Corrective Action Plans

Finding 499322 (2023-002)

Significant Deficiency 2023

PA

Internal Control / Segregation of Duties Cash Management Reporting

2023-002 U.S. Department of Housing and Urban Development– Assistance Listing # 14.239 Home Investment Partnerships Program Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The condition reported as item 2023-001 above also applies to the Township’s internal control o...

2023-002 U.S. Department of Housing and Urban Development– Assistance Listing # 14.239 Home Investment Partnerships Program Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The condition reported as item 2023-001 above also applies to the Township’s internal control over compliance with the requirements of federal programs. Planned Corrective Action: The Township acknowledges the potential effects of this condition. However, for such a small organization as we are, the Township believes that it would not be cost beneficial to hire additional personnel to provide for adequate segregation of duties at this time. The Board of Supervisors continues to closely monitor the financial transaction processes and has several control procedures in place to provided for as much segregation of duties as possible given the size of the Township’s staff. The following are the control procedures over federal programs that the Township currently has in place: • One Township supervisor is involved in the day-to-day activities of the federal program as he serves as the project manager for all Township projects. • The three Township supervisors personally review and formally approve the list of all bills proposed for payment (including those for federal programs and projects) at their monthly public meetings. In addition, the Township has a requirement that all checks require two authorized signatures, one of which must be a Township supervisor. • Each month’s complete financial statements are reviewed by the three supervisors at the monthly public meetings, and grant activities and updates are presented and discussed as well.

View Audit 322158

Finding 499321 (2023-001)

Significant Deficiency 2023

Broad Top Township

PA

Internal Control / Segregation of Duties Reporting Significant Deficiency

2023-001 Internal Control over Financial Reporting - Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The small size of the Township’s office staff does not allow for adequate segregation of duties. Standard practice regarding the design of a good system of internal cont...

2023-001 Internal Control over Financial Reporting - Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The small size of the Township’s office staff does not allow for adequate segregation of duties. Standard practice regarding the design of a good system of internal controls relies at least in part on a system of checks and balances accomplished by having different employees performing various functions within the accounting cycle. These checks and balances are not possible when the same person performs all of an interrelated series of tasks. Although the Township does have some compensating controls in place, there are still a number of situations where one person is responsible for all aspects of a transaction. Planned Action: The Township acknowledges the potential effects of this condition. However, for such a small organization as we are, the Township believes that it would not be cost beneficial to hire additional personnel in order to provide for adequate segregation of duties. As a compensating control, the Board continues to closely monitor the financial transaction process and has a number of control procedures in place to provide for the segregation of duties as much as possible given the size of the Township’s staff.

View Audit 322158

Finding 499311 (2023-004)

Significant Deficiency 2023

Town of Randolph, Ma

MA

Equipment & Real Property Management Procurement, Suspension & Debarment HUD Housing Programs

Root Cause Analysis: 1. Lack of awareness of federal requirements. Corrective Action(s): 1. Create and maintain detailed equipment logs for all federally funded equipment purchases and obtain training on the proper procedures for equipment record keeping, emphasizing the importance of these logs in ...

Root Cause Analysis: 1. Lack of awareness of federal requirements. Corrective Action(s): 1. Create and maintain detailed equipment logs for all federally funded equipment purchases and obtain training on the proper procedures for equipment record keeping, emphasizing the importance of these logs in federal fund management. 2. Action Item: o Description: Reach out to our Federal grants liaison for recommendation on best training to attend and when they will occur in FY25. Create and maintain a detailed equipment log for all federally funded equipment purchased. o Responsible Person/Department: Director Finance for the Randolph Public Schools. o Expected Completion Date: Training via DESE PD opportunities. Equipment log will be created by 9/2024. o Description:The equipment log will be created and maintained by the Director of Finance for the Randolph Public Schools. o Responsible Person/Department: Director Finance for the Randolph Public Schools. o Expected Completion Date: Log will be created by September 2024.

View Audit 322147

Finding 499309 (2023-002)

Significant Deficiency 2023

Town of Randolph, Ma

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Issue Date: May 23,2024 Audit Reference: 23-002 ARPA P&E Reports Non-Compliance Issue: Intemal Control over Compliance - Significant Deficiency Root Cause: There was a misunderstanding betu'een the Town and its engaged consultants related to the Town's allocation of ARPA funds regarding which entity...

Issue Date: May 23,2024 Audit Reference: 23-002 ARPA P&E Reports Non-Compliance Issue: Intemal Control over Compliance - Significant Deficiency Root Cause: There was a misunderstanding betu'een the Town and its engaged consultants related to the Town's allocation of ARPA funds regarding which entity was fulfilling the reporting requirements to Treasury. The consultants were filing state related reports and it was assumed that the firm was also fiting the required reports to Treasury. Corrective Action(s): l. Action ltem: a. The Town will be responsible for filing required reports to Treasury. b. The accounting office and the Director of Finance/Town Accountant will be responsible for this task. c. The required report for period ending 3131124 was filed timely.

View Audit 322147

Finding 499308 (2023-001)

Significant Deficiency 2023

Town of Randolph, Ma

MA

Allowable Costs / Cost Principles Significant Deficiency

Issue Date: May 23,2024 Audit Reference: 23-001 FEMA Vouchers signatures Non-Compliance Issue: Intemal Control over Compliance - Significant Deficiency Root Cause: There was a change in process implemented related to the form in which documents were being retained. The Town has a tax abatement progr...

Issue Date: May 23,2024 Audit Reference: 23-001 FEMA Vouchers signatures Non-Compliance Issue: Intemal Control over Compliance - Significant Deficiency Root Cause: There was a change in process implemented related to the form in which documents were being retained. The Town has a tax abatement program with senior volunteers that was used to assist in scanning hardcopy documents to electronic documents for paperless records retention. Corrective Action(s): l. Action ltem: a. The Town will no longer use volunteers for this task. An individuat lamiliar with the documents will scan the hardcopy records for retention ensuring that the documents are scanned completely and labeled clearly so that they can be easily identified, if needed. b. The accounting office and the Director ofFinance/Town Accountant will be responsible for the oversight of this improvement. c. This change in process has already been put in place.

View Audit 322147

Finding 499294 (2023-001)

Significant Deficiency 2023

Port Graham Village Council

AK

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.317 § 200.318 § 200.327

Finding 2023-001 Internal Control over Procurement Name of Contact Person: Francis Norman Corrective Action: Procurement Policy will be updated and followed Proposed Completion Date: 7/18/2024

View Audit 322114

Finding 499288 (2023-001)

Significant Deficiency 2023

The Housing Authority of the City of Key West, Florida

FL

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2023-001 - HQS Enforcements and Annual HQS Inspections Housing Voucher Cluster - Assistance Listing No. 14.871 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in ...

2023-001 - HQS Enforcements and Annual HQS Inspections Housing Voucher Cluster - Assistance Listing No. 14.871 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In response to the HOS enforcement and annual inspections finding for the Housing Authority of the City of Key West, FL 12-31-2023 audit, management has completed the following items in order to address the issue: • Hired a new HCV Program Manager, • Procured a new outside HCV inspection contractor, • Provided current staff training on HCV program HOS requirements, • Adopted the recommendation from our independent auditors to have the Assistant to the Director of Housing sample 10% of the HCV recertification files monthly to ensure compliance with federal regulations and housing quality standards - files that are found to be out of compliance will be reported to the Director of Housing & Executive Director. In addition, the following items will be done: • Consider changing the administrative plan to prohibit time extensions beyond 30 days, thereby requiring abatement of HAP effective the 31st day in all cases, • Update the job description of the Assistant to the Director of Housing & change the title of the position to Assistant to the Director of Housing/Compliance Specialist. Name(s) of the contact person(s) responsible for corrective action: Randy Sterling, Executive Director Planned completion date for corrective action plan: October 31, 2024.

View Audit 322102 Questioned Costs: $1

Finding 499276 (2023-003)

Significant Deficiency 2023

Town of Warwick

NY

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency

With regard to Section III Federal Award Findings and Questioned Costs, 2023-03, Suspension or Debarment, whereby you identified a concern in that the Town of Warwick did not have sufficient internal controls of Federal suspension and debarment verification, please be advised of the following correc...

With regard to Section III Federal Award Findings and Questioned Costs, 2023-03, Suspension or Debarment, whereby you identified a concern in that the Town of Warwick did not have sufficient internal controls of Federal suspension and debarment verification, please be advised of the following corrective action, which is effective immediately.It is the policy of the Town of Warwick to refrain from entering into contracts with (1) business entities, which are subject to Suspension or Debarment from Federal or State contracts, or (2) business entities, which utilize subcontractors which are subject to Suspension or Debarment from Federal or State contracts. Going forward, all RFPs will include the requirement that all bids specifically include language stating that the subject vender attests that it is not subject to Suspension or Debarment from Federal or State contracts, nor will it utilize any subcontractors subject to Suspension or Debarment from Federal or State contracts. When bids are opened and considered, the Town Clerk will check to ensure that the necessary language is included in the bid. The Town Clerk will also verify that the bidder, and any named subcontractor is not subject to Suspension or Debarment from Federal or State contracts. The Town will not consider any bid that lacks this necessary language. In the event that the Town Clerk identifies that a bidder, despite its attestation, is subject to Suspension or Debarment from Federal or State contracts, the Town Clerk will so inform that bidder. In the event that the Town enters into a contract, that is not subject to the bidding process, the Town Attorney shall review all proposed contracts includes language that the relevant party attests that it is not it is not subject to Suspension or Debarment from Federal or State contracts, nor will it utilize any subcontractors subject to Suspension or Debarment from Federal or State contracts. Should the relevant party become subject to Suspension or Debarment from Federal or State contracts, or utilize any subcontractors subject to Suspension or Debarment from Federal or State contracts, such would be grounds for termination of the subject contract.

View Audit 322086

Finding 499262 (2023-002)

Significant Deficiency 2023

Inupiat Community of the Arctic Slope

AK

Reporting Significant Deficiency

Finding 2023-002 Late Reporting and Noncompliance with Reporting Requirements Significant Deficiency Name of Contact Person: Lisa Taylor, CPA, ICAS Comptroller Corrective Action: ICAS has hired a grants manager that will administer grants and contracts within ICAS. Additional oversight should pre...

Finding 2023-002 Late Reporting and Noncompliance with Reporting Requirements Significant Deficiency Name of Contact Person: Lisa Taylor, CPA, ICAS Comptroller Corrective Action: ICAS has hired a grants manager that will administer grants and contracts within ICAS. Additional oversight should prevent late reporting. Proposed Completion Date: December 1, 2024.

View Audit 322071

Finding 499257 (2023-003)

Significant Deficiency 2023

Civic Arts

TX

Procurement, Suspension & Debarment Significant Deficiency

Management concurs with the recommendation as proposed and has implement a process to document comparison of all vendors meeting the covered transaction threshold to the System for Award Management (SAM) on a regular basis and when a new vendor is entered into the accounting system. This has been im...

Management concurs with the recommendation as proposed and has implement a process to document comparison of all vendors meeting the covered transaction threshold to the System for Award Management (SAM) on a regular basis and when a new vendor is entered into the accounting system. This has been implemented effective immediately.

View Audit 322061

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

Corrective Action Plans

Filters