Corrective Action Plans

Finding 499127 (2023-006)

Significant Deficiency 2023

Nobles County

MN

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

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 Questioned Costs § 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

Questioned Costs HUD Housing Programs Significant Deficiency

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

Questioned Costs HUD Housing Programs Significant Deficiency

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

Questioned Costs Cash Management Reporting § 200.303

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

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

View Audit 321877

Finding 499083 (2023-002)

Significant Deficiency 2023

Mobile Housing Authority

AL

Eligibility HUD Housing Programs Significant Deficiency

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

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

View Audit 321867

Finding 499066 (2023-002)

Significant Deficiency 2023

Douglas County

MN

Questioned Costs Eligibility Reporting § 200.303

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

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

View Audit 321840

Finding 499028 (2023-003)

Significant Deficiency 2023

Central Minnesota Housing Partnership, Inc.

MN

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

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

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

View Audit 321819

Finding 499027 (2023-002)

Significant Deficiency 2023

Watonwan County

MN

Internal Control / Segregation of Duties Questioned Costs Reporting § 200.303

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

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

View Audit 321815

Finding 499006 (2023-001)

Significant Deficiency 2023

Thurston County Economic Development Council

WA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.430

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

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

View Audit 321792 Questioned Costs: $1

Finding 498965 (2023-001)

Significant Deficiency 2023

Sealaska Heritage Institute

AK

Special Tests & Provisions Questioned Costs Significant Deficiency

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

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

View Audit 321781

Finding 498920 (2023-001)

Significant Deficiency 2023

Regent at Maplewood, LLC Dba: the Seasons at Maplewood

MN

Questioned Costs HUD Housing Programs Significant Deficiency

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

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

View Audit 321756

Finding 498891 (2023-003)

Significant Deficiency 2023

Clifford W. Beers and Subsidiaries

CT

Procurement, Suspension & Debarment Questioned Costs Significant Deficiency § 200.318 § 200.326

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

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

View Audit 321699

Finding 498881 (2023-001)

Significant Deficiency 2023

United Voices for Newcomer Rights

NM

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

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

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

View Audit 321664

Finding 498865 (2023-002)

Significant Deficiency 2023

District of Columbia Primary Care Association

DC

Questioned Costs Procurement, Suspension & Debarment Eligibility

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

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

View Audit 321617

Finding 498838 (2023-002)

Material Weakness 2023

Flathead Community Health Center Inc. Dba Greater Valley Health Center

MT

Special Tests & Provisions Material Weakness Significant Deficiency

GVHC implemented the physical review and controls described in the 2022 audit response. Our efforts were largely successful as the missing application was the only failure of the physical audit process we put in place. However, a failure of our technology and billing software was revealed. Our plan ...

GVHC implemented the physical review and controls described in the 2022 audit response. Our efforts were largely successful as the missing application was the only failure of the physical audit process we put in place. However, a failure of our technology and billing software was revealed. Our plan it to: 1. Continue to provide frequent education and training for front-desk staff to assist in preparation and required completion of the sliding fee applications and proof of income. 2. Continue to identify patients who have exhausted their limited Medicaid benefits and will now qualify for sliding fee scale for dental work. 3. Continue to review reports identifying patients with no end date identified for their sliding fee scale. For identified accounts, determine correct date and enter in the system. 4. Continue 100% audit of all sliding fee scale applications for accuracy of calculation and presence of necessary paperwork. Provide direct feedback to staff when errors are identified. Integrate changes to billing software into the process when sliding fee scales are adjusted and posted. Run reports of sliding fee scale discounts and audit for correct calculation. Anticipated completion date: October 31, 2024 Contact person responsible for corrective action: Mary Sterhan, CEO

View Audit 321590

Finding 498815 (2023-002)

Significant Deficiency 2023

Argentum

VA

Procurement, Suspension & Debarment Significant Deficiency § 200.303

FINDINGS—FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2023‐001 Financial Reporting Recommendation: A thorough review of significant account reconciliations should be performed and an understanding of asset capitalization requirements under generally accepted accounting principles should be obtained. ...

FINDINGS—FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2023‐001 Financial Reporting Recommendation: A thorough review of significant account reconciliations should be performed and an understanding of asset capitalization requirements under generally accepted accounting principles should be obtained. We recommend that Argentum develop and implement a thorough review process to ensure proper financial reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Argentum reviews the financial statements monthly with the President & CEO, outsourced accounting team and senior management team. As part of that process, we review any assets to be capitalized each month to ensure proper recording. Name(s) of the contact person(s) responsible for corrective action: James Balda Planned completion date for corrective action plan: 09/30/2024

View Audit 321537

Finding 498729 (2023-005)

Significant Deficiency 2023

Brown County

MN

Internal Control / Segregation of Duties Questioned Costs Eligibility

Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MNSADM and 2305MN5MAP, 2023 Pass-Through Agency: Minnesota Department of Human Service...

Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MNSADM and 2305MN5MAP, 2023 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Number: 2305MN5ADM and 2305MNSMAP Award Period: Year-Ended December 31, 2023 Type of Finding: Signiflcant Deficiency in lnternal Control over Compliance Recommendation: lt is recommended the County increase review over casefiles and ensure that there are performed on a periodic basis throughout the year. 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 plan: Barb Dietz, Human Services Director Planned completion date for corrective action plan: December 31, 2024

View Audit 321408

Finding 498728 (2023-004)

Significant Deficiency 2023

Brown County

MN

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MNSADM and 2305MNSMAP, 2023 Pass-Through Agency: Minnesota Department of Human Service...

Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MNSADM and 2305MNSMAP, 2023 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2305MNSADM and 2305MN5MAP Award Period: Year-Ended December 31, 2023 Type of Finding: Significant Deficiency in lnternal Control over Compliance and Other Matters Recommendation: lt is recommended the County ensure that someone is disbursing the money received to the collaborative in a timely fashion. Explanation of disagreement with audit finding: There is no disagreement with the audit frnding. Action taken in response to finding: The County has implemented procedures and policies to have a person ensure payments are made to the Collaborative in a timely manner. Name of the contact person responsible for corrective action plan: Barb Dietz, Human Services Director Planned completion date for corrective action plan: December 31, 2024

View Audit 321408

Finding 498727 (2023-003)

Significant Deficiency 2023

Brown County

MN

Internal Control / Segregation of Duties Questioned Costs Reporting

Federal Agency: U.S. Department of Health and Human Servrces Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MN5ADM and 2305MN5MAP,2023 Pass-Through Agency: Minnesota Department of Human Services ...

Federal Agency: U.S. Department of Health and Human Servrces Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MN5ADM and 2305MN5MAP,2023 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2305MN5ADM and 2305MN5MAP Award Period: Year-Ended December 31, 2023 Type of Finding: Significant Deficiency in lnternal Control over Compliance Recommendation: It is recommended the County implement procedures to have a secondary person review the reports before they are submitted to the Minnesota Department of Human Services. 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 contac{ person responsible for corrective action plan: Barb Dietz, Human Services Director Planned completion date for corrective action plan: December 31, 2024

View Audit 321408

Finding 498720 (2023-002)

Significant Deficiency 2023

Aid Upstate

SC

Cash Management Reporting Significant Deficiency

Contact Person: Tracy Carr, Andrew Hall Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: Monthly grant reimbursement reports have a limited window before the due date. ...

Contact Person: Tracy Carr, Andrew Hall Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: Monthly grant reimbursement reports have a limited window before the due date. Additional requirements have added time to properly prepare reimbursement reports. Gathering all supporting documentation before submission has increased the time needed before the complete reimbursement request package is ready. Each member of the finance team is sharing in the responsibilities to meet the deadline. Completion Date: Beginning September 1, 2024 and thereafter.

View Audit 321407

Finding 498669 (2023-001)

Significant Deficiency 2023

Pinellas County Housing Authority

FL

HUD Housing Programs Questioned Costs Significant Deficiency

Allowability — Landlord Overpayments Housing Voucher Cluster Significant Deficiency in Internal Controls Other Matter to Reported Under the Uniform Control Condition: The Authority made numerous overpayments in HAP to landlords starting in the month of October2023. A variance in HAP disbursements wa...

Allowability — Landlord Overpayments Housing Voucher Cluster Significant Deficiency in Internal Controls Other Matter to Reported Under the Uniform Control Condition: The Authority made numerous overpayments in HAP to landlords starting in the month of October2023. A variance in HAP disbursements was noted by the Department of Housing and Urban Development (HUD), and upon further investigation by management it was determined that the overpayment to landlords was not caught by staff when the original disbursements were made. Auditor Recommendations: The Authority should work on recapturing overpaid funds from landlords that have current tenant agreements. The Authority should also monitor internal controls in place with the new software to make sure the accounting software is functioning properly. Action Taken: Upon discovering the overpayments to the landlords, HCV department promptly issued letters informing them of the excess Housing Assistance Payment (HAP) received. The letter instructed the landlords to either repay the overpaid amounts or have them recouped from future HAP payments. To date $142,824, has been successfully collected. Cherly LaRock is responsible for overseeing the collection process, and a monthly report on the status of these overpayments is submitted to the Board. Additionally, the data transferred from HAB to Yardi was thoroughly reviewed and any issues that were identified during review were promptly corrected. Finally, a Yardi consultant was engaged to assist in the evaluating the PCI-IA HAP process within Yardi. With the consultant's assistance, new procedures and controls have been established to streamline HAP payments and prevent future overpayments to landlords.

View Audit 321386 Questioned Costs: $1

Finding 498593 (2023-004)

Significant Deficiency 2023

Baltimore Corps, INC

DC

Questioned Costs Reporting Significant Deficiency § 200.512

Finding 2023-004: Significant Deficiency and Noncompliance Over Reporting Responsible Official’s Response and Corrective Action Plan We concur with the finding. We acknowledge the importance of adhering to the Federal guidelines for the submission of the reporting package within the mandated nine-mo...

Finding 2023-004: Significant Deficiency and Noncompliance Over Reporting Responsible Official’s Response and Corrective Action Plan We concur with the finding. We acknowledge the importance of adhering to the Federal guidelines for the submission of the reporting package within the mandated nine-month period. This finding is a result of the transition in the accounting team. To address this, BCI will implement the following actions: 1. Policies and Procedures Development: We will create and enforce comprehensive policies and procedures to ensure that audits are initiated and completed promptly. This will include detailed timelines and checkpoints to monitor progress throughout the audit process. In addition, we will adhere to a year end closing process that reconciles all significant accounts. 2. Training for Grant Administration: We will provide training for individuals responsible for administering Federal assistance programs within BCI. This training will cover essential aspects of grant administration, ensuring that our team is well-equipped to manage these programs efficiently and in compliance with Federal requirements. Planned Implementation Date of Corrective Action Plan September 1, 2024 Person Responsible for Corrective Action Plan Caryn York, Executive Director

View Audit 321331

Finding 498582 (2023-002)

Significant Deficiency 2023

Sunshine Community Health Center, Inc.

AK

Special Tests & Provisions Questioned Costs Eligibility

Federal Award Finding: 2023-002 Significant Deficiency in Internal Control and Noncompliance with Special Tests and Provisions in Application of Organization's Sliding Fee Discounts Policy Name and Contact Person: Gina McCullough, Chief Financial Officer 907-733-2273 gmccullough@sunshineclinic.org C...

Federal Award Finding: 2023-002 Significant Deficiency in Internal Control and Noncompliance with Special Tests and Provisions in Application of Organization's Sliding Fee Discounts Policy Name and Contact Person: Gina McCullough, Chief Financial Officer 907-733-2273 gmccullough@sunshineclinic.org Corrective Action: The Organization will take steps to ensure that staff are proficient in the completion of the application of the slide adjustments within the EHR system and are working to improve the review process of those adjustments applied to ensure compliance. Proposed Completion Date: June 30, 2024

View Audit 321325

Corrective Action Plans

Filters