Corrective Action Plans

Finding 499945 (2023-003)

Significant Deficiency 2023

Community Development Corporation of Oregon

OR

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the pers...

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the person responsible for the plan.

View Audit 322891 Questioned Costs: $1

Finding 499944 (2023-002)

Significant Deficiency 2023

Community Development Corporation of Oregon

OR

Questioned Costs Reporting Cash Management

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the pers...

We now have a dedicated grants reviewer in finance to support project management's reporting since January 2024 with cross training in the finance team. We will update our practices guide to include the documentation process for compliance by October 2024. Lynn Ketch, Executive Director, is the person responsible for the plan.

View Audit 322891 Questioned Costs: $1

Finding 499935 (2023-002)

Significant Deficiency 2023

Episcopal Homes of Minnesota and Affiliates

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency

View of Responsible Officials: Management agrees with the finding and recommendation and will review procedures to ensure future reporting submissions are detail reviewed. Responsible Party Sherri Friedrich Estimated Completion December 31, 2024

View Audit 322883

Finding 499934 (2023-004)

Significant Deficiency 2023

Countryside Public Health

MN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Federal Agency: U.S. Department of Agriculture Federal Program Name: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Federal Award Identification Number and Year: 22MN004W1003, 2023 Pass-Through Agency: Minnesota Department of Health Pass...

Federal Agency: U.S. Department of Agriculture Federal Program Name: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Federal Award Identification Number and Year: 22MN004W1003, 2023 Pass-Through Agency: Minnesota Department of Health Pass-Through Number: 22MN004W1003 Award Period: Year Ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended Countryside Public Health Service implement procedures to ensure there are always two individuals involved in the determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Countryside Public Health Service will implement procedures to ensure there are always two individuals involved in the determination. Name of the contact person responsible for corrective action plan: Liz Auch, Administrator Planned completion date for corrective action plan: December 31, 2024

View Audit 322879

Finding 499914 (2023-001)

None 2023

Oregon Child Development Coalition, Inc.

OR

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Significant Deficiency § 200.406

FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2023-001 Head Start – Assistance Listing #93.600 Recommendation: The Organization should establish more defined written policies and procedures regarding credit card rebates that are in line with Uniform Guidance re...

FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2023-001 Head Start – Assistance Listing #93.600 Recommendation: The Organization should establish more defined written policies and procedures regarding credit card rebates that are in line with Uniform Guidance requirements, as well as establish organizational controls to ensure that such policies and procedures are being followed. Explanation of disagreement with audit findings: There is no disagreement with the audit finding. Action taken in response to finding: The issue was recognized by management shortly after the close of the fiscal year. The entire balance of accumulated points was converted to gift cards. A historical analysis of the coding for all purchases charged to the credit card during the year under audit is being performed. A proportional amount of the total value of the gift cards will be credited to each federal award as a reduction of costs. This process will continue to be performed on a regular basis for the duration of the use of the credit card in question. Action Plan: OCDC will move to utilizing credit cards that do not have a rewards program. Inquiries have been made with OCDC’s banking institution regarding the available options. The policies and procedures surrounding the use of credit cards will be documented in writing, and anyone who is entrusted to use an agency credit card will be required to sign a document acknowledging their understanding of those policies and procedures. Name(s) of the contact people responsible for correction action: Tong Lee, Chief Financial Officer Plan completion date for corrective action plan: November 30, 2024

View Audit 322843

Finding 499913 (2023-002)

Significant Deficiency 2023

Alabama Nursing Home Association Education Foundation

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.403 § 200.405

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Granto...

Planned Corrective Action: Management contact the facility receiving the overpayment to recoup the funds or ask the facility to provide proof the funds were used for qualifying purposes under the program. If funds are returned, they will be redistributed to other facilities or returned to the Grantor no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

View Audit 322841 Questioned Costs: $1

Finding 499912 (2023-001)

Significant Deficiency 2023

Alabama Nursing Home Association Education Foundation

AL

Period of Performance Significant Deficiency Matching / Level of Effort / Earmarking § 200.203 § 200.303

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home a...

Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the “Grantor”) to The Alabama Nursing Home Association Education Foundation (the “Foundation”), which permitted the Foundation to rely upon the certifications of nursing home applicants that the applicant had or will have sufficient unmet needs related to qualifying purposes due to the COVID‐19 pandemic to support the receipt of the various allocations of the herein described COVID‐19 Funds. Under the terms of the certification, each applying nursing home further certified that for ten (10) years it would maintain auditable records supporting the unmet need and use of the COVID‐19 Funds. This manner of requiring only a certification for the distribution to health care providers is consistent with the requirements the federal government used when distributing an array of emergency funding (e.g., provider relief funds, rural funds, and infection control funds) to health care providers to meet the unmet needs caused by the COVID‐19 pandemic. The term “COVID‐19 Funds” means those funds the Foundation received from the Grantor with respect to (i) The CARES Act Corona Virus Relief Funds for the period from January 31, 2020, through December 31, 2021, and (ii) America Rescue Plan Act (ARPA) funds for unmet needs for qualifying purposes incurred or to be incurred during the period March 11, 2021, through December 31, 2024. To provide further assurance that the COVID‐19 Funds were properly applied by the nursing home beneficiaries receiving COVID‐19 Funds through the Foundation, the Foundation is working with its outside accountants and legal counsel to develop a look‐back review plan. The framework of the lookback review plan will be for each nursing home beneficiary that received COVID‐19 Funds to submit during the calendar year 2024, a worksheet similar to the period reporting worksheets that are required by the federal Health Resources & Services Administration (HRSA) to justify the COVID‐19 provider relief funds, rural funds, and infection control funds received by health care providers. In addition to these HRSA type worksheets, a more in‐depth examination of a sample of nursing homes will be made by randomly selecting 10 nursing homes from a pool of the 30 nursing homes that received the most COVID‐19 Funds through the Foundation, plus another 10 nursing homes from the remainder of the pool of beneficiary nursing homes. These randomly selected nursing homes will be required to supply actual documentation supporting the COVID‐19 Funds received. This documentation will include invoices, payroll records, revenue journals, and cost reports. Among the provisions of the certifications submitted by each applying nursing home, is an acknowledgement that (i) the nursing home is subject to audit by the applicable State and federal agencies, and the Foundation, (ii) any COVID‐19 Funds received through the Foundation and not properly applied must be refunded, and the nursing home will comply with the requirement that it must maintain for ten (10) years auditable records supporting its use of the COVID‐19 Funds it received through the Foundation. In the event that it is determined that one or more nursing homes were unable to properly apply the COVID‐19 Funds to an unmet need for a qualifying purpose, those COVID‐19 Funds will be recouped and either redistributed to any nursing homes that are able show an unmet need continues to exist using a distribution formula consistent with past distributions of refunded COVID‐19 Funds, or returned to the Grantor. This redistribution or return to the Grantor will occur no later than December 31, 2024. Person(s) Responsible: John Matson, Executive Director

View Audit 322841

Finding 499885 (2023-002)

Significant Deficiency 2023

Special Health Resources for Texas, Inc.

TX

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

To ensure that the Sliding Fee Discount Form is being completed for all patients, the Revenue Cycle Manager will conduct new onsite trainings at all locations. The Revenue Cycle Manager will work closely with front line support staff, Clinic Managers, Director of Operations and the Director of Quali...

To ensure that the Sliding Fee Discount Form is being completed for all patients, the Revenue Cycle Manager will conduct new onsite trainings at all locations. The Revenue Cycle Manager will work closely with front line support staff, Clinic Managers, Director of Operations and the Director of Quality. They will conduct weekly audits to 5% of patient charts to ensure that the trainings are being successful.

View Audit 322795 Questioned Costs: $1

Finding 499881 (2023-002)

Significant Deficiency 2023

Jobs for America's Graduates

VA

Subrecipient Monitoring Reporting Significant Deficiency § 200.332

Management agrees with the recommendation and has added this report filing requirement to the grant onboarding checklist. The FFATA report was submitted and uploaded by the Director of Grants & Compliance on August 28 2024. This process will be overseen by the Director of Grants & Compliance and is...

Management agrees with the recommendation and has added this report filing requirement to the grant onboarding checklist. The FFATA report was submitted and uploaded by the Director of Grants & Compliance on August 28 2024. This process will be overseen by the Director of Grants & Compliance and is in place as of the date of this corrective action plan.

View Audit 322785

Finding 499878 (2023-002)

Significant Deficiency 2023

Augustana Lutheran Homes Inc. Dba: Gloria Dei Manor

MN

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Section 202 Direct Loan and Flexible Subsidy Assistance Loan Assistance No. 14.157 Security Deposits: The Project is required to maintain a separate security deposit cash account equal to or greater than the security deposit liability. The security deposit cash account was underfunded by $8,700 as o...

Section 202 Direct Loan and Flexible Subsidy Assistance Loan Assistance No. 14.157 Security Deposits: The Project is required to maintain a separate security deposit cash account equal to or greater than the security deposit liability. The security deposit cash account was underfunded by $8,700 as of December 31, 2023. Recommendation: All security deposit activity should be run through this account to ensure it is being properly utilized. Comparisons should be performed monthly to ensure the balance is maintained at a minimum equal to the security deposit liability. There is no disagreement with the audit finding. Action taken in response to finding: Management will continue to monitor the account to ensure properly funded. Management has transferred the $8,700 deficiency into the security deposit account on June 13, 2024. Name of the contact person responsible for corrective action: Cassandra Johnson Planned completion date for corrective action plan: June 13, 2024.

View Audit 322755

Finding 499849 (2023-002)

Significant Deficiency 2023

City of Mishawaka

IN

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Subject: 2023-002 Coronavirus State and Local Fiscal Recovery Funds – Reporting Federal Agency: Department of the Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Finding: Significant Deficiency Rec...

Subject: 2023-002 Coronavirus State and Local Fiscal Recovery Funds – Reporting Federal Agency: Department of the Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Finding: Significant Deficiency Recommendation: The Auditor recommends the City implement procedures to ensure reports are being reviewed by an individual or third-party familiar with the grant prior to their submission, including reconciliation of the report to the general ledger system. Planned Corrective Actions: The City made corrections during calendar year 2023 for a corresponding 2022. This current findings is a result of not being able to make edits in the ARPA reporting portal. A 2022 expenditure was overstated, and this 2023 expenditure was understated by the same amount.

View Audit 322710

Finding 499840 (2023-007)

Significant Deficiency 2023

Itasca County

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Ide...

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2305MN5ADM, 2305MN5MAP Compliance Requirement Affected: Reporting Award Period: Year Ended December 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review the annual LCTS Collaborative report before submission and document their review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin documenting the review of their annual LCTS Collaborative report. Name(s) of the contact person(s) responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2024

View Audit 322695

Finding 499799 (2023-002)

Significant Deficiency 2023

The Housing Authority of the City of Greenville

SC

Questioned Costs HUD Housing Programs Eligibility

Corrective Action The program issues are systemic; therefore the corrective actions are identical. The MTW flexibility permits tri-annual recertification. The agency has been conducting tri-annual recertification for elderly and disabled households. Effective with February 2025 recerts, now in proce...

Corrective Action The program issues are systemic; therefore the corrective actions are identical. The MTW flexibility permits tri-annual recertification. The agency has been conducting tri-annual recertification for elderly and disabled households. Effective with February 2025 recerts, now in process, tri-annuals will be applied to all households. This significantly reduces the number of recertifications performed by each staff and permits significantly more attention to monitoring, oversight, training and correction. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the year. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. It is anticipated that TGHA files will be fully in order by July 2025.

View Audit 322663 Questioned Costs: $1

Finding 499796 (2023-001)

Significant Deficiency 2023

Legal Services of Eastern Missouri, Inc.

MO

Subrecipient Monitoring Reporting Significant Deficiency

Finding No. 2023-001 Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date December 31, 2024 Corrective Action Plan: All necessary FFATA will be filed within 30 days. Legal Services of Eastern Missouri (LSEM) will develop policies...

Finding No. 2023-001 Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date December 31, 2024 Corrective Action Plan: All necessary FFATA will be filed within 30 days. Legal Services of Eastern Missouri (LSEM) will develop policies and procedures within 60 days to ensure that all FFATA reports are submitted in a timely manner. LSEM will provide training regarding all grant compliance for all staff involved in grant management and compliance within 90 days.

View Audit 322661

Finding 499783 (2023-002)

Significant Deficiency 2023

Tri-County Senior Citizens and Housing, Inc.

CO

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Finding 2023-002: Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development (Repeat of Finding 2022-002) Compliance Requirements: Cash Management, El...

Finding 2023-002: Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development (Repeat of Finding 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: The Operation Administrator is overall responsible the operation of Tri-County Senior Center and Housing; working together with the bookkeeping staff and Executive Director as partners to maintain financial records and budgets. The Executive Director will sporadically review tenant eligibility of new certifications and re-certifications, HAP Contracts, samples of monthly HAP Assistance Payment requests, and her presence when auditors are in-house as well any other assistance requested by Administrator. To ensure the health, safety, and well-being of the residents and staff, the Administrator oversees the responsibilities and duties of all other staff in their roles, (Administration Assistant/Program Administrator-Senior Center Activities; Administration Assistant-Membership, monthly newsletters, answer phones and any other duties requested by the Administrator), to guide them in their specific roles so they understand their duties and responsibilities as administrative staff, and ensuring the facility meets all regulatory compliance standards. If there are questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.

View Audit 322625

Finding 499774 (2023-001)

Significant Deficiency 2023

Greenwich Communities (f/ka)housing Authority of the Town of Greenwich

CT

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Management concurs with the finding and has established plans to provide additional training and review of tenant files going forward to ensure required inspections are performed and documentation is included in tenant files. Management will have certification schedules printed monthly, reviewed and...

Management concurs with the finding and has established plans to provide additional training and review of tenant files going forward to ensure required inspections are performed and documentation is included in tenant files. Management will have certification schedules printed monthly, reviewed and emailed to the third-party contractor who was hired to complete the annual inspections. In addition, all tenant files will be reviewed by management and approved.

View Audit 322620

Finding 499732 (2023-002)

Significant Deficiency 2023

Madison County Housing Authority

IL

HUD Housing Programs Reporting Significant Deficiency

Finding No. 2023-002 Significant Deficiency Personnel Responsible for Section 8 Director Corrective Action: Anticipated Completion Date: January 31, 2025 Corrective Action Plan: We take the proper review and documentation of review of our Housing Quality Standards (HQS) inspections prior ...

Finding No. 2023-002 Significant Deficiency Personnel Responsible for Section 8 Director Corrective Action: Anticipated Completion Date: January 31, 2025 Corrective Action Plan: We take the proper review and documentation of review of our Housing Quality Standards (HQS) inspections prior to their timely submission to the Public and Indian Housing Information Center (PIC) very seriously. We acknowledge the importance of this process and the need for consistent implementation. To address this finding, we will implement the following measures: 1. Documentation: A new documentation protocol will be established to provide clear proof that this process is occurring regularly. This will include date-stamped review logs and signatures from responsible staff members. We will institute a monthly review of 3 to 5 initial failed inspections. This review will: • Determine if repairs have occurred in a timely manner • Assess whether abatement letters should be sent • Be documented and included in our regular reporting 2. Training: We will conduct refresher training for all relevant staff to ensure they understand the importance of this process and their role in maintaining it. 3. Automated Reminders: We will implement an automated reminder system to alert staff when reviews and submissions are due. 4. Internal Review: Internal quarterly reviews will be conducted to ensure compliance with this process and to identify any potential issues early.

View Audit 322548

Finding 499731 (2023-001)

Significant Deficiency 2023

Madison County Housing Authority

IL

HUD Housing Programs Reporting Significant Deficiency

Finding No. 2023-001 – Significant Deficiency Personnel Responsible for Section 8 Director Corrective Action: Anticipated Completion Date: January 31, 2025 Corrective Action Plan: We acknowledge that while reviews of moved-out individuals are occurring, there was insufficient documentation...

Finding No. 2023-001 – Significant Deficiency Personnel Responsible for Section 8 Director Corrective Action: Anticipated Completion Date: January 31, 2025 Corrective Action Plan: We acknowledge that while reviews of moved-out individuals are occurring, there was insufficient documentation to support this process. We understand the importance of maintaining clear and accessible records to demonstrate our compliance and due diligence. To address this finding and implement the best practice recommendations, we will take the following steps: 1. Documentation Protocol: • Implement a standardized documentation process for move-out reviews. • Create a digital log that records the date of review, the reviewer's name, and the outcome of each review. • Ensure all documentation is easily accessible for future audits and internal reviews. 2. Monthly Landlord Verification: • Establish a monthly process to contact a sample of 3-5 landlords. • Provide these landlords with a current tenant listing for their properties. • Request verification of occupancy status for each listed tenant. • Document all responses and follow up on any discrepancies identified. 3. Move-Out Tracking: • Strengthen our move-out tracking procedures to ensure timely submission of Form HUD-50058. • Implement a system of alerts or reminders to prompt staff when 50058 submissions are due. • Conduct regular internal audits to verify the timeliness of 50058 submissions. 4. Training: • Provide comprehensive training to all relevant staff on the new documentation and verification processes. • Emphasize the importance of timely 50058 submissions and accurate move-out tracking.

View Audit 322548

Finding 499621 (2023-001)

Significant Deficiency 2023

Cuyahoga Metropolitan Housing Authority

OH

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

CUYAHOGA METROPOLITAN HOUSING AUTHORITY CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2023 U.S. Department of Housing and Urban Development The Cuyahoga Metropolitan Housing Authority (the Authority) respectfully submits the following corrective action plan for the year ended December 31, 2023. ...

CUYAHOGA METROPOLITAN HOUSING AUTHORITY CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2023 U.S. Department of Housing and Urban Development The Cuyahoga Metropolitan Housing Authority (the Authority) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 through December 31, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2023-001 Section 8 Project Based Cluster – Assistance Listing No. 14.856/14.182 Recommendation: We recommend the Authority review their process for scheduling inspections to ensure they are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review the inspection policies and procedures to ensure compliance with HQS guidelines and requirements. Name of the contact person responsible for corrective action: Claire Russ, Chief of Agency Analytics, Inspections and Technology Planned completion date for corrective action plan: December 31, 2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Bo Truett at 216-348-5000.

View Audit 322505

Finding 499582 (2023-002)

Significant Deficiency 2023

Housing Authority of the Town of Vernon

CT

HUD Housing Programs Eligibility Significant Deficiency

Response: Ensure that existing filing errors are corrected and to ensure that future filing accuracy is demonstrated. Vernon Housing is implementing the following: Vernon Housing has an existing quality control program to ensure that all HCV files are complete and up to date. In addition, Vernon Hou...

Response: Ensure that existing filing errors are corrected and to ensure that future filing accuracy is demonstrated. Vernon Housing is implementing the following: Vernon Housing has an existing quality control program to ensure that all HCV files are complete and up to date. In addition, Vernon Housing has reorganized itself with new staff being placed during the mid-year of FY23 and current. This Housing Program Manager position centralizes Housing program oversight with expertise necessary for a successful quality control system. The Agency fiscal year 2023 audit first noted the need for improved quality control Housing Choice voucher program and filing. The sample errors pointed out during the audit have been corrected and reviewed with associated personnel. Going forward since the beginning of CY 2024 the Housing program manager has reviewed all interims along with annual certifications completed by the direct reports for compliance and filing accuracy. A structured filing system has been identified for all staff personnel to follow and be assessed during the quality control review process. A monthly quality control schedule has been implemented to report to upper management during the department closing process. Management will continue to require staff to attend training and obtain the PH/HCV Specialist Certification as a mandatory job requirement. Management will continue efforts to standardize tenant files, perform supervisory and compliance file reviews and hold staff accountable for failure to adhere to the governing rules and regulations for file compliance. HCV Program staff will continue to use file review checklists when performing Recertification procedures, which require the review of Lease Addendums to ensure that the proper documentation is in the file. These are ongoing tasks. The Housing Program Manager will be responsible for these tasks. Planned Implementation Date of Corrective Action: October 2024 Person Responsible for Corrective Action: Shenoa Steves-Housing Program Manager

View Audit 322442

Finding 499571 (2023-004)

Significant Deficiency 2023

Housing Authority of Kansas City, Missouri

MO

Questioned Costs Special Tests & Provisions Significant Deficiency

Response to Finding 2023-004 The Authority generally concurs with the auditor’s findings and recommendations regarding the handling of HQS deficiencies. To address this, the Authority will implement a more rigorous process to ensure timely correction of deficiencies and adherence to abatement proced...

Response to Finding 2023-004 The Authority generally concurs with the auditor’s findings and recommendations regarding the handling of HQS deficiencies. To address this, the Authority will implement a more rigorous process to ensure timely correction of deficiencies and adherence to abatement procedures. 1. Enhanced Correction Process: • Effective October 2024, the Authority will introduce stricter timelines and automated reminders for staff to manage I IQS deficiencies. • Tf a deficiency is not corrected within the timeframe specified in the HAKC HCV Admin Plan, it will automatically escalate to the HCV Inspection Manager and Supervisor for immediate action. • Immediate actions include placing the unit on hold in the Elite system, issuing a notice to the landlord and participant, and sending an email to the Specialist to issue a voucher for the participant to move, if necessary. • A formal letter will be sent to both the landlord and tenant notifying them of the identified deficiencies, along with a set timeframe of 30 days for the repairs to be completed. A re-inspection date will be scheduled to verify that repairs have been made. 2. Abatement Process: • If repairs are not made by the set re-inspection date, an abatement letter will be sent to both the landlord and tenant, notifying them that HAP payments will cease on the first day of the following month, providing a minimum of 30 days' notice. • At this time, a letter will also be sent to the tenant notifying them that a voucher will be issued to allow them to move to a more suitable unit. 3. Termination of HAP Contract: • If repairs are still not completed by the end of the 30-day abatement period, the HAP contract will be terminated along with the HAP payment. A termination of HAP letter will be sent to the landlord and tenant for the current unit. 4. Documentation and Review Process: • The Inspection Department will maintain a weekly abatement spreadsheet documenting the reason for abatement, the start and end dates of the abatement, and any associated inspection reports. • This spreadsheet, along with the abated inspection documentation, will be reviewed at the beginning and end of each month before closeout to ensure that the abatement process is properly initiated and managed. Name of the contact person responsible for corrective action: Deputy Executive Director LaMonyka French Completion Date: December 2024 If the Department of Housing and Urban Development has questions regarding this plan, please call LaMonyka French, Deputy, Executive Director at (816) 968-4100.

View Audit 322424 Questioned Costs: $1

Finding 499570 (2023-003)

Significant Deficiency 2023

Housing Authority of Kansas City, Missouri

MO

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Response to Finding 2023-003 The Authority generally concurs with the auditor’s findings and recommendations. To address the finding related to inadequate documentation for rent reasonableness determinations, the Authority will implement the following corrective actions: 1. Immediate and Ongoing Tra...

Response to Finding 2023-003 The Authority generally concurs with the auditor’s findings and recommendations. To address the finding related to inadequate documentation for rent reasonableness determinations, the Authority will implement the following corrective actions: 1. Immediate and Ongoing Training: • To ensure consistency, increase staff knowledge, and reduce errors, the Authority will conduct immediate training sessions for all relevant staff, followed by annual refresher training. These sessions will focus on the correct procedures for documenting rent reasonableness and the importance of maintaining accurate and complete records. 2. Enhanced Quality Control and Error Monitoring: • The Authority will increase the frequency of quality control file reviews to identify errors promptly and address their root causes to prevent systemic issues. • Errors will be tracked by type and by the staff member responsible, allowing for the identification of patterns. Additional training will be provided for common error types and to individuals who are frequently responsible for errors. 3. Comprehensive File Reviews: • Quality reviews will be conducted on all files to ensure the presence of all required documents. It is anticipated that the initial comprehensive file review will take approximately one year to complete. • After the initial review, files will be selected randomly for review according to an established quality control schedule. This ongoing review process will ensure continuous compliance and address any issues as they arise. 4. Responsibility for Document Collection: • Each team member will be responsible for collecting any missing documents identified during the annual recertification, interim recertification, or change of unit processes. This accountability measure ensures that all necessary documentation is gathered and maintained consistently. 5. Adoption of a Digital Platform: • As part of the corrective action, the Authority has adopted a digital platform that requires the completion of all necessary fields before a rent determination can be finalized. This platform will also retain all documentation used to determine rent reasonableness for at least two years, ensuring thorough and accessible records. 6. Increased Random Audits: • Effective October 2024, random audits will be increased to monthly reviews to identify any discrepancies early and to ensure ongoing compliance with documentation requirements. Name of the contact person responsible for corrective action: Deputy Executive Director LaMonyka French Completion Date: December 2024

View Audit 322424

Finding 499569 (2023-002)

Significant Deficiency 2023

Housing Authority of Kansas City, Missouri

MO

HUD Housing Programs Reporting Significant Deficiency

Response to Finding 2023-002 The Authority generally concurs with the auditor’s findings and recommendations. The Authority has implemented procedures to ensure recertifications are promptly uploaded to the PIC system. Effective August 2024, we have adopted a system that flags any recertification no...

Response to Finding 2023-002 The Authority generally concurs with the auditor’s findings and recommendations. The Authority has implemented procedures to ensure recertifications are promptly uploaded to the PIC system. Effective August 2024, we have adopted a system that flags any recertification not uploaded to PIC. A HAKC Quality Control employee is responsible for daily uploads from Monday through Friday. With each upload, any fatal errors encountered are documented in an Excel spreadsheet. Once the error has been corrected in the PIC system, the correction is recorded on the spreadsheet, and the corresponding green status from PIC is printed for documentation, confirming that the issue has been resolved. To maintain ongoing compliance, bi-weekly audits will be conducted to verify that no files are missing from the PIC system. Name of the contact person responsible for corrective action: Deputy Executive Director LaMonyka French Completion Date: December 2024

View Audit 322424

Finding 499568 (2023-001)

Significant Deficiency 2023

Housing Authority of Kansas City, Missouri

MO

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Response to Finding 2023-001 The Authority generally concurs with the auditor’s findings and recommendations. To address these issues, the Authority has implemented the following corrective actions: 1. Mandatory Refresher Training: • Effective May 2024, the Authority has rolled out mandatory refresh...

Response to Finding 2023-001 The Authority generally concurs with the auditor’s findings and recommendations. To address these issues, the Authority has implemented the following corrective actions: 1. Mandatory Refresher Training: • Effective May 2024, the Authority has rolled out mandatory refresher training for all relevant staff on eligibility documentation and recertification processes. This training ensures that all staff are fully aware of the correct procedures and policies, and that they understand the importance of maintaining complete and accurate tenant files and performing recertifications in a timely manner. 2. Implementation of a New Tracking System: • A new tracking system has been implemented to ensure that all documentation is completed timely and verified by a supervisor. This system allows for real-time monitoring of the documentation process, ensuring that all required documents are included in the tenant files. 3. Utilization of Checklists: • The Authority has introduced a mandatory checklist that staff are required to use every time a file is accessed or updated. This checklist serves as a tool to ensure that all necessary steps are taken, and all required documentation is included in the tenant file. 4. Enhanced Monitoring by HCV Director and Supervisors: • The HCV Director and Supervisors will closely monitor the recertification process to ensure that all recertifications are completed in a timely manner and in accordance with policy. This includes ensuring that all participants receive and return their recertification paperwork as required. 5. Increased Frequency of Quality Control Reviews: • The Authority will continue to conduct quality control file reviews and will increase the frequency of these reviews to identify errors sooner. This proactive approach will help address the root causes of errors quickly and prevent systemic issues from developing. 6. Ongoing Quality Reviews: • Continuous quality reviews will be conducted for all files to ensure that all required documents are present and that all recertifications are performed on time. This ongoing process is designed to maintain high standards of accuracy and compliance in tenant file management. Name of the contact person responsible for corrective action: Deputy Executive Director LaMonyka French Completion Date: December 2024

View Audit 322424

Finding 499546 (2023-006)

Significant Deficiency 2023

Town of Fountain City

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.328

Finding 2023-006 – Coronavirus State and Local Fiscal Recovery Funds - Reporting (Significant Deficiency) Criteria: "The financial management system of each non-Federal entity must provide for the following: (2) Accurate, current, and complete disclosure of the financial results of each Federal aw...

Finding 2023-006 – Coronavirus State and Local Fiscal Recovery Funds - Reporting (Significant Deficiency) Criteria: "The financial management system of each non-Federal entity must provide for the following: (2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in §§ 200.328 Financial reporting . . . ." 34 CFR 76.722 states: "A State may require a subgrantee to submit reports in a manner and format that assists the State in complying with the requirements under 34 CFR 76.720 and in carrying out other responsibilities under the program." Context: There was no documented review by someone other than the preparer of the annual report to ensure the information submitted was complete and accurate. Per discussion with management, verbal review occurred but there is no documentation to support that review occurred. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that review of the annual report is documented. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect in 2024.

View Audit 322400

Corrective Action Plans

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