Corrective Action Plans

Finding 384400 (2023-002)

Significant Deficiency 2023

Parc Developmental Homes, Inc., Project No 072-11104

IL

Internal Control / Segregation of Duties HUD Housing Programs Significant Deficiency

2023-002 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects – CFDA No. 14.155 Recommendation: Management should fully fund the reserve for replacements and also ensure the Corporation makes the required payment to the reserve for replacements on a monthly bas...

2023-002 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects – CFDA No. 14.155 Recommendation: Management should fully fund the reserve for replacements and also ensure the Corporation makes the required payment to the reserve for replacements on a monthly basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management will monitor to ensure the Corporation makes the required payments to the reserve on a monthly basis. Name(s) of the contact person(s) responsible for corrective action: Debbie Congdon Planned completion date for corrective action plan: In process

View Audit 297532

Finding 384399 (2023-001)

Significant Deficiency 2023

Parc Developmental Homes, Inc., Project No 072-11104

IL

Internal Control / Segregation of Duties Reporting Significant Deficiency

U.S. Department of Housing and Urban Development 2023-001 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects – CFDA No. 14.155 Recommendation: Responsibilities and duties should be segregated whenever possible. When this condition exists, management's and the...

U.S. Department of Housing and Urban Development 2023-001 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects – CFDA No. 14.155 Recommendation: Responsibilities and duties should be segregated whenever possible. When this condition exists, management's and the board’s close supervision and review of accounting information can help to prevent or detect errors and irregularities. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Because the number of staff is inadequate to fully segregate duties, we feel that management staff must have the ability to record disbursement transactions and reconcile bank accounts with the general ledger, particularly for training purposes and periods when there are staff vacancies. Financial resources are insufficient to hire the additional staff to allow for greater segregation of responsibilities. Name(s) of the contact person(s) responsible for corrective action: Debbie Congdon Planned completion date for corrective action plan: In process

View Audit 297532

Finding 384398 (2023-002)

Significant Deficiency 2023

Parc Place, Inc., Project No. 072-Hd112

IL

Internal Control / Segregation of Duties HUD Housing Programs Significant Deficiency

2023-002 Section 811 – New Construction – Capital Advance Program – Supportive Housing for Persons with Disabilities – CFDA No. 14.181 Recommendation: To establish proper internal control over security deposit refunds, the Corporation should design and implement the necessary procedures to ensure th...

2023-002 Section 811 – New Construction – Capital Advance Program – Supportive Housing for Persons with Disabilities – CFDA No. 14.181 Recommendation: To establish proper internal control over security deposit refunds, the Corporation should design and implement the necessary procedures to ensure the move-out notifications are provided to the accounting office in a timely manner and ensure the tenant's security deposit is processed and refunded within 30 days of the move-out date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management will monitor future move-outs to ensure the security deposits are processed and refunded within 30 days of the move-out date. Name(s) of the contact person(s) responsible for corrective action: Debbie Congdon Planned completion date for corrective action plan: In process

View Audit 297529

Finding 384397 (2023-001)

Significant Deficiency 2023

Parc Place, Inc., Project No. 072-Hd112

IL

Internal Control / Segregation of Duties Reporting Significant Deficiency

U.S. Department of Housing and Urban Development 2023-001 Section 811 – New Construction – Capital Advance Program – Supportive Housing for Persons with Disabilities – CFDA No. 14.181 Recommendation: Responsibilities and duties should be segregated whenever possible. When this condition exists, mana...

U.S. Department of Housing and Urban Development 2023-001 Section 811 – New Construction – Capital Advance Program – Supportive Housing for Persons with Disabilities – CFDA No. 14.181 Recommendation: Responsibilities and duties should be segregated whenever possible. When this condition exists, management’s and the board’s close supervision and review of accounting information can help to prevent or detect errors and irregularities. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Because the number of staff is inadequate to fully segregate duties, we feel that management staff must have the ability to record disbursement transactions and reconcile bank accounts with the general ledger, particularly for training purposes and periods when there are staff vacancies. Financial resources are insufficient to hire the additional staff to allow for greater segregation of responsibilities. Name(s) of the contact person(s) responsible for corrective action: Debbie Congdon Planned completion date for corrective action plan: In process

View Audit 297529

Finding 384396 (2023-001)

Significant Deficiency 2023

Parc Residential Options, Inc., Project No. 072-Hd045

IL

Internal Control / Segregation of Duties Reporting Significant Deficiency

U.S. Department of Housing and Urban Development 2023-001 Section 811 – New Construction – Capital Advance Program – Supportive Housing for Persons with Disabilities – CFDA No. 14.181 Recommendation: Responsibilities and duties should be segregated whenever possible. When this condition exists, mana...

U.S. Department of Housing and Urban Development 2023-001 Section 811 – New Construction – Capital Advance Program – Supportive Housing for Persons with Disabilities – CFDA No. 14.181 Recommendation: Responsibilities and duties should be segregated whenever possible. When this condition exists, management’s and the board’s close supervision and review of accounting information can help to prevent or detect errors and irregularities. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Because the number of staff is inadequate to fully segregate duties, we feel that management staff must have the ability to record disbursement transactions and reconcile bank accounts with the general ledger, particularly for training purposes and periods when there are staff vacancies. Financial resources are insufficient to hire the additional staff to allow for greater segregation of responsibilities. Name(s) of the contact person(s) responsible for corrective action: Debbie Congdon Planned completion date for corrective action plan: In process

View Audit 297525

Finding 384386 (2023-002)

Significant Deficiency 2023

Lutheran Family Services in the Carolinas and Affiliates

NC

Allowable Costs / Cost Principles Significant Deficiency

Finding 2023-002 Name of contact person: Kirby Nickerson Corrective action: Management agrees with the finding and will take corrective action to update policies and procedures to ensure that the accounting for nonroutine transactions comply with generally accepted accounting principles. Proposed...

Finding 2023-002 Name of contact person: Kirby Nickerson Corrective action: Management agrees with the finding and will take corrective action to update policies and procedures to ensure that the accounting for nonroutine transactions comply with generally accepted accounting principles. Proposed completion date: March 31, 2024

View Audit 297490

Finding 384369 (2023-001)

Significant Deficiency 2023

The New Reidsville Housing Authority

NC

HUD Housing Programs Eligibility Significant Deficiency

Finding 2023-001 – Housing Choice Voucher Tenant Files – Eligibility – Noncompliance & Significant Deficiency – Housing Choice Voucher Program – ALN 14.871 The New Reidsville Housing Authority suffered a tremendous loss with the passing of the Housing Choice Voucher (HCV) and Public Housing Special...

Finding 2023-001 – Housing Choice Voucher Tenant Files – Eligibility – Noncompliance & Significant Deficiency – Housing Choice Voucher Program – ALN 14.871 The New Reidsville Housing Authority suffered a tremendous loss with the passing of the Housing Choice Voucher (HCV) and Public Housing Specialists within weeks of one another and immediately before the start of the fiscal year. As a small housing authority, the deaths of two of the five office employees who had a combined 33 years of Authority experience left a significant void in knowledge and experience. Although the two employees were cross trained on each other’s jobs, no remaining employees were fully trained or capable of assuming those positions or responsibilities. In the immediate months after the passing of the employees, temporary and consultant labor was utilized until the Authority filled the vacant positions. Unfortunately, employee turnover among the new hires created further voids in HCV personnel during and after the fiscal year. Although a comprehensive review of all tenant and participant files to ensure completeness and compliance had begun prior to the audit, the sudden declining health and subsequent passing of the Executive Director hindered efforts even further. All new and existing housing personnel have received and continue to receive housing-related training and cross training on both the Public and Housing Choice Voucher programs. Comprehensive file review, written documentation of all tasks, and an office-wide evaluation of processes will continue as the employees become accustomed to their new positions. Corrective Action Plan: We concur with this finding. We are emphasizing the importance of accurate and complete tenant file information with our staff and within their new positions. We are confident these errors and oversights will not occur in the future. An extensive tenant file review was underway but was not completed at the time of the audit. All staff are being trained in their positions, and future cross-training and peer review processes are currently being put into practice to execute an added layer of review for all tenant files. Person Responsible: Samantha Shumaker, Interim Director Anticipated Completion Date: June 30, 2024

View Audit 297483

Finding 384368 (2023-002)

Significant Deficiency 2023

The New Reidsville Housing Authority

NC

Questioned Costs HUD Housing Programs Eligibility

Finding 2023-002 – Low Income Public Housing Tenant Files – Eligibility – Noncompliance & Significant Deficiency – Public and Indian Housing – ALN 14.850 The New Reidsville Housing Authority suffered a tremendous loss with the passing of the Housing Choice Voucher and Public Housing Specialists wi...

Finding 2023-002 – Low Income Public Housing Tenant Files – Eligibility – Noncompliance & Significant Deficiency – Public and Indian Housing – ALN 14.850 The New Reidsville Housing Authority suffered a tremendous loss with the passing of the Housing Choice Voucher and Public Housing Specialists within weeks of one another and immediately before the start of the fiscal year. As a small housing authority, the deaths of two of the five office employees who had a combined 33 years of Authority experience left a significant void in knowledge and experience. Although the two employees were cross trained on each other’s jobs, no remaining employees were fully trained or capable of assuming those positions or responsibilities. In the months after the passing of the PH Specialist, temporary labor was utilized until such time as the position was filled on a permanent basis. Although a comprehensive review of all tenant and participant files to ensure completeness and compliance had begun prior to the audit, the sudden declining health and subsequent passing of the Executive Director hindered efforts even further. All new and existing housing personnel have received and continue to receive housing-related software-specific training and cross training on both the Public and Housing Choice Voucher programs. Comprehensive file review, written documentation of all tasks, and an office-wide evaluation of processes will continue as the employees become accustomed to their new positions. Corrective Action Plan: We concur with this finding. We are emphasizing the importance of accurate tenant file information, data entry, and calculations with our staff in their new positions. We are confident these errors and oversights will not occur in the future. An extensive tenant file review was underway but was not completed at the time of the audit. A thorough tenant file audit to detect and correct any misstatements will begin as well. All staff are being trained in their positions, and future cross-training and peer review processes are currently being put into practice to execute an added layer of review for all tenant files. Person Responsible: Samantha Shumaker, Interim Director Anticipated Completion Date: June 30, 2024

View Audit 297483 Questioned Costs: $1

Finding 384359 (2023-002)

Significant Deficiency 2023

Eastern University

PA

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University concurs with the audit finding of partial compliance and recognizes the need to fully comply with GLBA regulations. The University has updated its written risk assessment. The University is working on improving safeg...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University concurs with the audit finding of partial compliance and recognizes the need to fully comply with GLBA regulations. The University has updated its written risk assessment. The University is working on improving safeguards, improving continuous monitoring provided from a vendor, implementing procedures for staff training which will be required for all employees, implementing procedures for assessing service providers, documenting an incident response plan, and completing a written annual status report to the board. Person Responsible for Corrective Action Plan: Eric McCloy, CIO Anticipated Date of Completion: April 30, 2024. Board report will be June 30, 2024.

View Audit 297474

Finding 384339 (2023-001)

Significant Deficiency 2023

Chestnut Health Systems, INC

IL

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.430

An automated reporting process of salaries through our payroll provider (ADP) has been established to eliminate the manual data entry of payroll amounts. This will eliminate the opportunity for errors in manual salary entries.

View Audit 297454 Questioned Costs: $1

Finding 384307 (2023-002)

Significant Deficiency 2023

Desert Community College District

CA

Student Financial Aid Reporting Significant Deficiency

The District concurs with the finding. The District will establish new procedures to verify student Enrollment Reporting Roster data before submission. This will allow the district to identify discrepancies and make necessary adjustments and to ensure accurate information is reflected in the NSLDS w...

The District concurs with the finding. The District will establish new procedures to verify student Enrollment Reporting Roster data before submission. This will allow the district to identify discrepancies and make necessary adjustments and to ensure accurate information is reflected in the NSLDS website.

View Audit 297438

Finding 384306 (2023-001)

Significant Deficiency 2023

Desert Community College District

CA

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

The District concurs with the finding. The District will establish procedures such as monthly reconciliation for return to Title IV calculations to identify the funds that need to be returned and ensure that funds are returned within 45 days.

View Audit 297438

Finding 384296 (2023-003)

Significant Deficiency 2023

Virginia Housing Development Authority

VA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their processes over annual and quality-control inspections to ensure they are completed timely and in compliance with HUD’s requirements. Explanation of disagreement with...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend the Authority review their processes over annual and quality-control inspections to ensure they are completed timely and in compliance with HUD’s requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has contracted the services of a third-party vendor to assist with completing overdue inspections. The Authority has also hired a Senior Quality Control Inspector to assist with the completion of overdue inspections. The Senior Quality Control Inspector will develop a Quality Control Plan by [date]. The Authority is currently making software upgrades to align with HUD’s National Standards for the Physical Inspection of Real Estate (NSPIRE). In addition, the Authority is assessing technology needs of inspectors and considering possible technological improvements. Currently, The Authority PCOs have begun to monitor late inspections monthly. PCOs work with the LHAs to develop a plan to address late inspections and include a due date. Name(s) of the contact person(s) responsible for corrective action: Yilla Smith, Director, Housing Opportunity Programs and Initiatives Planned completion date for corrective action plan: June 30, 2024.

View Audit 297428

Finding 384290 (2023-001)

Significant Deficiency 2023

Virginia Housing Development Authority

VA

Questioned Costs HUD Housing Programs Eligibility

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend that the Authority review their internal controls over the eligibility requirements to ensure all documentation is maintained at the time of recertification. We recommend the Authority review t...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879/14.EHV Recommendation: We recommend that the Authority review their internal controls over the eligibility requirements to ensure all documentation is maintained at the time of recertification. We recommend the Authority review their internal controls over the HAP process to ensure the correct amounts are paid each month. We recommend the Authority review their process for uploading data to PIC to ensure each recertification gets submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has begun the assessment, development and implementation of several internal controls to address recertification documentation, HAP processes, and PIC data submission to ensure compliance with Federal regulations. The Authority will develop and implement a quality control process on or before June 30, 2024, to ensure all documentation is maintained, signed and dated by all required parties at the time of certification. Currently, the Authority has developed a checklist system for each step of the recertification process. The checklist includes each step of the recertification process, along with due dates, and responsible entities. While not a Federal Requirement, the Authority did establish the discretionary policy to require housing specialists sign and date the Housing Information Forms. This policy was implemented after this audit finding and would not have been a requirement of the one file reviewed by the audit team. However, this step is included in the checklist process. The Authority is actively working to modify the electronic documentation and record retention system and process. Planned implementation of new electronic documentation and record retention processes is contingent on system updates managed by third party venders, however new written internal procedures are under development. The Authority will develop and implement a quality control process for the HAP process on or before June 30, 2024. This will include procedures for Program Compliance Officers (PCOs) and HCVP’s Accounting Team to work closely and coordinate to ensure each responsible person fully understands their roles and responsibilities. The Authority will implement monthly reviews of HAP payments, by the Housing Choice Voucher Program Compliance Manager. The Authority PCOs and/or accounting staff will follow the procedures for correcting any issues identified during the reviews. Over the past year, the Authority has created a System and Reporting Team that is now responsible for timely PIC submissions and addressing discrepancies and/or errors in the PIC and/or EIV system. By having a dedicated team, the Authority now exceeds the HUD requirement of submitting PIC data within 60 days of the effective date of any action. The Authority submits PIC monthly, performs monthly reviews of PIC data, and ensures staff addresses all fatal errors. In addition to these processes, the System and Reporting Team receives one on one training to address specific and challenging errors and discrepancies. Name(s) of the contact person(s) responsible for corrective action: Yilla Smith, Director, Housing Opportunity Programs and Initiatives Planned completion date for corrective action plan: June 30, 2024

View Audit 297428 Questioned Costs: $1

Finding 384283 (2023-001)

Significant Deficiency 2023

Trinity Bible College and Graduate School

ND

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Trinity Bible College and Graduate School has implemented policies and procedures to address GLBA compliance and is taking steps to address all exceptions noted. Person Responsible for Corrective Action Plan: Executive Vice Presid...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Trinity Bible College and Graduate School has implemented policies and procedures to address GLBA compliance and is taking steps to address all exceptions noted. Person Responsible for Corrective Action Plan: Executive Vice President Vaughn Jordan and Director of IT Matthew Johnson Anticipated Date of Completion: End of fiscal year 2024.

View Audit 297426

Finding 384267 (2023-002)

Significant Deficiency 2023

Upland Unified School District

CA

Subrecipient Monitoring Reporting Significant Deficiency

The District will ensure that supporting documentation is maintained and saved on the shared drive for all expenditure reporting. These records should be maintained for a period of three years from the date of submission of the reports to the awarding agency or pass-through entity.

View Audit 297403

Finding 384240 (2023-001)

Significant Deficiency 2023

Santa Ana Unified School District

CA

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

1) The HR Master is the source report that will be used to report FTEs. The report is accessible through the Human Resources module as a download request, and has been modified to reflect a column for actual FTEs with a disclaimer of what positions to exclude from that report to generate the correct...

1) The HR Master is the source report that will be used to report FTEs. The report is accessible through the Human Resources module as a download request, and has been modified to reflect a column for actual FTEs with a disclaimer of what positions to exclude from that report to generate the correct count and/or sum of FTE totals. This revised HR Master reports is being shared with staff who are responsible for fulfilling FTE count requests. Having everyone informed of what source document to use for FTE reporting ensures that errors in FTE reporting are averted and minimized. 2) Requests for FTE counts should come directly to the Position Control office. The request must include specific instructions as to what FTE counts are being requested and what the purpose for the request is. Where applicable, the requesting department must provide the Position Control office with an excerpt of the report delineating the type of FTE counts request for the pertinent figures to be provided. 3) If the Position Control office staff is out, Human Resources is responsible for providing FTE counts to the requesting department by generating the HR Master report above, for the date range being requested; a copy of that report must be saved in a centralized electronic repository (Business Shared drive) with the corresponding program label and date range of the data requested. The downloaded reports serving as supporting documentation will then be accessible for providing to auditors, upon request, and the source documentation must be retained in compliance with federal/state/local program retention policies (in this instance, for subsequent 3 years. 4) As an added preventative measure, the department tasked with filing reports should always seek supporting documentation (if not already provided), and save it on the designated shared drive. This practice ensures accessibility for new staff members responsible for a particular program, allowing them to review past actions. It is essential to consistently attach supporting documentation to the filed report to preserve the audit trail and record-keeping procedures. Management understands the importance of addressing these issues promptly and effectively to ensure the integrity of our internal controls and compliance processes. Our team is fully committed to implementing the corrective actions above.

View Audit 297392

Finding 384236 (2023-001)

Significant Deficiency 2023

Town of Easton (the Easton Utilities Commission)

MD

Internal Control / Segregation of Duties Significant Deficiency Equipment & Real Property Management § 200.303

2023-001 ReConnect Program: Rural Assistance – Assistance Listing No. 10.752 Recommendation: We recommend the Commission continue with established policies and procedures implemented in March 2023 over internal controls to ensure review and approval of inventory expenditures are properly documented...

2023-001 ReConnect Program: Rural Assistance – Assistance Listing No. 10.752 Recommendation: We recommend the Commission continue with established policies and procedures implemented in March 2023 over internal controls to ensure review and approval of inventory expenditures are properly documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In July 2022, EUC implemented a process in which the Supervisor of Velocity Plant Operations reviews material requisitions before the paper requisitions move to Accounting for entry into the accounting system. In March of 2023, EUC implemented the requirement for material requisitions to be initialed in order to document the review process. In May 2023, EUC moved to an electronic material requisition process which does not allow material requisitions to be available for Accounting to enter until they have been approved by a designated approver. All costs are additionally reviewed by the Senior Staff Accountant and the Chief Financial Officer before being submitted for reimbursement to the USDA. Name of the contact person responsible for corrective action: Steve J. Ochse Planned completion date for corrective action plan: Corrective action was taken March 2023.

View Audit 297379

Finding 384232 (2023-005)

Significant Deficiency 2023

Western Piedmont Regional Transit Authority

NC

Reporting Subrecipient Monitoring Significant Deficiency

Name of Contact Person: Scott Cook Corrective Action/Management's Response: WPRTA will implement policies and procedures to ensure reports are submitted timely. Proposed Completion Date: Immediately and ongoing

View Audit 297376

Finding 384231 (2023-003)

Significant Deficiency 2023

St. Luke's Home and St. Luke's Home Foundation

ND

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve funds or debt service coverage ratio for the federal program ....

Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve funds or debt service coverage ratio for the federal program .. Responsible Individual: Amy Kreidt, CEO/Administrator and Brenda Thronburg, Accountant Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the Organization's reserve fund and debt service coverage ratio is completed with formal documentation noting the review. Anticipated Completion Date: 3/31/2024

View Audit 297360

Finding 384230 (2023-001)

Significant Deficiency 2023

Tolleson Elementary School District No. 17

AZ

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Grant Assistance Listing Number: 84.425U Contact Person: Anita Percell, Executive Director of Business Services Anticipated Completion Date: June 30, 2024 P...

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Grant Assistance Listing Number: 84.425U Contact Person: Anita Percell, Executive Director of Business Services Anticipated Completion Date: June 30, 2024 Planned Corrective Action: The District agrees with the recommendation to review federal requirements over prevailing wage rates and develop policies and procedures to ensure compliance with the Davis‐Bacon Act. In addition, the district will seek training pertaining to federally funded procurement and develop procedures to ensure we stay in compliance. Page

View Audit 297353

Finding 384229 (2023-001)

Significant Deficiency 2023

Atmore Senior Housing, Inc.

AL

HUD Housing Programs Procurement, Suspension & Debarment Significant Deficiency

Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Atmore Senior Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Smith, Dukes & Buckalew, L.L.P. P.O....

Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Atmore Senior Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Smith, Dukes & Buckalew, L.L.P. P.O. Box 160427 Mobile, Alabama 36616 Audit Period: July 1, 2022 – June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS-MAJOR FEDERAL AWARDS PROGRAM AUDIT Finding: 2023-001 Name of Contact Person: Cindy Fulford, Senior Accounting Manager Corrective Action: The Project has made the additional deposits to the reserve for replacement account to properly fund the account. Management will thoroughly review all deposits to ensure that the required monthly deposits have been made to the replacement reserve account in the amount required by HUD. Completion Date: August 16, 2023

View Audit 297344

Finding 384221 (2023-002)

Significant Deficiency 2023

Hannibal-Lagrange University

MO

Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University is making progress to fully comply with GLBA regulations. The University is in process to improve safeguards, monitoring, training, vendor management, and updating the information security program. The Director of Co...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: The University is making progress to fully comply with GLBA regulations. The University is in process to improve safeguards, monitoring, training, vendor management, and updating the information security program. The Director of Computer Services presented a written report to the executive board in January 2024 and this will now be provided and presented annually. The University has been transitioning into a more stable financial situation and intends to continue to provide needed resources in security areas. Administrators are working to add budget lines specific and unique to improving campus cybersecurity issues, demonstrating a commitment to continual improvement in these areas. Person Responsible for Corrective Action Plan: Dr. Michelle Todd, Director of Computer Services, Computer Sciences, Chair, Professor of Information Sciences Anticipated Date of Completion: Spring, 2025

View Audit 297334

Finding 384217 (2023-004)

Significant Deficiency 2023

Hill Top Home of Comfort, Inc.

ND

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2023-004 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants CFDA #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund or financial covenant calculations...

Finding 2023-004 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants CFDA #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund or financial covenant calculations. Responsible Individuals: Gerry Leadbetter, Administrator Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the program’s reserve fund and financial covenant calculations is completed with formal documentation noting the review. The Business Office Manager will reconcile the bank statement and sign off on the bank statement, along with the Administrator for the USDA Loan Reserve Bank Account and on the financial covenant calculation worksheets. Anticipated Completion Date: 03/31/2024

View Audit 297302

Finding 384215 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of Monroe

LA

HUD Housing Programs Eligibility Significant Deficiency

Finding 2023-003 Public Housing Tenant Files - Eligibility - Rent Calculations Federal Program: Public Housing Program -ALN 14.850, Grant Year 2022 & 2023 Condition & cause: We reviewed seventy-five (75) Public Housing Tenant Files and noted seven (7) files not in compliance, or 9.3 %. We noted the ...

Finding 2023-003 Public Housing Tenant Files - Eligibility - Rent Calculations Federal Program: Public Housing Program -ALN 14.850, Grant Year 2022 & 2023 Condition & cause: We reviewed seventy-five (75) Public Housing Tenant Files and noted seven (7) files not in compliance, or 9.3 %. We noted the following discrepancies: • Two (2) files with no verification of income; • Two (2) files that relied on tenant declaration without documenting the reason for not obtaining third-party verification; and • Three (3) miscalculations of annual income. The income calculation and verification deficiencies were the result of employee errors and failure by the Agency to properly review and correct the errors. We were able to extrapolate the total potential misstatement and found it to be immaterial to the financial statements. However, due to the percentage of files not in compliance, we feel the Agency has a significant deficiency in this area. Corrective action planned: Monroe Housing Authority will continue to develop more effective processes for measuring, monitoring, and reducing errors in subsidy payments due to rent calculation and tenant underreporting of income. Implementations and strategies to include: • Resolution of income and rent issues identified in the report and communication to Tenants where applicable. • Development and implementation of an ongoing quality control review process of income at initial certification and re-examination to mitigate wage/income calculation errors to PHA and tenants by: o Hiring (1) FTE to perform quality control review of verification of income (upfront and/or a third party), and Tenant files upon new lease and re-examinations. o Developing a Tenant File Review checklist to document the result of file reviews. • Partner with the National Association of Housing and Redevelopment Officials (NAHRO) and other agencies, where applicable, to train staff on Public Housing Occupancy, Eligibility, Income and Rent training to accurately calculate Tenant Rent and avoid common errors in occupancy and eligibility functions in addition to understanding updates to the HUD-50058. Person responsible for corrective action: Mr. William Smart, Executive Director, Housing Authority of the City of Monroe Anticipated Completion Date: June 30, 2024

View Audit 297297

Corrective Action Plans

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