Corrective Action Plans

Finding 401872 (2023-001)

Significant Deficiency 2023

American Academy McAllister Institute of Funeral Service, Inc.

NY

Special Tests & Provisions Student Financial Aid Significant Deficiency

May 7, 2024 U.S. Department of Education American Academy McAllister Institute of Funeral Services, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Auditors: CohnReznick 1301 Avenue of the Americas New York, NY 10019 Audit period: October 1...

May 7, 2024 U.S. Department of Education American Academy McAllister Institute of Funeral Services, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Auditors: CohnReznick 1301 Avenue of the Americas New York, NY 10019 Audit period: October 1, 2022 to September 30, 2023 The findings from the fiscal year 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FINANCIAL STATEMENT AUDIT SIGNIFICANT DEFICIENCY 2023-001 Federal Direct Loan Program Student Recommendation: We recommended in the prior year that the Institute review and revise its procedures to put controls in place to ensure required notifications regarding Federal Direct Loan Program proceeds are provided to par-ticipating students. Action Plan: We agree with both the finding and the recommendation. In the Summer 2023 semester, a system was implemented to send out the required notifications regarding Federal Direct Loan Program proceeds that have been applied to a participating student's account. If the U.S. Department of Education has questions regarding this plan, please call Robert Graber at 732-547-9549.

View Audit 309770

Finding 401831 (2023-001)

Significant Deficiency 2023

Association of Prosecuting Attorneys, Inc.

DC

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Eligibility

Finding Reference Number: 2023-001 – Significant Deficiency – Lack of Documentation of Verification of Vendors Description of Finding: APA verified vendor was neither suspended nor debarred and staff confirmed as such in writing. However, they did not print and/or maintain a copy of the screenshot f...

Finding Reference Number: 2023-001 – Significant Deficiency – Lack of Documentation of Verification of Vendors Description of Finding: APA verified vendor was neither suspended nor debarred and staff confirmed as such in writing. However, they did not print and/or maintain a copy of the screenshot for files. This was inconsistent with APA written procedures. Statement of Concurrence (or Nonconcurrence): Management concurs that there was one instance wherein it did not print and maintain the verification screenshot for its files. Corrective Action: Management will review and update its procurement procedures to include a contract review checklist to be signed and dated by the preparer and approved by the contract signer (General Counsel, COO or CEO). Said checklist will include a specific reference to the date suspension and debarment were checked and will serve as primary documentary support which will be included in the vendor contract files. Contact Information: For further details or questions regarding this corrective action plan, please contact: Name: Steven Naugle

View Audit 309743

Finding 401797 (2023-001)

Significant Deficiency 2023

Housing Authority of the City of Charlestown

IN

HUD Housing Programs Significant Deficiency

June 14th, 2024 Findings- Major Federal Award Programs Audit- Corrective Action Plan (CAP) Public Housing Capital Fund finding 2023-001 For the year ended September 30th, 2023, the audit conducted by Cherry Bekaert LLP found Significant Deficiency, Nonmaterial Noncompliance- Obligation and Expenditu...

June 14th, 2024 Findings- Major Federal Award Programs Audit- Corrective Action Plan (CAP) Public Housing Capital Fund finding 2023-001 For the year ended September 30th, 2023, the audit conducted by Cherry Bekaert LLP found Significant Deficiency, Nonmaterial Noncompliance- Obligation and Expenditure Verification for public housing capital fund grant. The recommendation to implement controls to ensure capital grants are fully obligated by contractual agreements and expended within the required deadlines will be put into procedure by management of the Housing Authority. Management understands the importance of obligating and expending capital fund grants and to remedy the above deficiency, the Housing Authority will take an approach that will implement controls within regulations. -The Charlestown Housing Authority will review 24 CFR 905.306 {a) and 24 CFR 905.306 (F), and other regulations required for compliance with capital funds. - The Charlestown Housing Authority will implement internal checks and balances when obligatlng and expending funds for grants to ensure timely contracts and expenditures. - The Housing Authority will obligate capital funds prior to the 24-month deadline and expend the funds within the 48-month deadline. Responsible Person: Leigh Bowyer Completion Date of CAP: 6/13/24

View Audit 309699

Finding 401719 (2023-001)

Significant Deficiency 2023

Northern Regional Hospital

NC

Reporting Significant Deficiency Internal Control / Segregation of Duties

2023-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend that the Organization ensure there are proper procedures in place for future submissions and that a formal review occur by someone other than the preparer. Explanation of disagreement with audit finding: Th...

2023-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend that the Organization ensure there are proper procedures in place for future submissions and that a formal review occur by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Northern Regional Hospital will adopt a policy to review all expenditures recorded and all submissions of reporting prior to the submission being made. This review will be done by someone independent of completing the preparation and will be documented as such. Name(s) of the contact person(s) responsible for corrective action: Derek White, Director of Operational Finance Planned completion date for corrective action plan: 6/30/24 If the Department of Health and Human Services has questions regarding this plan, please call Derek White, Director of Operational Finance at 336-719-7283.

View Audit 309652

Finding 401662 (2023-001)

Significant Deficiency 2023

Troy University

AL

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

Corrective Action Plan The University will consistently follow established procedures used to perform Title IV refund calculations for students who withdraw after the 60 percent point that comply with Title 34 of the Code of Federal Regulations, Part 668.22. Anticipated Completion Date; June 2024 Co...

Corrective Action Plan The University will consistently follow established procedures used to perform Title IV refund calculations for students who withdraw after the 60 percent point that comply with Title 34 of the Code of Federal Regulations, Part 668.22. Anticipated Completion Date; June 2024 Contact Person(s): Alicia Bookout Associate Vice Chancellor, Financial Aid

View Audit 309623

Finding 401552 (2023-008)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

Questioned Costs HUD Housing Programs Significant Deficiency

Special Tests – Formula Income – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reviews their controls over submitting forms to HUD to ensure they contain accurate information. Explanation of disagreement with audit finding: There is no disagre...

Special Tests – Formula Income – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reviews their controls over submitting forms to HUD to ensure they contain accurate information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New CFO is preparing a Subsidy Calculation procedure so new staff will be aware of what is eligible and non-eligible transactions for preparing forms. Name(s) of the contact person(s) responsible for corrective action: Shannon Sterling and/or Carlton Brown

View Audit 309583 Questioned Costs: $1

Finding 401551 (2023-007)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking

Allowable Costs – Operating Fund – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority establishes procedures to properly reconcile the revolving fund cash account to ensure that cash and interprogram accounts are properly reported at the program lev...

Allowable Costs – Operating Fund – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority establishes procedures to properly reconcile the revolving fund cash account to ensure that cash and interprogram accounts are properly reported at the program level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: There are procedures in place to settle interfunds if possible. Name(s) of the contact person(s) responsible for corrective action: J Daniels and Shannon Sterling

View Audit 309583

Finding 401549 (2023-006)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

HUD Housing Programs Reporting Significant Deficiency

Reporting – PIC – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC assures a quality control review is performed on the submissions to ensure timely and accurate reporting. Explanation of disagreement with au...

Reporting – PIC – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC assures a quality control review is performed on the submissions to ensure timely and accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Following CLA’s recommendation, SVP of Housing Choice will audit a random sample of 50058 submissions to PIC each month to ensure that all submissions are accurate in PIC. Additionally, the Agency is transitioning to Yardi software which should eliminate many of the submission issues caused by current enterprise software. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

View Audit 309583

Finding 401545 (2023-004)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

HUD Housing Programs Eligibility Significant Deficiency

Special Tests – Top of the Waiting List – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the Authority reviews their standard procedures to ensure requests for informal reviews are granted and notified to the applicant within 30 days of the receipt of the ...

Special Tests – Top of the Waiting List – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the Authority reviews their standard procedures to ensure requests for informal reviews are granted and notified to the applicant within 30 days of the receipt of the request. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency hired a dedicated Hearing Officer following last year’s audit. Unfortunately, during the period in question, the Hearing Officer went on maternity leave and then subsequently left the position resulting in a delay in completing hearings and reviews. The Agency has since contracted with a 3rd party to conduct hearings and reviews in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

View Audit 309583

Finding 401543 (2023-003)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Special Tests – Annual HQS and Quality Control Inspections – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that management review their controls for conducting HQS biennial and quality control re-inspections and ensure compliance standards are met. Explanatio...

Special Tests – Annual HQS and Quality Control Inspections – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that management review their controls for conducting HQS biennial and quality control re-inspections and ensure compliance standards are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Previously, staff used a 90-day window to select Quality Control samples. Doing so caused some QC inspections to be completed past the regulatory time period. Going forward, staff are selecting the sample size from a 45-day window. This allows sufficient time to complete the QC inspection within the regulatory time period. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

View Audit 309583

Finding 401542 (2023-002)

Significant Deficiency 2023

Goodwill Industries of Greater Cleveland and East Central, Ohio, Inc.

OH

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

In 2024 the manual component of the calculations has been eliminated and all calculations of billing units are now completed using an Excel spreadsheet.

View Audit 309574 Questioned Costs: $1

Finding 401511 (2023-001)

Significant Deficiency 2023

Vita Nova, Inc.

FL

HUD Housing Programs Special Tests & Provisions Significant Deficiency

May 22, 2024 Vita Nova, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Name and address of independent public accounting firm: Holyfield & Thomas, LLC, 125 Butler Street, West Palm Beach, FL 33407 Audit period: For the fiscal year ended Septembe...

May 22, 2024 Vita Nova, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Name and address of independent public accounting firm: Holyfield & Thomas, LLC, 125 Butler Street, West Palm Beach, FL 33407 Audit period: For the fiscal year ended September 30, 2023. The findings from the September 30, 2023 schedule of findings and questions costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FEDERAL AWARD PROGRAM AUDITS U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT (HUD) 2023-001 Significant deficiency for the Continuum of Care Program, Youth Homeless Demonstration Program (YHDP) – Assistance Listing No. 14.267. Recommendation: We recommend that when the rent reasonableness worksheet reflects that the proposed rent is not reasonable, the lease contracts should not be approved, and negotiations should begin with the landlord to get the rent within the reasonable range. To ensure this step is taken, we recommend that the Program Director review, and initial each rent reasonableness worksheet before the lease is signed for the client tenant. Action Taken: In September 2023, Vita Nova reassigned the YHDP program to the oversight of a new Director of Housing. In late October 2023, the new Director identified the specified issue as part of a detailed file review and immediately took action to correct this error. New lease agreements were established with both tenants as of November 2, 2023, using rent reasonable rates. Vita Nova has since taken additional steps to ensure this and other similar errors do not reoccur as follows: • Housing Case Managers are not authorized to complete rent reasonableness worksheets. This procedure is completed directly by the Director of Housing. • If the requested rent is found to not be reasonable, the Director of Housing initiates negotiations with the landlord. • If rent reasonable rates are not able to be negotiated, the lease will not be signed. • The Director of Housing approves all lease contracts and related rental costs. • Peer file reviews are conducted by Housing Case Managers (HCM) on a monthly basis, and review sheets are submitted to the Director of Housing. The Director of Housing then completes a follow-up internal review and returns any comments to the respective HCM(s) with a correction date for any needed revisions within 7 days. If the U.S. Department of Housing and Urban Development (HUD) has any questions regarding this plan, please call Kelly Landrum, Chief Operating officer at (561) 517-0040. Respectfully, Kelly A. Landrum Chief Operating Officer

View Audit 309564

Finding 401463 (2023-001)

Significant Deficiency 2023

Housing Authority of the County of Merced

CA

HUD Housing Programs Reporting Significant Deficiency

1. Finding 2023-001 a. Comments on the Finding and Each Recommendation: The Authority concurs with the finding. Additionally, we agree with the recommendations. b. Action(s) Taken or Planned on the Finding To address the significant deficiency in HQS re-inspections, we will immediately implement a s...

1. Finding 2023-001 a. Comments on the Finding and Each Recommendation: The Authority concurs with the finding. Additionally, we agree with the recommendations. b. Action(s) Taken or Planned on the Finding To address the significant deficiency in HQS re-inspections, we will immediately implement a streamlined scheduling and tracking system to ensure timely re-inspections and compliance with 24 CFR Part 982. Additionally, we have since replaced the staff member responsible for the non-compliance and reassigned these responsibilities to another department staff member to better allocate resources and talent to prioritize HQS re-inspections.

View Audit 309554

Finding 401449 (2023-101)

Significant Deficiency 2023

Central Arizona Shelter Services, Inc.

AZ

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles

Management agrees with this finding. CASS does not have any subrecipients. However, if CASS has subrecipients in the future, comprehensive written policies and procedures will be in place to ensure all subrecipients payments are made on a timely basis and all required documentation and communication...

Management agrees with this finding. CASS does not have any subrecipients. However, if CASS has subrecipients in the future, comprehensive written policies and procedures will be in place to ensure all subrecipients payments are made on a timely basis and all required documentation and communications will be retained as result of missing or inaccurate information in the subrecipient’s drawdown requests prior to remittance.

View Audit 309553

Finding 401430 (2023-001)

Significant Deficiency 2023

Harrison County, Mississippi

MS

Reporting Significant Deficiency Program Income

CORRECTIVE ACTION PLAN 2023-001 Item 2023-001 Significant Deficiency in Internal Control over Compliance Program Coronavirus State and Local Fiscal Recovery Fund, Assistance Listing 21.027 Compliance Requirement Reporting Criteria The U.S. Department of Treasury SLFRF Compliance and Report...

CORRECTIVE ACTION PLAN 2023-001 Item 2023-001 Significant Deficiency in Internal Control over Compliance Program Coronavirus State and Local Fiscal Recovery Fund, Assistance Listing 21.027 Compliance Requirement Reporting Criteria The U.S. Department of Treasury SLFRF Compliance and Reporting Guidance requires the County prepare quarterly submissions of the Project and Expenditure Report. The 2023 Compliance Supplement identifies multiple Key Line Items in the report, including cumulative expenditures and current period expenditures. Internal control should be established and maintained to provide reasonable assurance that these requirements are complied with by submitting the reports accurately. Condition For the fiscal year under audit, the Project and Expenditure Report reported cumulative expenditures as program income, and the total obligation was reported as cumulative expenditures before the amounts had actually been spent. This was noted on the first two quarterly reports, but the last two quarterly reports were corrected. Cause The County followed a process for reviewing the reports and understanding program requirements; however, the new and emerging nature of the program and related guidance limited the internal knowledge necessary to identify the errors. Effect Required reports submitted to the Federal Agency contained inaccuracies to identified key elements. Recommendation We recommend that the County expand its review process for key reports to consider if new or emerging funding merits additional staff training or the engagement of outside assistance. PERSON RESPONSIBLE FOR CORRECTION ACTION: Becky Haynes, County Auditor CORRECTIVE ACTION PLANNED: We agree with the finding and have initiated discussions to provide training and implement procedures to ensure compliance. We have made these changes during the fiscal year, where the last two quarterly reports were properly stated . ANTICIPATED COMPLETION DATE: September 30, 2023. See prior year finding 2022-001.

View Audit 309550

Finding 401413 (2023-001)

Significant Deficiency 2023

Boulder Crest Foundation

VA

Cash Management Reporting Significant Deficiency § 200.61

Corrective Action Plan For the year ended December 31, 2023 Identifying Number: 2023-001 Finding: The overall process for tracking federal funds spent and the reimbursement process is a manual process performed by one department. The Foundation lacks formal policies for reimbursement and timely...

Corrective Action Plan For the year ended December 31, 2023 Identifying Number: 2023-001 Finding: The overall process for tracking federal funds spent and the reimbursement process is a manual process performed by one department. The Foundation lacks formal policies for reimbursement and timely review of calculations throughout the year. Corrective Action Taken or Planned: Management is actively working with the awarding agencies to fully understand the compliance requirements and implement appropriate policy and process to administer the federal programs. Management is reviewing the current procedures and formalizing the process for tracking and reporting of federal funds. The responsible individuals for the plan are the Chief Executive Officer and Controller.

View Audit 309540

Finding 401406 (2023-001)

Significant Deficiency 2023

Community Mental Health Partnership of Southeast Michigan

MI

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency § 200.332

Corrective Action Plan Finding: 2023-001 – Communications with Subrecipients (repeat comment) Condition: Contracts with subrecipients did not include portions of required disclosures. Corrective Action Plan: CMHPSM added an additional staff position, Regional Project Assistant, to do additional w...

Corrective Action Plan Finding: 2023-001 – Communications with Subrecipients (repeat comment) Condition: Contracts with subrecipients did not include portions of required disclosures. Corrective Action Plan: CMHPSM added an additional staff position, Regional Project Assistant, to do additional work on contracts. This position was added after the April 2023 Board meeting to assist with contract reviews. The position reports up to CJ Witherow.

View Audit 309525

Finding 401401 (2023-001)

Significant Deficiency 2023

Neighborhood Healthsource

MN

Reporting Significant Deficiency

Finding # 2023-001 Condition The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the annual Federal Financial Report within 90 days of the required reporting end date. Response The Fede...

Finding # 2023-001 Condition The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the annual Federal Financial Report within 90 days of the required reporting end date. Response The Federal Financial Report was filed late in 2023 due to an extended vacancy of a key finance position. The position has now been filled and should not be an issue going forward. Responsible Party Curt Engels, Finance Director Estimated Completion On-going

View Audit 309519

Finding 401370 (2023-001)

Significant Deficiency 2023

Lake Area Improvement Corporation

SD

Significant Deficiency Internal Control / Segregation of Duties

Action Plan for Addressing Audit Finding on Intermediary Relending Program (IRP) Funds 1. Introduction Purpose: To address the audit finding regarding the Intermediary Relending Program (IRP) funds that were not fully insured by the Federal Deposit Insurance Corporation (FDIC) and to implement cor...

Action Plan for Addressing Audit Finding on Intermediary Relending Program (IRP) Funds 1. Introduction Purpose: To address the audit finding regarding the Intermediary Relending Program (IRP) funds that were not fully insured by the Federal Deposit Insurance Corporation (FDIC) and to implement corrective actions to ensure compliance with U.S. Department of Agriculture requirements. Scope: This action plan focuses on ensuring that all reserves and cash in the IRP revolving fund are fully insured or collateralized with U.S. Government obligations, as outlined in 7 CFR Part 4274.332(b). 2. Audit Findings Summary Finding: IRP funds on deposit with a local financial institution were not fully insured by the FDIC. Questioned Costs: None. Criteria: U.S. Department of Agriculture requires all reserves and cash in the IRP revolving fund to be fully insured or collateralized. Cause: Management was aware of the requirement but inadvertently overlooked it due to an influx of cash received during the year. Effect: Inadequate internal controls over compliance could result in noncompliance with grantor agency requirements and jeopardize LAIC’s continued participation in the program. Recommendation: Management should be aware of all program requirements and take appropriate action to correct deficiencies. 3. Action Steps Action Step 1: Review and Understand Program Requirements Finding Addressed: Lack of full insurance or collateralization of IRP funds. Description: Conduct a comprehensive review of 7 CFR Part 4274.332(b) and related requirements to ensure both team members and board of directors understand the compliance obligations. Responsible Person: Executive Director Resources Needed: Access to relevant regulatory documents, training materials. Timeline: Complete review and training by July 15, 2024. Success Criteria: All relevant staff have reviewed the regulations and can demonstrate understanding of the requirements. Action Step 2: Implement Monitoring and Controls Finding Addressed: Inadequate internal controls over compliance. Description: Develop and implement internal controls to monitor the insurance and collateralization status of IRP funds regularly. Responsible Persons: Executive Director and Administrative Assistant Resources Needed: Financial monitoring and monthly reviews. Timeline: Controls implemented by July 31, 2024. Success Criteria: Regular monitoring reports indicating compliance with insurance and collateralization requirements. Action Step 3: Secure Additional Insurance or Collateralization Finding Addressed: IRP funds not fully insured by the FDIC. Description: Ensure all IRP funds on deposit are either fully insured by the FDIC or collateralized with U.S. Government obligations. Responsible Persons: Executive Director and Administrative Assistant Resources Needed: Coordination with local financial institutions, legal advice if needed. Timeline: Complete by September 1, 2024. Success Criteria: Documentation showing that all IRP funds are fully insured or collateralized. Action Step 4: Regular Reporting to Board of Directors Finding Addressed: Inadequate internal controls over compliance. Description: Establish a regular reporting through monthly financials to update governance on the status of IRP fund compliance. Responsible Person/Team: Administrative Assistant Resources Needed: Reporting template, monthly meeting schedules. Timeline: Start regular reporting by September 26, 2024 Success Criteria: Monthly reports submitted to board of directors, with compliance status and any issues addressed. 4. Monitoring and Reporting Monitoring Process: Progress will be monitored through regular monthly meetings and monthly internal audits. Reporting Frequency: Monthly reports to board of directors. Responsible Person/Team: Executive Director and Administrative Assistant 5. Review and Adjustments Review Schedule: The action plan will be reviewed quarterly to assess progress and make necessary adjustments. Adjustment Process: Adjustments will be based on feedback from internal audits and progress reports, with updates approved by board of directors. 6. Conclusion Summary: This action plan outlines the steps to address the audit finding regarding the IRP funds and to ensure full compliance with USDA requirements. Commitment: LAIC is committed to implementing these actions to enhance internal controls, ensure compliance, and maintain continued participation in the IRP program. _________________________________________________________ Brooke Rollag, Executive Director

View Audit 309466

Finding 401348 (2023-003)

Significant Deficiency 2023

Marygrove Non-Profit Housing Corporation II

MI

Special Tests & Provisions Allowable Costs / Cost Principles HUD Housing Programs

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-003 – Replacement Reserve Account Finding Type. Immaterial noncompliance; Significant def...

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-003 – Replacement Reserve Account Finding Type. Immaterial noncompliance; Significant deficiency in internal control over compliance (Special Tests and Provisions) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (CFDA# 14.157) Condition. The replacement reserve balance was not maintained in an interest-bearing account. Effect. As a result of this condition, the reserve for replacements account was underfunded during 2023 as no interest was earned. Plan. Management agrees with finding 2023-003 and has developed the following plan. Management will request a waiver from HUD for the interest-bearing requirement on the project’s reserve account due to the fees charged by Bank of America, which will exceed any interest earned on the account. Contact Person Responsible for This Corrective Action: David DeFrain, Vice President of Finance Anticipated completion date: June 30, 2024

View Audit 309440

Finding 401347 (2023-002)

Significant Deficiency 2023

Marygrove Non-Profit Housing Corporation II

MI

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-002 – Replacement Reserve Withdrawals Finding Type. Immaterial noncompliance; Significant...

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-002 – Replacement Reserve Withdrawals Finding Type. Immaterial noncompliance; Significant deficiency in internal control over compliance (Special Tests and Provisions) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (CFDA# 14.157) Condition. Certain capital expenditures, amounting to $6,135, were requested and reimbursed from the reserve for replacements after already having been requested and reimbursed from the reserve. Management corrected this oversight and transferred the duplicate reimbursed funds from the Project's operating account to the reserve for replacements in May 2024. Effect. As a result of this condition, the reserve for replacements account was underfunded during 2023. Plan. Management agrees with finding 2023-002 and has developed the following plan. All invoices submitted for reserve disbursement requests will be compared to those on prior withdrawals. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2024

View Audit 309440

Finding 401346 (2023-001)

Significant Deficiency 2023

Marygrove Non-Profit Housing Corporation II

MI

Allowable Costs / Cost Principles Eligibility HUD Housing Programs

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance; Sig...

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 – Eligibility - Tenant File Documentation Finding Type. Immaterial noncompliance; Significant deficiency in internal control over compliance (Eligibility) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (CFDA# 14.157) Condition. Out of a sample of 8 tenant files, it was noted: 1. One out of eight instances where a tenant EIV was not run within 90 days of move in; 2. One out of eight instances where a tenant's saving and checking accounts were not verified by a third party; 3. One out of eight instances where the incorrect balance was used to determine the tenant's checking account balance; 4. Two out of eight instances where a copy of the tenant's security deposit was not maintained in the tenant file; Effect. As a result of this condition, certain tenant files did not contain all required supporting documentation. Plan. Management agrees with finding 2023-001. All files are to be inspected in the current fiscal year to ensure compliance with HUD regulations. File maintenance will be competed following each move in and annual recertification. In addition to one-on-one training, the housing administrator has signed up for additional training including a WebEx on annual recertification and a basic EIV course. Additional training sessions are forthcoming. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2024

View Audit 309440

Finding 401344 (2023-003)

Significant Deficiency 2023

Marygrove Non-Profit Housing Corporation

MI

HUD Housing Programs Allowable Costs / Cost Principles Significant Deficiency

Corrective Action Plan Marygrove Nonprofit Housing Corp, dba Theresa Maxis Apartments Project No. 044-11119 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-003 – Required Replacement Reserve Deposits Finding Type. Immaterial noncompliance; Significant ...

Corrective Action Plan Marygrove Nonprofit Housing Corp, dba Theresa Maxis Apartments Project No. 044-11119 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-003 – Required Replacement Reserve Deposits Finding Type. Immaterial noncompliance; Significant deficiency in internal control over compliance (Special Tests and Provisions) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (ALN# 14.157)  Section 8 Housing Assistance Payments (ALN#14.195) Condition. Out of 12 required monthly deposits, 3 deposits were not made in the correct amount as approved by HUD. Effect. As a result of this condition, the reserve for replacements account was underfunded during 2023. Plan. Management agrees with finding 2023-003 and has developed the following plan. The site accountant will validate the accuracy of the reserve payment in the month prior to the end of the project’s fiscal year. Any shortfalls will be corrected by either (a) a payment request to Berkadia for mortgaged projects with escrow accounts, or (b) with a correcting payment to the reserve account maintained by the managing agent. Contact Person Responsible for This Corrective Action: Laura Maisevich, Senior Housing Manager Anticipated completion date: June 30, 2024

View Audit 309439

Finding 401343 (2023-002)

Significant Deficiency 2023

Marygrove Non-Profit Housing Corporation

MI

Special Tests & Provisions Allowable Costs / Cost Principles HUD Housing Programs

Corrective Action Plan Marygrove Nonprofit Housing Corp, dba Theresa Maxis Apartments Project No. 044-11119 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-002 – Timely Payment of Mortgage Balance Finding Type. Immaterial noncompliance, Significant def...

Corrective Action Plan Marygrove Nonprofit Housing Corp, dba Theresa Maxis Apartments Project No. 044-11119 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-002 – Timely Payment of Mortgage Balance Finding Type. Immaterial noncompliance, Significant deficiency in internal controls over compliance (Special Tests and Provisions) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (ALN# 14.157) Condition. Out of 12 monthly payments on the Project's HUD insured mortgage payable, that are due each fiscal year, 1 payment was late, resulting in a late fee. Effect. As a result of this condition, the mortgage was not paid on time. While there was ultimately payment of the delinquent monthly balance, the lack of effective internal controls could lead to future significant noncompliance. Plan. Management agrees with finding 2023-002 and has developed the following plan. Mortgage invoices are now sent to two accounts payable employees, as well as a monitored inbox, to ensure timely processing. Contact Person Responsible for This Corrective Action: David DeFrain, Vice President of Finance Anticipated completion date: June 30, 2024

View Audit 309439

Finding 401322 (2023-001)

Significant Deficiency 2023

Housing Authority of the City of Jonesboro

GA

HUD Housing Programs Subrecipient Monitoring Eligibility

CORRECTIVE ACTION PLAN Finding 2023-001 - Housing Choice Voucher Tenant File s - Eligibility - Int ernal Control over Tenant Files - Non compliance & Significant Deficiency - Housing Choice Voucher Program - ALN 14.871 CORRECTIVE ACTION PLAN: 1. All of Jonesboro HCV Specialists and HCV Mana...

CORRECTIVE ACTION PLAN Finding 2023-001 - Housing Choice Voucher Tenant File s - Eligibility - Int ernal Control over Tenant Files - Non compliance & Significant Deficiency - Housing Choice Voucher Program - ALN 14.871 CORRECTIVE ACTION PLAN: 1. All of Jonesboro HCV Specialists and HCV Manager took a Nan McKay Workshop, HCV and Public Housing Rent Calculation Course. The dates of this course were May 7, 2024 - May 9, 2024. 2. JHA has discussed the issues of the 13 files discovered during the audit and spoken to staff about making sure they know what to do. Additional training and discussion of the errors has been scheduled for next Wednesday, May 29, 2024. This was delayed due to JHA recently hiring a new full time HCV Specialist and JHA wanted to ensure all caseworkers were present and had proper training on the specific errors we incurred during the audit. 3. Peer Review - Janet Wiggins was the only one reviewing caseworker files. Janet reviews about 20 files per month. JHA has had discussion and will be expanding the number of files that are reviewed on a monthly basis. Janet Wiggins will still randomly select files as she has been doing, but each caseworker will also audit up to 5 random files from other caseworkers throughout the month to double the amount of files per month that are reviewed, which will also help us catch errors if they exist. PERSON RESPONSIBLE: N an M cKay / Paul G. Wright / Janet Wiggins ANTICIPATED COMPLETIO N DATE ( See Below ): 1. #l from above was Completed May 7, 2024 through May 9, 2024 by a Trainer from Nan McKay. 2. #2 was discussed in a staff meeting on May 29, 2024. I, Paul Wright, went over the 13 files with staff and discussed the importance of making sure that we ensure proper documentation is in the file whether full time status of children or EIV that is used to make a computation, we ensure that we are using the appropriate and proper amount of check stubs and that they are consecutive, we discussed making sure that our calculations themselves are correct if weekly, bi-weekly,monthly or annual income is used. We discussed making sure if working on a file that already has had an annual that we make sure any interim is inserted properly and we pay the correct amount on our HAP check run. 3. #3 was discussed during staff meeting on May 29, 2024 by Paul G. Wright and Janet Wiggins. I had previously spoken with HCV Manager, Janet Wiggins, and Assistant HCV Manager, Nora Schmidt, about increasing the number of files that we audit on a monthly basis. Janet examines each file when she performs a move or transfer, which is typically over 20 per month. All caseworkers will review 5 files per month from another caseworker for accuracy and make sure everything looks and is correct. This will about double the amount of files that are being reviewed on a monthly basis. This is being implemented currently and will continue moving forward. All the steps listed in the corrective action plan have been addressed and staff has been advised and trained. Peer review has begun and will continue moving forward to help increase the number of files that audited/ reviewed on a monthly basis. It is with these efforts that JHA hopes to reduce and hopefully eliminate the errors that we received during the 2023 Fiscal Year Audit.

View Audit 309426

Corrective Action Plans

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