Corrective Action Plans

Finding 1155089 (2024-001)

Material Weakness 2024

St. Croix Labor Union Mutual Homes, Inc. Phase II

VI

HUD Housing Programs Questioned Costs Subrecipient Monitoring

A. Current Findings on the Schedule of Findings, Section 8 program administration and Recommendations 1. Finding 2024-1 a. Comments on the Finding and Each Recommendation We concur that certain 50059s were not signed timely. b. Action(s) Taken or Planned on the Finding We are training staff and moni...

A. Current Findings on the Schedule of Findings, Section 8 program administration and Recommendations 1. Finding 2024-1 a. Comments on the Finding and Each Recommendation We concur that certain 50059s were not signed timely. b. Action(s) Taken or Planned on the Finding We are training staff and monitoring compliance at this property to ensure 50059s are timely signed or residents will be placed in legal.

View Audit 367393

Finding 1155088 (2024-002)

Material Weakness 2024

St. Croix Labor Union Mutual Homes, Inc. Phase I

NJ

HUD Housing Programs Questioned Costs Subrecipient Monitoring

Current Findings on the Schedule of Findings, Physical Inspection and Recommendations 2. Finding 2024-2 c. Comments on the Finding and Each Recommendation In accordance with HUD program guidelines under which the Project operates, the annual tenant recertification Form 50059 is required to be signed...

Current Findings on the Schedule of Findings, Physical Inspection and Recommendations 2. Finding 2024-2 c. Comments on the Finding and Each Recommendation In accordance with HUD program guidelines under which the Project operates, the annual tenant recertification Form 50059 is required to be signed by the tenant prior to the required annual recertification date. d. Action(s) Taken or Planned on the Finding The CRM Compliance Department will schedule bi-annual on-site visits to provide training as well monitoring the all recertifications to ensure that they are completed timely.

View Audit 367392

Finding 1155087 (2024-001)

Material Weakness 2024

St. Croix Labor Union Mutual Homes, Inc. Phase I

NJ

Questioned Costs HUD Housing Programs

A. Current Findings on the Schedule of Findings, Section 8 program administration and Recommendations 1. Finding 2024-1 a. Comments on the Finding and Each Recommendation Management failed to maintain the property in good repair and received a score of 0 on its 2024 NPIRE inspection b. Action(s) Tak...

A. Current Findings on the Schedule of Findings, Section 8 program administration and Recommendations 1. Finding 2024-1 a. Comments on the Finding and Each Recommendation Management failed to maintain the property in good repair and received a score of 0 on its 2024 NPIRE inspection b. Action(s) Taken or Planned on the Finding Our Maintenance Team performed a 100% property inspection and subsequently made all repairs based on that inspection. As a result the property underwent an NSPIRE inspection on July 17, 2025 which resulted in a score of a 77.

View Audit 367392

Finding 1155066 (2024-002)

Material Weakness 2024

Pembina County Housing Authority

ND

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Contact Person Tawnya T, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2025.

View Audit 367379

Finding 1155065 (2024-001)

Material Weakness 2024

Pembina County Housing Authority

ND

HUD Housing Programs Questioned Costs Eligibility

Contact Person Tawnya T, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff. Planned Completion Date for CAP December 31, 2025.

View Audit 367379

Finding 1155063 (2024-006)

Material Weakness 2024

Muskogee County

OK

Questioned Costs Procurement, Suspension & Debarment

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the new county grant a...

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. The Board of County Commissioners will work with the new county grant administrator to ensure proper grant administration.

View Audit 367369 Questioned Costs: $1

Finding 1155031 (2024-001)

Material Weakness 2024

Watts Healthcare Corporation

CA

Questioned Costs Subrecipient Monitoring Cash Management

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients a...

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients above 200% FPG, with no discount applied. • Patient Reclassification – All previously misclassified patients are being reclassified to full-pay status. Prior balances will be reconciled in accordance with HRSA requirements and organizational policy. • Staff Training – Front office, billing, and eligibility staff will undergo mandatory refresher training on the Sliding Fee Discount Program, income verification, and proper application of the fee schedule. Additional refresher training on Self-Pay procedures will be led by the Director of Member Services. • Ongoing Monitoring – A quarterly compliance audit of the sliding fee program has been implemented. Results will be reviewed by management, with corrective actions taken as necessary. • Transparency & Communication – Patients will be notified in writing of their payment category. Appeals or questions will be addressed per organizational policy and HRSA guidelines. • Financial Remediation – Refunds will be issued to patients who were overcharged. For cases involving undercharges, the outstanding balance will be applied to the patient’s next visit. Personnel responsible for implementation: Jose Juarez, Director of Member Services Date of implementation: August 31, 2025

View Audit 367364 Questioned Costs: $1

Finding 1155029 (2024-001)

Material Weakness 2024

Bauer Family Resources, Inc.

IN

Questioned Costs HUD Housing Programs Material Weakness

Recommendation: The Organization should follow established controls to ensure timely submission of the Data Collection Form. This should include assignment of responsibility to a designated official and be monitored by management. Corrective Actions: Our accounting department is now fully in-house a...

Recommendation: The Organization should follow established controls to ensure timely submission of the Data Collection Form. This should include assignment of responsibility to a designated official and be monitored by management. Corrective Actions: Our accounting department is now fully in-house and all partnerships with the outside accounting firm, Wipfli, have been terminated. This year and moving into the future, we do not anticipate having any issues with completing our audit on time. This audit for 2024 will be completed in a timely manner.

View Audit 367354

Finding 1154985 (2024-003)

Material Weakness 2024

American Indian Council on Alcoholism Inc.

WI

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.302 § 200.305 § 200.317 § 200.327 § 200.332

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person: Renee LaFle...

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person: Renee LaFleur, Executive Director Anticipated Date of Completion: December 31, 2025

View Audit 367335

Finding 1154984 (2024-004)

Material Weakness 2024

American Indian Council on Alcoholism Inc.

WI

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

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional procurement policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person:...

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional procurement policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person: Renee LaFleur, Executive Director Anticipated Date of Completion: December 31, 2025

View Audit 367335 Questioned Costs: $1

Finding 1154978 (2024-003)

Material Weakness 2024

Elm Hill Water District

MA

Significant Deficiency Internal Control / Segregation of Duties Questioned Costs

Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.

View Audit 367318

Finding 1154976 (2024-001)

Material Weakness 2024

Elm Hill Water District

MA

Significant Deficiency Internal Control / Segregation of Duties Questioned Costs

Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.

View Audit 367318

Finding 1154958 (2024-002)

Material Weakness 2024

Recovery Cafe of Clark County

WA

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.430 § 200.512

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and...

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and pay raise letters for approvals. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

View Audit 367294

Finding 1154957 (2024-001)

Material Weakness 2024

Recovery Cafe of Clark County

WA

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.512

Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of ...

Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of future reporting requirements for the Organization. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

View Audit 367294

Finding 1154955 (2024-003)

Material Weakness 2024

Waushara County

WI

Questioned Costs Reporting Significant Deficiency

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and...

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and signoff needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan in place 2025 reporting in 2026.

View Audit 367288

Finding 1154954 (2024-001)

Material Weakness 2024

Sumter County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403 § 200.415

FA 2024-001 Improve Budgetary Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Thro...

FA 2024-001 Improve Budgetary Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425U210012 (Year: 2021) Questioned Costs: $21,615 Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund program revealed instances in which expenditures had not been properly approved by the pass- through entity. Corrective Action Plans: Going forward, the Sumter County Schools Program Director will review, sign, and date all purchase orders to signify that the Program Director has verified that the federal program costs have been written and approved in the consolidated application and/or the budget has been amended to include the costs and approved in the consolidated application and the costs are accurately reflected in the general ledger prior to payment. Estimated Completion Date: August 1, 2025 Contact Person: Jannie Carter, Finance Director Telephone: (229)931-8500 Email: janniecarter@sumterschools.org

View Audit 367287 Questioned Costs: $1

Finding 1154952 (2024-002)

Material Weakness 2024

Southwestern Area Health Education Center, Inc.

CT

Questioned Costs Cash Management Period of Performance § 200.302 § 200.305

Condition: The Organization’s expenditure reports filed with the grantor for the cost reimbursement-based grant were overstated, and the Organization was overpaid by $182,167, of which $26,730 was received after yearend. The overpayment has not yet been refunded back to the grantor, over a year afte...

Condition: The Organization’s expenditure reports filed with the grantor for the cost reimbursement-based grant were overstated, and the Organization was overpaid by $182,167, of which $26,730 was received after yearend. The overpayment has not yet been refunded back to the grantor, over a year after the performance period of the grant had ended. Recommendation: The Organization should coordinate with the grantor the return of the unspent funds. The Organization should reevaluate its grant expenditure reporting procedures to better mitigate the risk of inaccurate filing and improper reimbursement. Views of Responsible Officials and Planned Corrective Actions: The Organization agrees with the finding and recommendation. The anticipated completion date for the corrective action is October 30, 2025.

View Audit 367273 Questioned Costs: $1

Finding 1154950 (2024-004)

Material Weakness 2024

Housing Authority of the City of New Britain

CT

Questioned Costs Procurement, Suspension & Debarment § 200.67 § 200.88

Finding 2024-004: PROCUREMENT, SUSPENSION, AND DEBARMENT Description of Finding: For any amounts above the Petty Cash ceiling, but not exceeding $250,000 in accordance with revisions to 2CFR 200.67 and 2 CFR 200.88, the NBHA may use small purchase procedures. Under small purchase procedures, the NBH...

Finding 2024-004: PROCUREMENT, SUSPENSION, AND DEBARMENT Description of Finding: For any amounts above the Petty Cash ceiling, but not exceeding $250,000 in accordance with revisions to 2CFR 200.67 and 2 CFR 200.88, the NBHA may use small purchase procedures. Under small purchase procedures, the NBHA shall obtain a reasonable number of quotes (preferably three); however, for purchases of less than $10,000, per NDAA Section 806 also known as Micro Purchases, only one quote is required provided the quote is reasonable. Statement of Concurrence or NonConcurrence: Identified 4 instances in which sufficient documentation was not maintained to support the procurement of a vendor. Corrective Action: Three of the vendors have services that will be put out to bid (landscaping, contract repairs and hazardous cleanup). The third service provided is generally of an emergency nature (plumbing) as we have a licensed plumber on staff. NBHA will make sure we have secured verbal quotes for each occurrence before obligating the vendor. Name of Contact Person: Tracy Blackwell Projected Completion Date: 09/30/2025

View Audit 367267 Questioned Costs: $1

Finding 1154948 (2024-002)

Material Weakness 2024

Housing Authority of the City of New Britain

CT

Questioned Costs HUD Housing Programs Material Weakness

Finding 2024-002: HOUSING ASSISTANCE PAYMENT Description of Finding: During the term of each assisted lease, and for at least three years thereafter, the PHA must keep: (1) A copy of the executed lease; (2) The HAP contract; and (3) The application from the family. (24 CFR 982.158 (e) The PHA may no...

Finding 2024-002: HOUSING ASSISTANCE PAYMENT Description of Finding: During the term of each assisted lease, and for at least three years thereafter, the PHA must keep: (1) A copy of the executed lease; (2) The HAP contract; and (3) The application from the family. (24 CFR 982.158 (e) The PHA may not pay any housing assistance payment to the owner until the HAP contract has been executed. (24 CFR 982.305 (c)(2)) Statement of Concurrence or NonConcurrence: A sample of 25 participants in the Housing Choice Voucher Program. There were 5 identified instances in which the HAP contract was not properly executed by either the landlord or the PHA. Corrective Action: It was found that the 5 identified instances were completed by staff no longer with the authority. The five have been corrected. Staff have now been trained to perform and review of the contract during any annual or interim certification. All new moves and changes to contracts are given to the manager to ensure utility responsibilities are correctly reflected in the lease, contract, and in the software and that families are correctly credited. The HCV Director will due random review of files to ensure compliance. Name of Contact Person: Maribel Aguliar Projected Completion Date: 09/30/2025

View Audit 367267 Questioned Costs: $1

Finding 1154946 (2024-009)

Material Weakness 2024

Franklin County, Florida

FL

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.403 § 200.405

We agree with the findings and recommendations. This was an isolated incident whereas the payment amount was mistakenly pulled from the wrong line on a contractor’s pay application. This overpayment was missed in the subject fiscal year as the program was still active. Once the overpayment was ident...

We agree with the findings and recommendations. This was an isolated incident whereas the payment amount was mistakenly pulled from the wrong line on a contractor’s pay application. This overpayment was missed in the subject fiscal year as the program was still active. Once the overpayment was identified, the county sought reimbursement from the vendor for the overpayment and has since received the funds. The reimbursement will be included as program revenues in the next audit report. The County will reconcile contract values as each pay application is processed in lieu of awaiting program/project closeout in the future.

View Audit 367258 Questioned Costs: $1

Finding 1154943 (2024-001)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Reporting Questioned Costs Subrecipient Monitoring § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: Th...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: The FFATA subawards were not submitted timely to the Federal Funding Accountability and Transparency Act Subaward Reporting System (“FSRS”). The review and approval occurred after the FFATA subaward was submitted to the FSRS. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has created a policy regarding the FFATA reporting process. In this process the Electronic Handbook (EHB) is reviewed weekly to ensure that if new awarded funding is released, BCHN is alerted to the need to complete the FFATA report. BCHN has created a spreadsheet to track all the awarded funding and due dates for FFATA reports. Every month, at the board meeting, the spreadsheet is presented to the board with any new awarded funding and when the FFATA report is completed. BCHN has begun a process where the FFATA report is put together by the Finance Manager and reviewed and signed off by the CFO before submitting the report. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154942 (2024-004)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencin...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154941 (2024-003)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Allowable Costs / Cost Principles Questioned Costs § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Description of Finding: There w...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154923 (2024-003)

Material Weakness 2024

Sovereign Equity Fund

ND

Questioned Costs Cash Management Subrecipient Monitoring § 200.305

August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #3 – Sovereign Equity Fund – Fisc...

August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #3 – Sovereign Equity Fund – Fiscal Year End 12/31/2024 To Whom It May Concern: Funds were drawn down in advance under a reimbursement-based award, potentially violating federal cash management standards (2 CFR §200.305). As referenced and in relation to Finding #2 - Grant funds were drawn in excess of current expenditure needs, which resulted in the Organization being required to return the excess funds to the federal government. 2024-002 – Cash Management, 2 CFR 200.305 (Payment). Corrective Actions: • The Organization has returned the excess funds to the federal government.. • Revise internal procedures to include verification of expenditures for eligible and allowable expenses before initiating a draw request. • Develop a drawdown checklist and require supporting documentation for incurred costs, retain supporting documentation for all drawdowns. • Require Executive Director approval prior to all federal drawdowns. • Conduct training on federal reimbursement protocols for program and finance staff. Responsible Party: Grants Manager / Executive Director Target Completion Date: Policy update within 2 weeks; checklist rollout within 30 days Sincerely, Courtney Chavis Executive Director

View Audit 367244 Questioned Costs: $1

Finding 1154893 (2024-005)

Material Weakness 2024

Southwest Health and Human Services

MN

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

Finding Number: 2024-005 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer T...

Finding Number: 2024-005 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey – Fiscal Officer Corrective Action Planned: The planned corrective action is to review report instructions regularly, accurately identify appropriate eligible revenue and expenditures for each report and review for accuracy by implementing secondary review of the data that is being reported as well as resubmit any report corrections timely. An improved process has been implemented for verifying FTE payroll splits and verifying staff time is allocated to the appropriate program. Anticipated Completion Date: October 31, 2025

View Audit 367223 Questioned Costs: $1

Corrective Action Plans

Filters