admin costs. With these additional eligible activities, our matching amount could have been over 50%. Therefore, even if some identiﬁed items were considered ineligible our match would not be in jeopardy since we have a lot of eligible costs that DHS covers that would be considered match.

View Audit 367739

Finding 1155448 (2024-009)

Material Weakness 2024

County of Allegheny, Pennsylvania

PA

Questioned Costs Allowable Costs / Cost Principles § 200.405

ACED has developed a procedure to ensure that cross charges are done timely. The process is outlined in the attached policy and procedure manual. (p. 38). Since the error occurred due to staff turnover, current ACED staff have been trained and others cross-trained to process cross charges and proper...

ACED has developed a procedure to ensure that cross charges are done timely. The process is outlined in the attached policy and procedure manual. (p. 38). Since the error occurred due to staff turnover, current ACED staff have been trained and others cross-trained to process cross charges and properly record them in JDE. ACED will re-examine all cross-charges to identify charges that were not properly recorded in JDE.

View Audit 367739 Questioned Costs: $1

Finding 1155445 (2024-004)

Material Weakness 2024

County of Allegheny, Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting

B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file...

B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file out of compliance sub recipient forms per the timetable noted in Section D below.C. Timetable of dates for performance of planned corrective action steps including completion date: Slated to begin new process August 1, 2025 for new contracts and/or contract renewals. Once process has been finalized, ACHD Fiscal will also review past agreements that are still in effect. D. Description of monitoring to be performed to ensure corrective action steps are taken: ACHD Financial Manager and Grants Manager will ensure lists and monitoring activities are maintained.

View Audit 367739

Finding 1155443 (2024-002)

Material Weakness 2024

County of Allegheny, Pennsylvania

PA

Questioned Costs Allowable Costs / Cost Principles Reporting

ACHD Fiscal will review open “amount remaining” on contracts at year end. Send listing to all program managers within the Health Department for review. If applicable for year-end service dates, ACHD Fiscal to accrue.

View Audit 367739

Finding 1155430 (2024-001)

Material Weakness 2024

Crossroads Young Men's Christian Association, Inc.

IN

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.320

IN 2025, REVIEWS WERE PUT INTO PLACE TO ANALYZE IF A PROJECT WOULD MEET FEDERAL COMPLIANCE REQUIREMENTS WHEN FUNDING SOURCES ARE BEING DETERMINED. FOR FUTURE PROJECTS, IF FEDERAL FUNDING WILL BE USED ON A PROJECT AFTER CONSTRUCTION BEGINS, WE WILL REASSESS TO DETERMINE IF COMPETITIVE BIDDING IS FEAS...

IN 2025, REVIEWS WERE PUT INTO PLACE TO ANALYZE IF A PROJECT WOULD MEET FEDERAL COMPLIANCE REQUIREMENTS WHEN FUNDING SOURCES ARE BEING DETERMINED. FOR FUTURE PROJECTS, IF FEDERAL FUNDING WILL BE USED ON A PROJECT AFTER CONSTRUCTION BEGINS, WE WILL REASSESS TO DETERMINE IF COMPETITIVE BIDDING IS FEASIBLE.

View Audit 367716 Questioned Costs: $1

Finding 1155427 (2024-004)

Material Weakness 2024

Forth Mobility Fund

OR

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

2024-004 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findi...

2024-004 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: There is no disagreement with the audit findings. Action Plan: Effective September 30, 2024, we established written policies and procedures regarding tracking and reporting first-tier subawards under the Federal Funding Accountability and Transparency Act. Moving forward, we will strengthen these procedures by incorporating an additional review step to ensure compliance with federal special reporting requirements. This added oversight will help maintain accuracy, consistency, and accountability in the reporting process. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Cho Heide, Contracts & Compliance Manager Plan completion date for corrective action plan: September 30, 2025

View Audit 367713

Finding 1155419 (2024-001)

Material Weakness 2024

Congregation Iched Anash

NY

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Questioned Costs § 200.318 § 200.403 § 200.404

Corrective Action Taken Management concurs with the finding. The Organization transferred $151,099.42 from its operating funds back into the SFSP program account prior to the financial statements being available to be issued, thereby restoring the unallowable charge. Additionally, to prevent recurre...

Corrective Action Taken Management concurs with the finding. The Organization transferred $151,099.42 from its operating funds back into the SFSP program account prior to the financial statements being available to be issued, thereby restoring the unallowable charge. Additionally, to prevent recurrence, the Organization obtained competitive bids and received approval for a written payroll services contract before June 2025, in advance of the start of the camp season (i.e. the Organization’s operating period). This process was conducted in accordance with federal procurement requirements. Planned Ongoing Corrective Action: The Organization has strengthened its procurement and contract approval procedures to ensure all future contracts funded by the SFSP are subject to competitive bidding, documented in writing, and approved by the State agency prior to charging costs to the program. Responsible Official: Chaim Mendel Friedman, Camp Program Administrator, is responsible for overseeing corrective actions and ensuring compliance with procurement standards and cost allowability requirements. Completion Date of Corrective Actions: Corrective actions were completed prior to the date the financial statements were available to be issued, with continuing oversight in subsequent program years.

View Audit 367698 Questioned Costs: $1

Finding 1155416 (2024-005)

Material Weakness 2024

City of Wilton

ND

Cash Management Internal Control / Segregation of Duties Questioned Costs

Contact Person – Pattie Solberg, City Auditor Corrective Action Plan – The City should follow their procedures for signing off on all requests for reimbursement reports before submitting the federal reimbursement. Completion Date – December 1, 2025

View Audit 367687

Finding 1155390 (2024-001)

Material Weakness 2024

Plymouth Housing Authority

MA

Questioned Costs Special Tests & Provisions HUD Housing Programs

Clarification notice was sent out to all landlords beginning August 12, 2025 to reiterate HQS standards andenforcement policy. Staff has been trained and procedures changed to track, document and enforce HQS Inspection Standards. Effective September 1, 2025, all open and future failed inspections ar...

Clarification notice was sent out to all landlords beginning August 12, 2025 to reiterate HQS standards andenforcement policy. Staff has been trained and procedures changed to track, document and enforce HQS Inspection Standards. Effective September 1, 2025, all open and future failed inspections are to follow the revised guidance and current HCV Admin plan.

View Audit 367657

Finding 1155384 (2024-001)

Material Weakness 2024

Cheyenne Health and Wellness Center Doing Business As Healthworks

WY

Reporting Questioned Costs Allowable Costs / Cost Principles

2024-001 Reporting Corrective action planned: For employee expenses calculation for the Uniform Data System (UDS) reporting annual accrued PTO calculations will not be used. Anticipated completion date: Complete date of this corrective action plan is immediate. The next UDS report is due 2/15/2026. ...

2024-001 Reporting Corrective action planned: For employee expenses calculation for the Uniform Data System (UDS) reporting annual accrued PTO calculations will not be used. Anticipated completion date: Complete date of this corrective action plan is immediate. The next UDS report is due 2/15/2026. For the 2025 UDS report accrued PTO for employees will not be included employee expenses. Contact person responsible for corrective action: Margaret Cox CFO mcox@wyhealthworks.org

View Audit 367639

Finding 1155367 (2024-001)

Material Weakness 2024

Suffolk County, New York

NY

Eligibility Questioned Costs Subrecipient Monitoring § 200.303

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant...

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant eligibility, nor did it ensure that non-long-term care program participants were properly classified. Sixty participants were selected for testing and the following exceptions were noted: • For five of sixty participants selected for testing, the County was unable to provide documentation that a program supervisor had approved the application. • For one of sixty participants selected for testing, the County was unable to provide a signed participant application. • For one of sixty participants selected for testing, upon reapplication and further documentation, a long-term care case was determined to be non-long-term care, but the County did not make this change and the participant was misclassified. Questioned Costs Undetermined. Recommendation The County should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility. It should also enhance procedures and internal controls to ensure participants are correctly classified as long-term care versus non-long-term care. Corrective Action Plan The Medicaid Division will continue to emphasize the need for signatures at both levels of eligibility Examiner level and Quality Control Examiner II or higher level. This will be stressed at all appropriate training for not only new staff but current staff as well. As far as the “misclassified” the Consumer left nursing home during a period when documentation requirements were waived, due to the Public Health Emergency (COVID-19); The coverage was correct, but coding indicated the need for Long Term Care. This code does not allow or authorize any services on its own, and as such, no inappropriate services were authorized. Even though this has little impact the Division will continue to stress to staff and supervisors the need to properly code cases. NYS DOH is in the process of transitioning away from LDSS 3209 forms and automating the process; we will continue to work with our state partners to assist in this transition when it becomes available to us. This transition should mitigate these type of situations. Action Date September 5, 2025 Final Implementation Date December 31, 2025 Name And Phone No. Of Person Responsible For Implementation James Sluder – 631-854-5830

View Audit 367602

Finding 1155356 (2024-002)

Material Weakness 2024

Jewish Family & Children's Service of Southern Arizona, Inc.

AZ

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

Management reviewed their internal control policies and procedures and made changes to accounting operations to resolve this issue going forward.

View Audit 367600

Finding 1155354 (2024-002)

Material Weakness 2024

Goodwill Industries of Michiana, Inc.

IN

Questioned Costs Cash Management Significant Deficiency

2024-002 PAYROLL POPULATION The Organization uses general ledger detail to create draws to submit reimbursement claims. Some reimbursements are for payroll expenses that are paid through a separate system. The Organization could not reconcile the general ledger to the payroll software detail used to...

2024-002 PAYROLL POPULATION The Organization uses general ledger detail to create draws to submit reimbursement claims. Some reimbursements are for payroll expenses that are paid through a separate system. The Organization could not reconcile the general ledger to the payroll software detail used to submit reimbursements. Recommendation: The Organization should perform and maintain monthly reconciliations of the payroll software, general ledger, and draw detail that all agree. Action Taken: The Organization was billing the grantor for payroll fees, the additional fees for each employee or contract that participated in the grant. Originally, the funds were coded to payroll (compensation) expenses, which generated a discrepancy between the Payroll Register and the General Ledger. The unemployment expense was also coded to benefits, which created a variance between the payroll register (generated from payroll software) and the general ledger. Going forward, the trail balance and general ledger will be reconciled to the draw request. Additionally, the team has been trained in how to properly code these expenses. Contact Person: Shire Kuch Effective Date: 25 September 2025.

View Audit 367596

Finding 1155338 (2024-001)

Material Weakness 2024

Baldwin County Electric Membership Corporation

AL

Questioned Costs

Management does not believe that the finding warrants a corrective plan in that the finding was an oversight of existing internal controls. The Cooperative believes that closer adherence to existing internal controls will eliminate the future occurrence of this type of error.

View Audit 367578 Questioned Costs: $1

Finding 1155337 (2024-001)

Material Weakness 2024

Belmont Housing Associates, Inc.

CO

Questioned Costs Cash Management HUD Housing Programs

Management should ensure surplus cash is calculated in a timely matter in order to make any required deposit to the residual receipts account.

View Audit 367572 Questioned Costs: $1

Finding 1155336 (2024-003)

Material Weakness 2024

Maine Sate Housing Authority

ME

Questioned Costs Subrecipient Monitoring Reporting

2024-003: Reporting – Temporary Assistance for Needy Families (TANF) State Programs Name of Contact Person(s): Bobbie Crooker, Director of Energy and Housing Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees that for 2024 the Pr...

2024-003: Reporting – Temporary Assistance for Needy Families (TANF) State Programs Name of Contact Person(s): Bobbie Crooker, Director of Energy and Housing Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees that for 2024 the Program Delivery Report, the Program Projections Report, and many of the Monthly Household reports did not have evidence of submission and that the Closeout Report was not filed timely. This issue occurred due to staff turnover within the LIHEAP Team, within the Fiscal Team, and within the EHS Department overall, as well as due to an insufficient monitoring process or what was required. The State of Maine DHHS verbally informed MaineHousing that all 2024 reporting requirements have been satisfied. EHS is in the process of developing and implementing the use of an up-to-date report tracking spreadsheet for the Department. As part of the training for newly onboarded staff, such as the new department Director, the newly hired Quality Contral Specialist, and the newly hired Fiscal Compliance Coordinator, EHS has also identified who is responsible for maintaining the tracking spreadsheet, identified who is responsible for the information contained in specific reports, identified who is responsible for submitting each report, and identified who is responsible for updating the department calendar with reminders for report due dates. This spreadsheet will help ensure that all reports for all programs are submitted accurately and in a timely manner in accordance with state guidelines for report submission. Additionally, EHS walked through the process and what is required with a representative from Maine DHHS. For TANF, this process and tracking has been fully implemented. Proposed Completion Date: Completed

View Audit 367570

Finding 1155330 (2024-005)

Material Weakness 2024

City of Muskegon Heights

MI

Questioned Costs Allowable Costs / Cost Principles Cash Management

2024-005 – Reporting (Repeat Finding) Auditor Description of Condition and Effect. While the City performed the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting for each quarter of 2024, the Project and Expenditure reports for the first three quarters of 2024 did not ...

2024-005 – Reporting (Repeat Finding) Auditor Description of Condition and Effect. While the City performed the required Coronavirus State and Local Fiscal Recovery Funds expenditure reporting for each quarter of 2024, the Project and Expenditure reports for the first three quarters of 2024 did not report any current period expenditures. Rather, the cumulative expenditures for the year were included in the fourth quarter Project and Expenditure report. In addition, the Project and Expenditure reports for the third and fourth quarters of 2024 were not filed within the required timeframe. As a result of this condition, the City did not comply completely with the reporting requirements of the Coronavirus State and Local Fiscal Recovery Funds grant. Auditor Recommendation. We recommend that the City review the reporting requirements for each grant and complete all required reporting as required under the terms of the grant agreement. Corrective Action. City staff has accessed these reports and attempted to submit all required reports. Ongoing reports have been submitted on time. Assistance will be sought with federal agencies as necessary. Responsible Person. Finance Director Anticipated Completion Date. December 31, 2025

View Audit 367568

Finding 1155296 (2024-001)

Material Weakness 2024

Triangle Elderly Housing Corporation

NC

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Triangle Elderly Housing Corporation 1363 West Market Street Smithfield, NC 27577 Name of auditee: Triangle Elderly Housing Corporation HUD auditee identification number: FHA/Contract #053-11250 Name of audit firm: O. Douglas Covington, C.P.A., P.A. Period covered by the audit: January 1, 2024 thru ...

Triangle Elderly Housing Corporation 1363 West Market Street Smithfield, NC 27577 Name of auditee: Triangle Elderly Housing Corporation HUD auditee identification number: FHA/Contract #053-11250 Name of audit firm: O. Douglas Covington, C.P.A., P.A. Period covered by the audit: January 1, 2024 thru December 31, 2024 CAP prepared by: Name: Davita W. Hill Position: Housing Director Telephone: 919-934-6066 1. Finding 2024-001 a. Comments on the Finding and Each Recommendation We are in agreement with the finding. b. Action(s) Taken or planned on the finding: A corrected fund authorization has been sent to HUD and Berkadia, our Lender, to update the current monthly reserve for replacement deposit amount for the project. Moving forward, we will continue to submit all fund authorizations to the HUD Account Executive, while being sure to include our Berkadia Account Representative in each correspondence and follow-up with each representative to assure the authorization has been approved and fully executed by all parties. Additionally, I will relay an executed copy of the Fund Authorization to our Finance Specialist, Renee Davis, to ensure the increased amount is correct and reflected in the Projects Mortgage Statement immediately following the effective date of the increase.

View Audit 367539 Questioned Costs: $1

Finding 1155280 (2024-001)

Material Weakness 2024

City of Pittsburgh

PA

Questioned Costs Subrecipient Monitoring § 200.332

Finding 2024-001: Subrecipient Monitoring Federal Agency: U.S. Department of Housing and Urban Development Frogram Name: COVID 19 — HOME Investment Partnerships Program and HOME Investment Partnerships Program (HOME) - ALN 14.239; Award Identification Number: MC420501 Criteria of Specific Requiremen...

Finding 2024-001: Subrecipient Monitoring Federal Agency: U.S. Department of Housing and Urban Development Frogram Name: COVID 19 — HOME Investment Partnerships Program and HOME Investment Partnerships Program (HOME) - ALN 14.239; Award Identification Number: MC420501 Criteria of Specific Requirement: Per 2 CFR 200.332, a pass-through entity must monitor the activities of subrecipients as necessary to ensure that the subaward is used for authorized purposes, in compliance with federal statutes, regulations, and the terms and conditions of the subaward. Condition: During our testing of subrecipient monitoring, we noted that the City did not perform required monitoring procedures during the year. Questioned Costs: Unknown Cause: The City did not have adequate internal controls in place to ensure compliance with subrecipient monitoring requirements, and staffing turnover contributed to the lack of oversight. Effect: The City was not in compliance with subrecipient monitoring requirements. Identification as a Repeat Finding: This is not a repeat finding from the prior audit. Recommendation: We recommend the City implement controls to ensure compliance with subrecipient monitoring, documenting monitoring activities performed and following up on any identified deficiencies in a timely manner. Views of Responsible Officials and Planned Corrective Actions: Management agrees; see corrective action plan below. History The City initiated monitoring of the HOME program in March 2023, and the local office of the Department of Housing and Urban Development (HUD) initiated its own monitoring in June 2023. To avoid duplicative work, the City shifted its approach and reviewed closed programs while HUD monitored open programs. These monitoring efforts resulted in significant updates to program policies and procedures. The City's monitoring was completed in October 2023 and HUD's monitoring was finalized in October 2024. Correction Action Plan Since October 2024, the City has collaborated with its subrecipient, the Urban Redevelopment Authority (URA), to implement a streamlined, informal quarterly review process. While formal HOME monitoring has not occurred since the end of the HUD monitoring, the City will initiate a review before the end of 2025 to return to compliance. Monitoring will occur annually moving forward.

View Audit 367516 Questioned Costs: $1

Finding 1155278 (2024-003)

Material Weakness 2024

Sibley County

MN

Questioned Costs Eligibility Material Weakness § 200.303

Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: •Citizenship verification continues to be an error prone area. As ...

Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: •Citizenship verification continues to be an error prone area. As an automated system process, the majority of our cases successfully complete the interface with SSA to determine citizenship. Determining the root cause of these errors is not always simple, but some contributing factors are failed interface links between MAXIS and SSA. Citizenship details on the MEMI panel which isn’t part of the normal review workflow for recertifications as it holds “additional” member information that typically doesn’t change from year to year. Also, human error plays a role as this type of verification is typically requested at the time a case opens and normally doesn’t change throughout the life of the case. Despite reminders and manual reviews, cases are still being missed. System modernization would go a long way to mitigate these types of error. In addition to continuing the reminders for staff, and periodically checking cases for failed interface verifications, the financial assistance supervisor will request ad-hoc reports from DHS specifically for healthcare cases that have a missing citizenship verification field or coded as “N” for no verification on the MEMI panel in MAXIS. This report will be shared with staff to target cases with missing citizenship verifications. In addition, it has been determined that the use of SMI to verify citizenship has been approved, however this verification has not been added to the case file in some instances which results in an error finding. •Asset verification rules have changed over the past year and a half and although the previous CAP stated we would hold reviews of this policy during regular unit meetings, the financial assistance supervisor has only held one review. This area will be revisited using state training in Trainlink and staff will be reminded that any information reported on an application or renewal needs to be compared to the information recorded in MAXIS and conflicting information needs to be verified. In addition, the process of receiving verifications will be reviewed. Currently, verification documents must be accepted from the client by any means, including mail, fax, paper, or email. Email containing verifications may be sent to the primary Financial Assistance email (recommended) but also may be sent to the agency’s primary email or the primary worker’s personal work email (not recommend). This puts the responsibility of moving those verifications to the case file on several different people. This process may lead to verifications being received but not added to the case files. Best practices will be shared with staff. Anticipated Completion Date: Trainlink training was shared and reviewed at the next in person unit meeting, September 4th. Ad-Hoc reports will be requested for the next quarter, October 6th Reviewing receipt of verification procedures will occur over the next several months and modifications (if necessary) or best practices will be shared January 2026.

View Audit 367509

Finding 1155277 (2024-002)

Material Weakness 2024

Sibley County

MN

Questioned Costs Eligibility Significant Deficiency § 200.303

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A ...

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: John Stepien, Financial Assistance Supervisor Corrective Action Planned: The Financial Assistance supervisor will run BOBI report MNCM 220A at least 2 times per month to identify outstanding verifications for MA cases in METS. This will identify specific cases missing SSN verifications. Anticipated Completion Date: The MNCM 220A reported is generated quarterly. The anticipated completion date is October 6th for the next quarterly report.

View Audit 367509

Corrective Action Plans

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