Corrective Action Plans

Finding 499256 (2023-002)

Significant Deficiency 2023

Civic Arts

TX

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Management concurs with the recommendation as proposed and has developed written policies and procedures related to federal payments and allowability of costs. This has been implemented effective immediately.

View Audit 322061

Finding 499235 (2023-003)

Significant Deficiency 2023

Entrepreneurship for All, Inc.

MA

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Item # 2023-003 Reconciliation of Bank Accounts (Significant Deficiency in Internal Control) Criteria: Under GAAP, bank accounts are required to be reconciled on a regular basis to ensure that they are properly stated under the accrual basis of accounting. Condition: During the year under audit, ...

Item # 2023-003 Reconciliation of Bank Accounts (Significant Deficiency in Internal Control) Criteria: Under GAAP, bank accounts are required to be reconciled on a regular basis to ensure that they are properly stated under the accrual basis of accounting. Condition: During the year under audit, the Organization did not reconcile the ending balances of all accounts held with financial institutions during the fiscal year. Cause: The Organization did not compare the balances per statements received for bank accounts from financial institutions with its own internal account balances and failed to make the necessary accrual based accounting adjustments for reconciling items. Effect: Failure to update internal controls to comply with the requirements of the GAAP could result in ineffective monitoring of costs allocated to the federal program. Recommendation: The Organization should strengthen its internal control practices by updating its policies and procedures to comply with GAAP. Views of Responsible Officials and Planned Corrective Actions: Management has been making updates to its policies and procedures throughout 2024 to be in full compliance with GAAP. This exercise is anticipated to be complete by the end of the fiscal year.

View Audit 322032

Finding 499232 (2023-001)

Significant Deficiency 2023

Samaritas and Subsidiaries

MI

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

For the Year Ended December 31, 2023 Finding Number 2023-001 Contact Person(s): Cynthia Sikina, Interim CFO Wendy Perry, Director of Budget & Contracts Corrective Action Planned: Contract terms will be reviewed to ensure understanding of the billing terms and will be documented in the contract manag...

For the Year Ended December 31, 2023 Finding Number 2023-001 Contact Person(s): Cynthia Sikina, Interim CFO Wendy Perry, Director of Budget & Contracts Corrective Action Planned: Contract terms will be reviewed to ensure understanding of the billing terms and will be documented in the contract management system in accordance with the Samaritas contract approval procedure. Cash draws will be aligned with actual cash expenditures for any cost reimbursement contract/grant to limit draws to immediate cash needs in accordance with Title 2 U.S. Code of Federal Regulations Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards (the Uniform Guidance), Subpart D – Post Federal Award Requirements, Section 200.305 Federal Payment. Anticipated Completion Date: Date completed June 30, 2023

View Audit 322026

Finding 499213 (2023-009)

Significant Deficiency 2023

Shatterproof A Nonprofit Corporation

CT

Internal Control / Segregation of Duties Cash Management Significant Deficiency

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expendi...

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expenditures. Management will also reinforce the importance of employees providing the appropriate invoices or supporting documentation for all expenditures submitted for payment. Expenditures will not be paid without the appropriate supporting documentation. All approvals will be tracked through an online system. In addition, management will reinforce the importance of reviewing the timing of when expenditures are incurred, to ensure they are recorded in the appropriate fiscal year. Anticipated completion date: Implemented November 2023

View Audit 321990

Finding 499206 (2023-008)

Significant Deficiency 2023

Shatterproof A Nonprofit Corporation

CT

Internal Control / Segregation of Duties Cash Management Significant Deficiency

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expendi...

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expenditures. Management will also reinforce the importance of employees providing the appropriate invoices or supporting documentation for all expenditures submitted for payment. Expenditures will not be paid without the appropriate supporting documentation. All approvals will be tracked through an online system. In addition, management will reinforce the importance of reviewing the timing of when expenditures are incurred, to ensure they are recorded in the appropriate fiscal year. Anticipated completion date: Implemented November 2023

View Audit 321990

Finding 499182 (2023-004)

Significant Deficiency 2023

Shiloh Home Inc.

CO

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.328

Corrective Action Plan: Management is developing a process to include a periodic review of all compliance aspects related to the grants including financial and performance reporting. This will be completed by December 31, 2024. Individual responsible for corrective action plan: Steven Ramirez

View Audit 321973

Finding 499130 (2023-009)

Significant Deficiency 2023

Nobles County

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Eligibility § 200.303 § 200.403

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a secondary person review the reports and in a timely manner. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

View Audit 321906

Finding 499129 (2023-008)

Significant Deficiency 2023

Nobles County

MN

Reporting Internal Control / Segregation of Duties Significant Deficiency

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County review the contract with MN DHS, and implement proper review and approval procedures for all LCTS reports. We recommend that paper copies are kept on file for the required timeframe. We recommend that the County implement procedures to remit the quarterly funding to the collaborative in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to ensure all requirements of LCTS special provisions are followed. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

View Audit 321906

Finding 499128 (2023-007)

Significant Deficiency 2023

Nobles County

MN

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

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

View Audit 321906

Finding 499127 (2023-006)

Significant Deficiency 2023

Nobles County

MN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency ...

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Award Period: Year Ended December 31, 2023 Recommendation: We recommend procedures and controls be implemented to ensure each quarterly listing is properly reviewed and accurate employees are on the listings. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

View Audit 321906

Finding 499126 (2023-005)

Significant Deficiency 2023

Nobles County

MN

Allowable Costs / Cost Principles Eligibility Significant Deficiency § 200.403

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency ...

Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2305MN5ADM, 2305MN5MAP; 2023 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2023 Recommendation: We recommend that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2024

View Audit 321906

Finding 499114 (2023-002)

Significant Deficiency 2023

Bronx Community Health Network, Inc.

NY

Subrecipient Monitoring Reporting HUD Housing Programs § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-002 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) – Significant Deficienc...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-002 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) – Significant Deficiency Description of Finding: There was no evidence of review and approval by someone other than the preparer of the FFATA subawards that were submitted to the FSRS. The FFATA subawards were not submitted timely to the Federal Funding Accountability and Transparency Act Subaward Reporting System (“FSRS”). Statement of Concurrence: We concur with the finding above. Corrective Action: As of September 1, 2023, BCHN implemented a workflow where FFATA information will be reported to the FSRS upon receipt of the Notices of Award. In addition, as of September 9, 2024, the FFATA report will be reviewed by someone other than the preparer prior to submission and evidence of the approval maintained. Completion Date: September 9, 2024. Name of Contact Person: James Paine, Ph.D. Chief Executive Officer Tel. No.: (718) 405-4993 E-mail: jpaine@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call James Paine at (718) 405-4993. Sincerely yours, _________________________ James Paine, Ph.D. Chief Executive Officer

View Audit 321903

Finding 499111 (2023-002)

Significant Deficiency 2023

Regent at Apple Valley, LLC Dba: the Seasons at Apple Valley

MN

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to maintain tenant security deposits in a separate bank account in an amount adequate to cover the security deposit liability. The security deposit bank account balance was not adequate to cover the security depos...

Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to maintain tenant security deposits in a separate bank account in an amount adequate to cover the security deposit liability. The security deposit bank account balance was not adequate to cover the security deposit liability. Recommendation: Recommend management fund the security deposit account in an amount that is adequate to cover the security deposit liability. There is no disagreement with the audit finding. Action taken in response to finding: We have funded the security deposit account in an amount adequate to cover the security deposit liability. Name of the contact person responsible for corrective action: Cassandra Johnson Planned completion date for corrective action plan: July 2024

View Audit 321895

Finding 499110 (2023-001)

Significant Deficiency 2023

Regent at Apple Valley, LLC Dba: the Seasons at Apple Valley

MN

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that manage...

Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that management work with HUD to have the current management agreement approved. There is no disagreement with the audit finding. Action taken in response to finding: We have contacted HUD to obtain an approved management agreement. Name of the contact person responsible for corrective action: Cassandra Johnson Planned completion date for corrective action plan: September 2024

View Audit 321895

Finding 499086 (2023-002)

Significant Deficiency 2023

Sound Generations

WA

Cash Management Reporting Significant Deficiency § 200.303

Type of Finding: Significant Deficiency in Internal Control over Compliance - Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023 P...

Type of Finding: Significant Deficiency in Internal Control over Compliance - Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023 Pass-Through Agency: City of Seattle Pass-Through Number(s): DA23-1109 Award Period: January 1, 2023 through December 31, 2023 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-Federal entity must “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring the Organization of the Treadway Commission (COSO).” Condition: During testing of reporting, it was noted that, for one sample, documentation was not retained of approval of financial reporting. Questioned Costs: None Context: A sample of 9 financial reports was made from a population of 54 total reports. Of the 9 sampled, 1 was missing evidence of authorized personnel review and approval. Cause: In this one instance, verbal approval was given rather than emailed approval. Effect: Without adequate documentation and controls in place to ensure costs are reasonable and intended for the program charged, Sound Generations could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that Sound Generations is entitled to under the terms of the grant. Repeat Finding: No. Recommendation: CLA recommends that documentation is retained as proof of authorized personnel review. Views of responsible officials and planned corrective actions: Sound Generations agrees with the finding. Sound Generations has revised its approval process to include digital signatures with time stamps by authorized personnel on all documentation rather than emailed approvals. Responsible Official: Carlos Rojas, Chief Financial Officer; Christina Hannan, Controller Anticipated Completion Date: March 31, 2024

View Audit 321877

Finding 499083 (2023-002)

Significant Deficiency 2023

Mobile Housing Authority

AL

Eligibility HUD Housing Programs Significant Deficiency

Action Taken: MHA will review and enhance as necessary the program’s existing quality control (QC) file review procedures as well as daily data validation reports to include a measure that cross-checks existing reports in the Yardi system of record and aids in validating data routinely submitted to ...

Action Taken: MHA will review and enhance as necessary the program’s existing quality control (QC) file review procedures as well as daily data validation reports to include a measure that cross-checks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. To further mitigate the risk posed by frequent turnover among Housing Specialist-I (HS-I) staff, MHA will increase the frequency of training on rent and income determination for all staff including tenured team members and new hires, alike, to occur quarterly. In 2023, MHA implemented a Housing Specialist-II Team Lead to oversee HS-I staff processing annual reexaminations in accordance with 24 CFR 982.516. This team member is responsible for ensuring families are notified in a timely manner and if they do not comply with the annual reexamination requirement, they receive termination notices in compliance with HUD and MHA Administrative Plan requirements. MHA also implemented two compliance analysts in 2023; we will add another compliance analyst staff person in 2024 to increase the percentage of files undergoing quality control review. These three (3) Compliance Analyst will report to the Operations and Compliance Manager who monitors HUD’s PIC system and analyzes discrepancies between PIC data and MHA data housed in the Yardi system of record. This information is maintained in the program file. Name of Responsible Person: Paul and Magdalene Watkins, Program Administration Team Projected Completion Date: 12/31/2024

View Audit 321867

Finding 499066 (2023-002)

Significant Deficiency 2023

Douglas County

MN

Eligibility Reporting Significant Deficiency § 200.303

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate a...

Recommendation: It is recommended County management add an additional control review over the eligibility of casefile reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to designate an internal reviewer to continually review the casefile eligibility determinations throughout the year. Name of the contact person responsible for corrective action plan: Jill Frisell, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 321840

Finding 499028 (2023-003)

Significant Deficiency 2023

Central Minnesota Housing Partnership, Inc.

MN

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Rural Rental Housing Loans - Federal Assistance Listing #10.415 Recommendation: The Organization should review security deposits as a part of month-end close procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to fi...

Rural Rental Housing Loans - Federal Assistance Listing #10.415 Recommendation: The Organization should review security deposits as a part of month-end close procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement a review step during the tracking of security deposits to verify the security deposit asset is equal to or greater than the security deposit liability and will correct any that are underfunded. Names of the contact persons responsible for corrective action: Julie Schueller, Finance Director and Deanna Hemmesch, Executive Director Planned completion date for corrective action plan: December 31, 2024

View Audit 321819

Finding 499027 (2023-002)

Significant Deficiency 2023

Watonwan County

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

Finding Number: 2023-002 Finding Title: Local Collaborative Time Study (LCTS) Annual Spending Report Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks Corrective Action Planned: The 2023 report was revised and completed by the Fiscal Offi...

Finding Number: 2023-002 Finding Title: Local Collaborative Time Study (LCTS) Annual Spending Report Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Erin Marks Corrective Action Planned: The 2023 report was revised and completed by the Fiscal Officer. Effective immediately and on going, the spending report will be completed by the Fiscal Officer and reviewed by the Supervisor. Narrative detail and programmatic reporting will be completed by the Collaborative Coordinator and reviewed by the Director. Anticipated Completion Date: 12/31/2024

View Audit 321815

Finding 499006 (2023-001)

Significant Deficiency 2023

Thurston County Economic Development Council

WA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.430

Significant Deficiency in Internal Control and Compliance over Major Programs Funding Agency: Department of Treasury ALN: 21.027 Recommendation: JSP recommends that the program manager and a member of the finance committee knowledge about 2 CFR 200.430(i)(1) review the executive director costs char...

Significant Deficiency in Internal Control and Compliance over Major Programs Funding Agency: Department of Treasury ALN: 21.027 Recommendation: JSP recommends that the program manager and a member of the finance committee knowledge about 2 CFR 200.430(i)(1) review the executive director costs charged to the Coronavirus State and Local Recovery Funds program. There is no disagreement with the audit finding. The corrective action was immediately implemented when it was identified in September of 2023, conducted over the period ending December 31, 2023. A review of the timesheets from October – December of 2023 reflects that this had been addressed. Action planned in response to finding: Treasurer of the Board of Directors and federal program manager shall review the executive director’s cost allocations within timesheets. Names of the contact person(s) responsible for corrective action: Michael Cade (EDC Executive Director), Michael McGauly (Board of Directors Treasurer), and Matt Stacey (EDC Finance Manager). Planned completion date for corrective action plan: September 2023

View Audit 321792 Questioned Costs: $1

Finding 498965 (2023-001)

Significant Deficiency 2023

Sealaska Heritage Institute

AK

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

September 24, 2024 To whom it may concern: Sealaska Heritage Institute (SHI) respectfully submits the following corrective action plan for the year ending December 31, 2023. Our independent single federal audit was performed by Kendall, Prebola and Jones, LLC 133 Mann Street, PO Box 259, Bedford PA...

September 24, 2024 To whom it may concern: Sealaska Heritage Institute (SHI) respectfully submits the following corrective action plan for the year ending December 31, 2023. Our independent single federal audit was performed by Kendall, Prebola and Jones, LLC 133 Mann Street, PO Box 259, Bedford PA 15522. The following finding was discovered, and a corrective plan has been implemented: ALN Number 84.356A ALN Title Alaska Native Educational Programs Federal Award Years: 10/01/22 – 09/30/23 09/30/23 – 09/29/24 Type of Finding: Significant Deficiency in Internal Control over Compliance Condition and Context: SHI is engaged in a construction project, and it is partially funded by federal funds. While SHI primarily oversees educational programs and their reporting requirements, SHI was aware that Federal prevailing wage requirements apply to construction projects funded with Federal monies, and had conveyed this to its prime contractor for the construction project. SHI concurs with the auditor finding that SHI did not have timely submittal and review of the certified payrolls as required. Upon late review of the certified payrolls furnished to SHI by the design-build contractor and its subcontractors employed on this project, SHI confirmed that all wages paid met or exceed the prevailing wage rates for Juneau, Alaska. In order to ensure timely tracking and compliance with Federal prevailing wage requirements for this project, SHI has committed to the following corrective action plan. Corrective Action: • SHI’s design-build (prime) contractor for this project has been informed that it must provide certified payrolls to SHI for all workers on this project employed by itself or its subcontractors with contracts valued at $2,000 or more within seven (7) days of the end of each weekly pay period. Contractor will provide these either by e-mailing them to SHI’s Project Manager and/or by posting them on Procore, the construction management application it uses and to which SHI’s Project Manager has access. • SHI’s Project Manager will log and review the certified payrolls weekly, comparing them against the prevailing wage rates indicated in General Decision Number AK20240001 or any preceding or superseding document, and will maintain a record of said payrolls. • Should any construction project happen in the future, SHI will ensure an experienced federal audit consultant provides proper training in the particulars of construction project compliance requirements to the Project Manager and Finance Staff before the start of the project. • Prior to the start of any future construction project, SHI will develop a reporting requirement calendar that is checked/implemented during the course of the project. Completion Dates: Grant Award Compliance Review.……………………………………….. 06/24 Development of Compliance corrective action…………………….. 07/24 Implementation of Compliance corrective action………………… 07/24 Project Manager review/training in reporting requirements.. 06/24 SHI, the COO, and their contracted financial firm have discussed the corrective action plan and are working cooperatively to ensure that all deadlines are met for construction compliance and reporting purposes. Lee A. Kadinger Chief Operating Officer

View Audit 321781

Finding 498920 (2023-001)

Significant Deficiency 2023

Regent at Maplewood, LLC Dba: the Seasons at Maplewood

MN

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to maintain tenant security deposits in a separate bank account in an amount adequate to cover the security deposit liability. The security deposit bank account balance was not adequate to cover the security depos...

Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to maintain tenant security deposits in a separate bank account in an amount adequate to cover the security deposit liability. The security deposit bank account balance was not adequate to cover the security deposit liability. Recommendation: Recommend management fund the security deposit account in an amount that is adequate to cover the security deposit liability. There is no disagreement with the audit finding. Action taken in response to finding: We have funded the security deposit account in an amount adequate to cover the security deposit liability. Name of the contact person responsible for corrective action: Cassandra Johnson Planned completion date for corrective action plan: July 2024

View Audit 321756

Finding 498891 (2023-003)

Significant Deficiency 2023

Clifford W. Beers and Subsidiaries

CT

Procurement, Suspension & Debarment Significant Deficiency § 200.318 § 200.326

Department of the Treasury Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR se...

Department of the Treasury Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review and modify the procurement policy and conflict of interest policy and make all necessary changes for compliance. Name of the contact person responsible for corrective action: Michael Riso, CFO Planned completion date for corrective action plan: June 30, 2024

View Audit 321699

Finding 498881 (2023-001)

Significant Deficiency 2023

United Voices for Newcomer Rights

NM

Subrecipient Monitoring Cash Management Allowable Costs / Cost Principles § 200.1 § 200.303

Recommendation UVNR should implement procedures to ensure thorough monitoring and accurate accounting of all subrecipient expenditures. Subrecipients should be required to submit properly supported invoices with their reimbursement requests. It is also recommended that authorized gra...

Recommendation UVNR should implement procedures to ensure thorough monitoring and accurate accounting of all subrecipient expenditures. Subrecipients should be required to submit properly supported invoices with their reimbursement requests. It is also recommended that authorized grant personnel diligently review and approve these invoices to ensure that reimbursements are made only for actual expenditures. Management Response Corrective Action: 1. Meet with subrecipient to clarify compliance issues with 2023 disbursements and to discuss plans of action for 2024 through grant period end (occurred on 9/10/24). 2. Subrecipient will invoice monthly providing grant personnel with an invoice and general ledger of expenses. 3. Grant personnel will adopt a policy of reviewing subrecipient’s monthly invoices and supporting documents, including adding a requirement for grant personnel to approve and sign subrecipient invoices before drawing down from the federal award’s payment management system. 4. Signed and approved grant invoices and supporting documentation will also be shared with accounts for approval before drawing down from the federal award’s payment management system. 5. Grant personnel will meet regularly with accountants for thorough and continuous monitoring of the award, including accurate accounting of subrecipient funds Due Date of Completion: September 30, 2024 - ongoing Responsible Party(ies): Co-Executive Directors

View Audit 321664

Finding 498865 (2023-002)

Significant Deficiency 2023

District of Columbia Primary Care Association

DC

Procurement, Suspension & Debarment Eligibility Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: This condition was primarily the result of a heavy reliance on external subject matter experts (SMEs) for technical aspects of programmatic workplan deliverables, as well as the use of single-sourcing selection carveouts in the interests...

Views of Responsible Officials and Planned Corrective Actions: This condition was primarily the result of a heavy reliance on external subject matter experts (SMEs) for technical aspects of programmatic workplan deliverables, as well as the use of single-sourcing selection carveouts in the interests of efficiency, that are provided for in the organization’s procurement policies & procedures. These instances of single sourcing nonetheless required additional levels of documentation and justification when in use, which was always not the case. Starting in August 2024, all program and compliance staff will be re-trained on federal procurement policy documentation and justification requirements. The Organization will also embark on concerted efforts to expand its pool of qualified and eligible SME vendors, to ensure more reliance on competitive bidding and minimize the future use single-source procurement. A comprehensive review of current Organizational policies and procedures will also be undertaken, to ensure that they are aligned and consistent with current federal procurement guidelines and requirements. Responsible Official: Peter Kiburi, Senior Director of Finance.

View Audit 321617

Corrective Action Plans

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