Corrective Action Plans

Finding 393880 (2023-010)

Material Weakness 2023

MI

Questioned Costs Cash Management Period of Performance § 200.305

The YWCA will implement the following changes in its accounting procedures. 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The C...

The YWCA will implement the following changes in its accounting procedures. 1. The Staff Accountant will review the period each expenditure is related to and record the invoice to the appropriate period when entering it into accounts payable. The month and year will be noted on the invoice. 2. The CFO will review the month and year noted by the Staff Accountant prior to entry into accounts payable.

View Audit 304072 Questioned Costs: $1

Finding 393879 (2023-009)

Significant Deficiency 2023

YWCA West Central Michigan

MI

Questioned Costs Cash Management Significant Deficiency § 200.305

The YWCA will implement the following changes in its accounting procedures. Each month, an aged open accounts payable report will be produced as part of the month end closing. Invoices that are past due will be paid in the following batch of payments (which are typically run weekly). If it is deter...

The YWCA will implement the following changes in its accounting procedures. Each month, an aged open accounts payable report will be produced as part of the month end closing. Invoices that are past due will be paid in the following batch of payments (which are typically run weekly). If it is determined that the invoice is not being paid for a valid reason, it will be removed from accounts payable at that time.

View Audit 304072 Questioned Costs: $1

Finding 393865 (2023-007)

Significant Deficiency 2023

YWCA West Central Michigan

MI

Subrecipient Monitoring HUD Housing Programs Significant Deficiency

The YWCA will address any open items from the 2023 HUD monitoring assessment and close any findings. Future findings, if any, will be closed with HUD within 30 days of receipt of the findings.

View Audit 304072

Finding 393863 (2023-005)

Significant Deficiency 2023

YWCA West Central Michigan

MI

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

The YWCA will implement the following changes in its accounting procedures: 1. For each client in the HEAL program, where the YWCA pays rent for the client, a rent reasonableness form will be completed by the HEAL program staff and approved by the HEAL Program Director and Sr. Director. The form wil...

The YWCA will implement the following changes in its accounting procedures: 1. For each client in the HEAL program, where the YWCA pays rent for the client, a rent reasonableness form will be completed by the HEAL program staff and approved by the HEAL Program Director and Sr. Director. The form will be saved in the client’s file within the Bizstream client management program. The rent reasonableness form will also be submitted to the finance department prior to, or along with a request for the client’s first rent payment.

View Audit 304072

Finding 393807 (2023-001)

Material Weakness 2023

The Dream Program, Inc.

VT

Internal Control / Segregation of Duties Significant Deficiency

Auditors Finding: Finding No.:2023-001 (2022-002) Issue: The DREAM Program did not properly document approval on invoices for various expenses. Root Cause: The organization had not implemented an explicit approval process throughout the whole year being audited. Corrective Action Planned: ● Effectiv...

Auditors Finding: Finding No.:2023-001 (2022-002) Issue: The DREAM Program did not properly document approval on invoices for various expenses. Root Cause: The organization had not implemented an explicit approval process throughout the whole year being audited. Corrective Action Planned: ● Effective June 2023, the Organization requires all invoices to be explicitly approved by both the operations director and the executive director in Bill.com prior to the payment being sent out. ● All transactions are reviewed by the bookkeeper at the close of month and a CPA quarterly. ● Relevant staff will meet post-audit to debrief, and continue to meet quarterly during existing “internal audit” meetings, to better identify areas for improvement. The organization will continue to strengthen our review process by initiating more involvement from our Board of Directors’ Finance Committee. Persons Responsible for Corrective Actions: Mike Foote, Executive Director; Christina Cramer, Business Manager; Kayla Brosilow, Operations Director; Bookkeeper; External Accountant; Board Finance Committee Meeting

View Audit 303991

Finding 393767 (2023-001)

Significant Deficiency 2023

Plumas County Community Development Commission

CA

HUD Housing Programs Reporting Significant Deficiency

Management's Response: The Fiscal Year-End 2023 Single Audit was late due to the previous three Single Audits also being late. PCCDC's Finance Team has worked meticulously to get those submissions completed. The Finance Team has also implemented procedures that adhere to deadlines and policies set b...

Management's Response: The Fiscal Year-End 2023 Single Audit was late due to the previous three Single Audits also being late. PCCDC's Finance Team has worked meticulously to get those submissions completed. The Finance Team has also implemented procedures that adhere to deadlines and policies set both internally and the Agency's funding sources. The devotion of the team along with higher standards led by the Finance Director will ensure timely and accurate submissions. Estimated Completion Date: 07/01/2023 Responsible Party: Cindy Ramsey - Finance Director

View Audit 303951

Finding 393703 (2023-002)

Significant Deficiency 2023

Planned Parenthood North Central States

MN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

Title X – Assistance Listing No. 93.217Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, adequately documented, and retained for each patient in accordance with organizational policies and program requirements. Explana...

Title X – Assistance Listing No. 93.217Recommendation: We recommend management review its patient intake process to ensure income and household size is properly verified, adequately documented, and retained for each patient in accordance with organizational policies and program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has put a process in place to ensure patient income and household size is accurately identified and documented. Patients report their income and household size to the health center staff, who enter the information into the electronic medical record system (NextGen). After the information is entered, a registration form (B209) is printed and given to the patient to review, verify, and sign. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: April 15, 2024

View Audit 303852

Finding 393646 (2023-002)

Material Weakness 2023

Ray County Memorial Hospital

MO

Material Weakness Reporting Significant Deficiency

2023-002 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Reporting schedule will be corrected as indicated to ensure lost revenue calculation is correct. Anticipated completion date: June 30, 2024 Contact person responsible for corrective action: David Usher, Chief Financi...

2023-002 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Reporting schedule will be corrected as indicated to ensure lost revenue calculation is correct. Anticipated completion date: June 30, 2024 Contact person responsible for corrective action: David Usher, Chief Financial Officer

View Audit 303788

Finding 393645 (2023-001)

Significant Deficiency 2023

Ray County Memorial Hospital

MO

Material Weakness Significant Deficiency Internal Control / Segregation of Duties

2023-001 Policies and Procedures for Federal Awards Corrective action planned: Policies and procedures for the tracking and usage of federal funds will be written and run through the appropriate approval process to be added to the facilities Policy Manual. Anticipated completion date: June 30, 20...

2023-001 Policies and Procedures for Federal Awards Corrective action planned: Policies and procedures for the tracking and usage of federal funds will be written and run through the appropriate approval process to be added to the facilities Policy Manual. Anticipated completion date: June 30, 2024 Contact person responsible for corrective action: David Usher, Chief Financial Officer

View Audit 303788

Finding 393445 (2023-001)

Significant Deficiency 2023

Community Resource Project, Inc.

CA

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking

The agency agrees with the material finding on improper cutoff and depreciation. The agency was following advice from their previous auditors and now learning the correct way to record these items Community Resource Project, Inc. will strive to implement changes immediately. Going forward the agency...

The agency agrees with the material finding on improper cutoff and depreciation. The agency was following advice from their previous auditors and now learning the correct way to record these items Community Resource Project, Inc. will strive to implement changes immediately. Going forward the agency will implement a procedure to properly cutoff end-of-year expenses and have already begun recording depreciation for grant funded vehicles in the correct manner. Person(s) Responsible: Elizabeth Bianchi-Rossi, Finance Director Timing for Implementation: February 2024 – Once the agency learned of these errors, Community Resource Project, Inc. have already implemented a new procedure for the cutoff period at the end of the year and have changed our depreciation method to ensure the full value of the vehicle gets depreciated.

View Audit 303663 Questioned Costs: $1

Finding 393405 (2023-011)

Significant Deficiency 2023

Northampton County

NC

Eligibility Significant Deficiency

Finding 2023-011 Inaccurate Resources Entry Name of contact: Lisa Broady, Adult Medicaid Supervisor Corrective Action: Proposed Completion Date: Corrective Actions for finding 2023-008, 2023-009, 2023-010, and 2023-011 also apply to State Award findings. Section IV - State Award Findings and Questio...

Finding 2023-011 Inaccurate Resources Entry Name of contact: Lisa Broady, Adult Medicaid Supervisor Corrective Action: Proposed Completion Date: Corrective Actions for finding 2023-008, 2023-009, 2023-010, and 2023-011 also apply to State Award findings. Section IV - State Award Findings and Question Costs Unit meetings will be held during the week of March 4, 2024 with implementation effective immediately. Section III - Federal Award Findings and Question Costs (continued) Adult Medicaid supervisors will be meeting with staff to ensure that all resources have been updated, entered and documented correctly in NCFast and case files and NCFast are matching. A unit meeting will be scheduled to be held during the week of March 4, 2024 with implementation effective immediately.

View Audit 303645

Finding 393404 (2023-010)

Significant Deficiency 2023

Northampton County

NC

Eligibility Significant Deficiency

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 I...

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 Inadequate Request for Information Name of contact: Corrective Action: Family and Children's Medicaid with staff on making sure TWN and OVS is ran on every application and recert as well as paying attention to other information received. Adult Medicaid supervisors will meet with staff to ensure that the TWN is being run in NCFast for all applications/recerts and that all case files include online verifications and case documentation of all resources countable and non-countable for vehicles and property. Section III - Federal Award Findings and Question Costs Family and Children's Medicaid supervisors will be meeting with staff to ensure they are receiving correct information, counting and entering correct information into NCF. Supervisor will randomly check at least 10 cases a month to assure accuracy. Adult Medicaid supervisors will be meeting with staff to ensure that they are imputing and listing income correctly in NCFast on all applications/recerts. Also, will ensure that prior to case terminations, clients have been evaluated properly for all AMA programs and proper procedures have been followed before terminating a case. Unit meetings will be held during the week of March 4, 2024 with implementation effective immediately. Supervisor will continue to review 10 cases each month to assure correct information has been keyed and correct procedures has been done prior to case termination. Family and Children's Medicaid supervisors will meet with staff on IV-D referrals and discuss when to key them. A unit meeting with staff during the week of March 4, 2024.

View Audit 303645

Finding 393403 (2023-009)

Significant Deficiency 2023

Northampton County

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 I...

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 Inadequate Request for Information Name of contact: Corrective Action: Family and Children's Medicaid with staff on making sure TWN and OVS is ran on every application and recert as well as paying attention to other information received. Adult Medicaid supervisors will meet with staff to ensure that the TWN is being run in NCFast for all applications/recerts and that all case files include online verifications and case documentation of all resources countable and non-countable for vehicles and property. Section III - Federal Award Findings and Question Costs Family and Children's Medicaid supervisors will be meeting with staff to ensure they are receiving correct information, counting and entering correct information into NCF. Supervisor will randomly check at least 10 cases a month to assure accuracy. Adult Medicaid supervisors will be meeting with staff to ensure that they are imputing and listing income correctly in NCFast on all applications/recerts. Also, will ensure that prior to case terminations, clients have been evaluated properly for all AMA programs and proper procedures have been followed before terminating a case. Unit meetings will be held during the week of March 4, 2024 with implementation effective immediately. Supervisor will continue to review 10 cases each month to assure correct information has been keyed and correct procedures has been done prior to case termination. Family and Children's Medicaid supervisors will meet with staff on IV-D referrals and discuss when to key them. A unit meeting with staff during the week of March 4, 2024.

View Audit 303645

Finding 393402 (2023-008)

Significant Deficiency 2023

Northampton County

NC

Eligibility Significant Deficiency

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 I...

Finding 2023-008 IV-D Cooperation with Child Support Name of contact: Felicia Bullock, Family and Children’s Medicaid Supervisor Corrective Action: Proposed Completion Date: Finding 2023-009 Inaccurate Information Entry Name of contact: Corrective Action: Proposed Completion Date: Finding 2023-010 Inadequate Request for Information Name of contact: Corrective Action: Family and Children's Medicaid with staff on making sure TWN and OVS is ran on every application and recert as well as paying attention to other information received. Adult Medicaid supervisors will meet with staff to ensure that the TWN is being run in NCFast for all applications/recerts and that all case files include online verifications and case documentation of all resources countable and non-countable for vehicles and property. Section III - Federal Award Findings and Question Costs Family and Children's Medicaid supervisors will be meeting with staff to ensure they are receiving correct information, counting and entering correct information into NCF. Supervisor will randomly check at least 10 cases a month to assure accuracy. Adult Medicaid supervisors will be meeting with staff to ensure that they are imputing and listing income correctly in NCFast on all applications/recerts. Also, will ensure that prior to case terminations, clients have been evaluated properly for all AMA programs and proper procedures have been followed before terminating a case. Unit meetings will be held during the week of March 4, 2024 with implementation effective immediately. Supervisor will continue to review 10 cases each month to assure correct information has been keyed and correct procedures has been done prior to case termination. Family and Children's Medicaid supervisors will meet with staff on IV-D referrals and discuss when to key them. A unit meeting with staff during the week of March 4, 2024.

View Audit 303645

Finding 393379 (2023-004)

Significant Deficiency 2023

Chippewa Hills School District

MI

Cash Management School Nutrition Programs Special Tests & Provisions

Finding 2023-004 - Corrective Action Plan CHSD - 2022-2023 Audit Findings Finding 2023-004 – SPECIAL TESTS AND PROVISIONS (repeat comment) Type: Significant Deficiency in Internal Control / Noncompliance Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: As of year-end the D...

Finding 2023-004 - Corrective Action Plan CHSD - 2022-2023 Audit Findings Finding 2023-004 – SPECIAL TESTS AND PROVISIONS (repeat comment) Type: Significant Deficiency in Internal Control / Noncompliance Program: Child Nutrition Cluster (ALN 10.553, 10.555 and 10.559) Condition: As of year-end the District had a fund balance in the non-profit food service fund in excess of three months’ operating expenses by approximately $157,881. Criteria: The USDA requires that the District limit its net cash resources to an amount that does not exceed 3 months average expenditures of the non-profit food service fund per requirements in 7 CFR Part 210.14(b). Cause: This condition was caused by the meal claims increasing and having more reimbursements come in than anticipated. Corrective action to be taken: Over the 2023-2024 school year, the District will continue to leverage the excess fund balance to improve the quality of the food service program. Efforts to address the ongoing excess fund balance condition are ongoing and, while planning started in the 2022-2023 school year, an aggressive food service capital reinvestment project is scheduled to be completed in the 2023-2024 school year. This $220,000+ project will address equipment replacement and student service improvements in both the High School and the Middle School. The spend down associated with this project is anticipated to offset the excess fund balance on June 30, 2023, as noted in this finding. However, anticipating the potential for continued Food Service Program funding support at a state and federal level, the CHSD food service department will continue to monitor the fund balance with the goal of proactively managing any forecasted excess balance by continuing to offer more new food choices and improve the quality of the food served (including more fresh produce and better-quality ingredients). These improvements will continue to be in conjunction with the Michigan Department of Education's Office of School Support Services which will again approve the spending plan. The corrective action timeline is as follows: The corrective action is effective immediately and encompasses the ongoing efforts on the part of the District to comply with program criteria while balancing unpredictable statutory revenue streams against spending forecasts in the highly volatile food service market conditions. The District anticipates compliance with the Fund Balance condition set forth in the program by 6-30-2024. District Leader Responsible for Corrective Action Plan: The Food Service Administrator will be responsible for ensuring compliance with this corrective action. Respectfully submitted, Marc Forrest, Director of Finance

View Audit 303635

Finding 393364 (2023-010)

Significant Deficiency 2023

South Carolina State Housing Finance and Development Authority

SC

Questioned Costs HUD Housing Programs Special Tests & Provisions

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the authority review the equity roll forward of programs to identify and correct errors in the correct reporting period. Explanation of disagreement with audit finding: There is no disagreement with the...

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the authority review the equity roll forward of programs to identify and correct errors in the correct reporting period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Processes are being updated to include a monthly reconciliation of program equity to be performed by Finance staff in cooperation with Program staff. Finance staff are undergoing substantial training to improve both programmatic understanding and financial systems knowledge. Name(s) of the contact person(s) responsible for corrective action: Ellen Eudy, Deputy Director, Financial Operations and John Morrison, Controller Planned completion date for corrective action plan: Training in progress with reconciliation process to be completed by June 30, 2024.

View Audit 303627 Questioned Costs: $1

Finding 393361 (2023-009)

Significant Deficiency 2023

South Carolina State Housing Finance and Development Authority

SC

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend that the Authority implements controls in order to ensure reporting requirements are met in accordance with applicable grant agreements and regulations. Explanation of disagreement with audit finding: T...

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend that the Authority implements controls in order to ensure reporting requirements are met in accordance with applicable grant agreements and regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Action planned/taken in response to finding: The Director of HCVP Operations and the Director of HCVP Administration will each independently review their portions of the SEMAP certifications that apply to their business units and sign off. Once complete, all SEMAP certifications for the HCVP will be forwarded to the Director of Rental Assistance and Compliance for final review/validation. The Director of Rental Assistance and Compliance will be responsible for directly submitting validated SEMAP data to HUD. Name(s) of the contact person(s) responsible for corrective action: Lenzy Morris, HCVP Director of Operations, Yolanda Dennison, HCVP Director of Administration, and Lisa T. Wilkerson, Director of Rental Assistance and Compliance Planned completion date for corrective action plan: Effective with fiscal year 2024 SEMAP certification.

View Audit 303627

Finding 393358 (2023-008)

Significant Deficiency 2023

South Carolina State Housing Finance and Development Authority

SC

Questioned Costs Eligibility HUD Housing Programs

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that tenant files contain all required documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action...

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that tenant files contain all required documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Current processes in place require collection and review of documentation by individual HPC assigned to a particular file. Upon transfer to the associated administrative team member, a second review is to be conducted to verify all required documentation is present. Any omissions require the HPC to reach out and supply mission documentation before action can be processed. We also secured a contract with The Work Number solution to assist with third party income verifications. Name(s) of the contact person(s) responsible for corrective action: Entire HCVP team and management. Planned completion date for corrective action plan: Currently implemented and ongoing.

View Audit 303627 Questioned Costs: $1

Finding 393355 (2023-007)

Significant Deficiency 2023

South Carolina State Housing Finance and Development Authority

SC

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend that the Authority sets up a separate interest-bearing account and executes a depository agreement with their financial institution and HUD; alternatively, we recommend that the Authority obtains a waive...

Housing Voucher Cluster – Assistance Listing Numbers 14.871/14.879 Recommendation: We recommend that the Authority sets up a separate interest-bearing account and executes a depository agreement with their financial institution and HUD; alternatively, we recommend that the Authority obtains a waiver from this requirement if local regulation prohibits the Authority from following 24 CFR section 982.156. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Housing Voucher Cluster funds are held by the Treasurer for the State of South Carolina. The depository agreements in place are between the depository institution and the state Treasurer. SC Housing submitted a waiver request to the local HUD field office on March 29, 2023. We followed up on the request most recently on January 24, 2024 and to date, no response has been received. In the meantime, SC Housing is continuing to work with the State Treasurer’s Office to identify a solution that would allow SC Housing to enter into a general depository agreement (GDA) that would provide third party rights to HUD. Modifications have been made to the state financial accounting sytems to track the funds in question separately, but we are trying to determine how, and even if, the funds can be housed in a separate bank account, while still adhering to state regulation. Name(s) of the contact person(s) responsible for corrective action: Ellen Eudy, Deputy Director, Financial Operations and Lisa Wilkerson, Director of Rental Assistance and Compliance Planned completion date for corrective action plan: Waiver request submitted to HUD local field office on March 29, 2023. Alternative solution is in discussion with State Treasurer’s Office .

View Audit 303627

Finding 393338 (2023-001)

Significant Deficiency 2023

Winslow Gardens

RI

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

FEDERAL AWARD FINDINGS AND QUESTIONED COSTS: Finding 2023-001 The Organization does not have the required insurance coverage determined by HUD and exposes themselves to potential liability. Program Operating Assistance for Troubled Multifamily Housing Projects - 14.164 Description of Finding Tw...

FEDERAL AWARD FINDINGS AND QUESTIONED COSTS: Finding 2023-001 The Organization does not have the required insurance coverage determined by HUD and exposes themselves to potential liability. Program Operating Assistance for Troubled Multifamily Housing Projects - 14.164 Description of Finding Two months of gross potential receipts was in excess of the Fidelity Bond maintained by the Organization. Statement of Concurrence or Non-Concurrence Management concurs with this finding. Corrective Action Effective February 5, 2024, the Organization had increased their Fidelity Bond coverage for the 2024 fiscal year. Name of Contact Person Joseph Durand Projected Completion Date February 5, 2024

View Audit 303617

Finding 393337 (2023-002)

Significant Deficiency 2023

Southwest Kansas Area Agency on Aging, INC

KS

HUD Housing Programs Significant Deficiency

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002: Section 8 Housing Choice Voucher Program CFDA 14.871 Condition: The Organization did not maintain documentation on file that a redetermination of reasonable rent was completed prior to the contract anniversary. We noted the rent was reasonable...

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002: Section 8 Housing Choice Voucher Program CFDA 14.871 Condition: The Organization did not maintain documentation on file that a redetermination of reasonable rent was completed prior to the contract anniversary. We noted the rent was reasonable, however, there was no documentation of the Organization testing rent reasonableness in seven different tenant files. Criteria: The Organization must maintain records to document the basis for the determination that rent to owner is a reasonable rent (initially and during the term of the housing assistance payment contract). 24 CFR 982.507. Cause: The Organization failed to maintain documentation in the tenant file. Effect: There is potential of renewing rent to owner agreements in excess of Fair Market Rent. Recommendation: Management should document the redetermination of rent reasonableness in accordance with 24 CFR 982.507. Grantee Response: Management agrees with the finding and will properly document reasonable rent going forward.

View Audit 303607

Finding 393336 (2023-001)

Significant Deficiency 2023

Southwest Kansas Area Agency on Aging, INC

KS

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-001: Section 8 Housing Choice Voucher Program – CFDA 14.871 Grant Period: Year ended September 30, 2023 Condition: The Organization did not complete the Housing Quality Control Inspection Test to properly implement all the requirements of 2 CFR Sec...

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-001: Section 8 Housing Choice Voucher Program – CFDA 14.871 Grant Period: Year ended September 30, 2023 Condition: The Organization did not complete the Housing Quality Control Inspection Test to properly implement all the requirements of 2 CFR Section 982.405 of Title 2 U.S. Code of Federal Regulations Part 982, Section 8 Tenant-Based Assistance: Housing Voucher Program. Criteria: In accordance with 2 CFR Section 982.405(b), PHA’s must conduct supervisory quality control HQS (Housing Quality Standards) inspections. Cause: The Organization’s did not complete their internal review of the HQS standards as required by Section 982.405(b). Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without verifying these procedures, there is a higher risk of noncompliance with program compliance requirements. Recommendation: Management should perform a supervisory quality control over the HQS inspections. The inspection should follow the guidelines set forth in 24 CFR 985.2. Grantee Response: Management agrees with the finding and will complete the Quality Control Inspection going forward.

View Audit 303607

Finding 393279 (2023-001)

Significant Deficiency 2023

Shenandoah Area Agency on Aging, INC

VA

Reporting Significant Deficiency Internal Control / Segregation of Duties

2023-001: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging - Title III, Part B-Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part Cl - Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting (Signi...

2023-001: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging - Title III, Part B-Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part Cl - Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting (Significant Deficiency) Condition: The 13th Aging Monthly Report required by the pass through agency, Virginia Department of Aging and Rehabilitative Services (VDARS) was not submitted timely and contained inaccurate revenue and expendituredata. Criteria: VDARS requires the annual 13th Month Aging Monthly Report to be submitted by November 15th. The report must contain complete and accurate information as a restating of the monthly reporting for the fiscal year. Cause: The 13th Aging Monthly Report was not reconciled to underlying financial records, resulting in unexplained differences between the report and trial balance provided as part of the audit. Additionally, the report was not submitted by November 15, 2023. Effect: The submission of the 13th AMR was not performed timely and included data that did not agree to underlying financial records. This should have been caught during the course of a review process before submission. Therefore, it is considered a significant deficiency of internal controls over compliance. Recommendation: Ensure reporting is submitted timely by the deadline stated by VDARS. Implement a review process for each monthly submission, including documentation of the review. Reconcile the federal, state and local totals reported in the Aging Monthly Report to the underlying financial records as stated in the financial system to ensure accuracy before submission to VDARS. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The AMR report was not filed in a timely manner. Management plans to implement a process to ensure that the AMR report will be submitted by the November 15th deadline.

View Audit 303569

Finding 393278 (2023-002)

Significant Deficiency 2023

Jamestown Regional Medical Center

ND

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Federal Agency Name: Department of Health and Human Services Federal Assistance Listing: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: Expense carryforward was improperly submitted as unused lost revenue in Period 1, which caused the...

Federal Agency Name: Department of Health and Human Services Federal Assistance Listing: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: Expense carryforward was improperly submitted as unused lost revenue in Period 1, which caused the amount to be improperly carried forward to Period 5 from the previous report. Corrective Action Plan: All tracking and reports will be reviewed by someone other than the preparer. The reviewer will sign off by email or by physical signature that they have reviewed and agree with the support. Responsible Individuals: Beverly Fiferlick, CFO Anticipated Completion Date: June 30, 2024

View Audit 303568

Finding 393257 (2023-002)

Significant Deficiency 2023

Leeway-Welton Housing Corporation

CT

Questioned Costs HUD Housing Programs Significant Deficiency

Unauthorized disbursements from the reserve fund were made. Recommendation: CLA recommends the Project return the withdrawn funds back to the reserve funds when the funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in resp...

Unauthorized disbursements from the reserve fund were made. Recommendation: CLA recommends the Project return the withdrawn funds back to the reserve funds when the funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has received the delayed rental income payments and is working to return the funds. Name of the contact person responsible for corrective action: Matthew Fontaine, Controller DeMarco Management Corp. Planned completion date for corrective action plan: April 1, 2024

View Audit 303527 Questioned Costs: $1

Corrective Action Plans

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