Corrective Action Plans

Finding 41567 (2022-001)

Material Weakness 2022

Community Health Centers of Central Wyoming, Inc.

WY

Material Weakness Reporting Significant Deficiency

2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: This finding is the same finding from the previous year?s audit regarding our contractual adjustments and bad debt being understated. Our response then ? Community Health Centers of Central Wyoming will record patient...

2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: This finding is the same finding from the previous year?s audit regarding our contractual adjustments and bad debt being understated. Our response then ? Community Health Centers of Central Wyoming will record patient refunds payable at year end as a liability rather than as a credit to accounts receivable and will also record prepaid dental services as deferred revenue rather than a credit to accounts receivable. In calculating a bad debt allowance, Community Health Centers of Central Wyoming will not extend the period that the bad debt allowance is based on beyond six months ? is still valid for this issue. Our financials were updated after reporting for Provider Relief Funds which resulted in understatement of the contractual allowance. We have corrected the issue of calculating the allowance as of March 31, 2022. We will correct the lost revenue on the next PRF reporting cycle. Anticipated completion date: March 31, 2022 Contact person responsible for corrective action: Kevin Lanham, CFO

View Audit 45228

Finding 41553 (2022-002)

Significant Deficiency 2022

Community Action Marin

CA

Reporting Significant Deficiency

Corrective Action: All grant and contract agreements and their associated reporting requirements and filing deadlines will be centralized, maintained, and properly reviewed to esure that periodic reporting requirements and filing deadlines are always met in a timely manner. Person Responsible: Chi...

Corrective Action: All grant and contract agreements and their associated reporting requirements and filing deadlines will be centralized, maintained, and properly reviewed to esure that periodic reporting requirements and filing deadlines are always met in a timely manner. Person Responsible: Chief Financial Officer Timing for Implementation: Immediate

View Audit 46367

Finding 41505 (2022-001)

Significant Deficiency 2022

Infectious Diseases Society of America

VA

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Department of Health and Human Services 2022-001 Protecting and Improving Health Globally ? Assistance Listing No. 93.318 Recommendation: We recommend IDSA implement procedures to ensuring costs are allowable and time is allocated properly to the grant. Explanation of disagreement with audit findin...

Department of Health and Human Services 2022-001 Protecting and Improving Health Globally ? Assistance Listing No. 93.318 Recommendation: We recommend IDSA implement procedures to ensuring costs are allowable and time is allocated properly to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Out of approximately 30 employees billing to the CDC grant, the audit review uncovered two errors in our calculation of billable payroll. ? An employee received a pay increase outside of our normal annual raise process, due to a promotion. We did not pick up the higher pay rate, and therefore, undercharged the grant for the final six months of the grant that ended on September 29, 2022. The salary was corrected for the calculations of the new grant year that began on September 30, 2022. ? An employee received vacation pay as part of her final paycheck, when she left IDSA. We incorrectly billed CDC for the pro-rated portion of the vacation pay. The net of these two errors was an undercharge to the CDC grant billing of $549. Planned completion date for corrective action plan: N/A - we believe that our policies and review are adequate to insure accurate billings to the grant. Name of the contact person responsible for corrective action: Barton Groh, Vice President of Finance & Administration If the Department of Health and Human Services has questions regarding this plan, please call Barton Groh, Vice President of Finance & Administration at 703-299-0108.

View Audit 38593

Finding 41497 (2022-003)

Significant Deficiency 2022

Columbia College Dba Columbia College Hollywood

CA

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

The institution does not dispute this finding. This was an isolated incident and no further instances of this nature occurred. There was a personnel change in the staff member responsible for completing refund calculations. The automated notice for this particular student's withdrawal had been sent ...

The institution does not dispute this finding. This was an isolated incident and no further instances of this nature occurred. There was a personnel change in the staff member responsible for completing refund calculations. The automated notice for this particular student's withdrawal had been sent to the prior employee, who by that time was no longer with the college. The new individual did not see the notice and was not aware that a refund calculation was required. There was a brief window when all notifications were switched to the new staff member, and this particular status change was processed during that transition. The refund has now been processed and all unearned aid for the term has been returned. We have two personnel trained on completing/reviewing R2T4 calculations to serve as a checks-and-balance within the department. This finding was reviewed with all staff members in the department to ensure compliance moving forward.

View Audit 38278

Finding 41496 (2022-002)

Significant Deficiency 2022

Columbia College Dba Columbia College Hollywood

CA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

The institution does not dispute the finding. This was an isolated incident and no further instances of this nature occurred. There was a delay in processing the refund as the R2T4 was completed just before our holiday break. The staff member that handles the return in COD would have completed it up...

The institution does not dispute the finding. This was an isolated incident and no further instances of this nature occurred. There was a delay in processing the refund as the R2T4 was completed just before our holiday break. The staff member that handles the return in COD would have completed it upon return to the office in early January but then she was out of the office for longer than anticipated due to symptoms resulting from a positive diagnosis of Covid. Upon her return, she completed the refund and it posted to the ledger 19 days late. Each position within the department has now been cross trained so that any one staff member's extended absence does not impact the operation and our ability to maintain regulatory compliance. This finding as reviewed with all staff members in the department to ensure compliance moving forward.

View Audit 38278

Finding 41495 (2022-001)

Significant Deficiency 2022

Columbia College Dba Columbia College Hollywood

CA

Questioned Costs Student Financial Aid Eligibility

The institution does not dispute this finding. This was an isolated incident and no further instances of this nature occurred. The staff member mistakenly thought that a PLUS denial from a prior academic year was for the academic year in question, thereby awarding additional Unsub for an independent...

The institution does not dispute this finding. This was an isolated incident and no further instances of this nature occurred. The staff member mistakenly thought that a PLUS denial from a prior academic year was for the academic year in question, thereby awarding additional Unsub for an independent student. Once the error was found, the ineligible Unsub amount was returned. Staff was provided proper training with respect to reviewing documentation to confirm accuracy of awards being packaged. This finding was reviewed with all staff members in the department to ensure compliance moving forward.

View Audit 38278 Questioned Costs: $1

Finding 41444 (2022-001)

Significant Deficiency 2022

Southwest Kansas Area Agency on Aging, INC

KS

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency § 200.318 § 200.319 § 200.326

CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 Southwest Kansas Area Agency on Aging, Inc. respectfully submits the following corrective action plan for the fiscal year ended September 30, 2022. Name and address of independent public accounting firm: Kennedy McKee and Company LLP P...

CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 Southwest Kansas Area Agency on Aging, Inc. respectfully submits the following corrective action plan for the fiscal year ended September 30, 2022. Name and address of independent public accounting firm: Kennedy McKee and Company LLP P.O. Box 1477 Dodge City, Kansas 67801 Audit period: October 01, 2021 through September 30, 2022 The findings from the September 30, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS AND QUESTIONED COSTS - Major Federal Award Programs Audit U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2022-001 Title III Aging Cluster Title III B Supportive Services CFDA 93.044 Title III C Nutrition Services CFDA 93.045 Title III C Nutrition Services Incentive CFDA 93.053 Grant Period: Year ended September 30, 2022 Condition: The Organization did not have a written procurement policy to properly implement all the requirements of 2 CFR Section 200.318 through 200.326 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Criteria: In accordance with 2 CFR Section 200.319(c), non-federal entities must have written procedures for procurement transactions. Such policy should incorporate all requirements within 2 CFR 200.318 through 200.326 of the Uniform Guidance. Cause: The Organization?s procurement policy does not incorporate all the requirements of 2 CFR Section 200.318 through 200.326 of the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program compliance requirements. Southwest Kansas Area Agency on Aging, Inc. Corrective Action Plan February 9, 2023 Recommendation: Management should continue to develop comprehensive written policies and procedures to administer all federal programs. Current written policies should be evaluated for inclusion of and compliance with Uniform Guidance requirements. Grantee Response: Management agrees with the finding and will adopt written policies to comply with Uniform Guidance requirements. If the Oversight Agency has questions regarding this plan, please call Rick Schaffer at (620) 225-8230. Sincerely yours, Rick Schaffer Executive Director 236 San Jose Drive Dodge City, KS 67801

View Audit 36909

Finding 41441 (2022-004)

Significant Deficiency 2022

Freeman Regional Health Services

SD

Equipment & Real Property Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303 § 200.313

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Equipment and Real Property Management Finding Summary: Federal-funded equipment and real property is not disti...

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Equipment and Real Property Management Finding Summary: Federal-funded equipment and real property is not distinguished separately from non-federal-funded equipment and real property within the Facility's fixed asset listing. Responsible Individuals: Phillip Husher, CFO, Freeman Regional Health Services Corrective Action Plan: Freeman Regional Health Services will review our fixed asset policies and procedures in order to identify expenditures for Federal-Funded equipment. We will update our current fixed asset listing to identify federally funded equipment. Anticipated Completion Date: December 31st, 2023.

View Audit 37685

Finding 41438 (2022-004)

Significant Deficiency 2022

City and Borough of Wrangell, Alaska

AK

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-004 ? Deadline for Federal Single Audit ? Noncompliance and Internal Control Over Compliance ? Significant Deficiency Corrective Action Plan The Borough will work with external auditors to have a financial statement draft prior to their fieldwork. Beginning balance reconciliations and y...

Finding 2022-004 ? Deadline for Federal Single Audit ? Noncompliance and Internal Control Over Compliance ? Significant Deficiency Corrective Action Plan The Borough will work with external auditors to have a financial statement draft prior to their fieldwork. Beginning balance reconciliations and year-end adjustments will be complete by September 5th, and a final trial balance and general ledger will be submitted to the external auditors. Expected Completion Date: Fiscal year 2023

View Audit 37635

Finding 41437 (2022-003)

Significant Deficiency 2022

Housing Authority of the City of Galveston, Texas

TX

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-003 Housing Choice Vouchers -Assistance Listing No. 14.871 - Special Tests - HQS Inspections Recommendation: The Authority should imple...

2022-003 Housing Choice Vouchers -Assistance Listing No. 14.871 - Special Tests - HQS Inspections Recommendation: The Authority should implement processes to ensure all HQS biennial and re-inspections are completed timely and that there is proper documentation of approved extensions and abatements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: During this time GHA was short staffed and had a large number of initial inspections which are necessary to execute HAP contracts timely and to ensure adequate lease up. This coupled with the requirement for routine regular inspections created a large number of inspections at one time. During that time reports were run monthly to identify inspection requirement dates. Currently, GHA is caught up with inspections and inspections are three months ahead. Going forward, GHA will run the inspection reports twice a month to ensure inspection dates are not missed. Name(s) of the contact person(s) responsible for corrective action: Maria Godwin Planned completion date for corrective action plan: This is complete. GHA has hired and trained a new inspector and all inspections are current and three months ahead. GHA will run the inspection ad-hoc report twice a month to ensure inspection dates are tracked thoroughly. GHA will continue to conduct and submit all inspections timely.

View Audit 37744

Finding 41436 (2022-002)

Significant Deficiency 2022

Housing Authority of the City of Galveston, Texas

TX

Questioned Costs HUD Housing Programs Eligibility

2022-002 Housing Choice Vouchers - Assistance Listing No. 14.871 - Eligibility Recommendation: The Authority should implement processes to ensure...

2022-002 Housing Choice Vouchers - Assistance Listing No. 14.871 - Eligibility Recommendation: The Authority should implement processes to ensure that all documentation is received and that the correct inputs are being accurately reported on the HUD-50058. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: During this time GHA's HCV program was extremely short staffed and GHA was using temporary employees to assist in program delivery. Specifically, the department suffered two staff- members deaths, one family emergency that removed dedicated staff from this task, and two resignations. GHA has hired and trained new staff to ensure that recertifications are being performed annually for all tenants as applicable. The annual recertifications will be three months ahead by the end of 2023. Name(s) of the contact person(s) responsible for corrective action: Maria Godwin Planned completion date for corrective action plan: GHA has hired and trained new staff and will conduct additional refresher training courses for existing staff focusing on accuracy. This will be complete by August 2023. GHA annual recertification's are currently being completed timely and will be three months ahead by the end of 2023.

View Audit 37744 Questioned Costs: $1

Finding 41435 (2022-001)

Significant Deficiency 2022

Housing Authority of the City of Galveston, Texas

TX

HUD Housing Programs Reporting Significant Deficiency

2022-001 Housing Choice Vouchers - Assistance Listing No. 14.871 - Reporting Recommendation: The Authority should implement processes to ensure...

2022-001 Housing Choice Vouchers - Assistance Listing No. 14.871 - Reporting Recommendation: The Authority should implement processes to ensure the HUD-50058's are submitted into the PIC system timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: During this time GHA's HCV program was extremely short staffed and GHA was using temporary employees to assist in program delivery. Specifically, the department suffered two staff- members deaths, one family emergency that removed dedicated staff from this task, and two resignations. GHA has hired and trained new staff and increased the form 50058 submissions times to daily. GHA also provided training to existing staff on the importance of timely completion of form 50058. There is now dedicated back-up staff to assist with this important task. Name(s) of the contact person(s) responsible for corrective action: Maria Godwin Planned completion date for corrective action plan: This is complete. GHA has hired and trained both new and existing staff in form 50058 submission. Form 50058's are submitted daily.

View Audit 37744

Finding 40156 (2022-001)

Significant Deficiency 2022

B-K Health Center, Inc. (d/b/a Nepa Community Health Care)

PA

Reporting Internal Control / Segregation of Duties Significant Deficiency

B-K Health Center Inc. d/b/a NEPA Community Health Care (the Organization) respectfully submits the following corrective action plan for the year ending September 30, 2022. Audit Finding Reference: 2022-001 ? Significant Deficiency in Internal Control ? Reporting Condition/Context: The Organizat...

B-K Health Center Inc. d/b/a NEPA Community Health Care (the Organization) respectfully submits the following corrective action plan for the year ending September 30, 2022. Audit Finding Reference: 2022-001 ? Significant Deficiency in Internal Control ? Reporting Condition/Context: The Organization was required to submit the Annual Federal Financial Report by July 30, 2022 and the report was submitted on September 1, 2022. This is not a statistically valid sample. Recommendation: The Organization should implement procedures to identify and ensure compliance with all reporting requirements for the program. Planned Corrective Action: Both the CEO and CFO will add the reporting deadlines to their calendars to ensure timely filing. The CFO will prepare the document for reporting and the CEO will certify documents. A monthly update will be given to the finance committee as to reports filed for the prior month. Name of Contact Person: Kristen Follert, CEO Anticipated Completion Date: 1/19/2023

View Audit 37315

Finding 40148 (2022-002)

Significant Deficiency 2022

Chippewa Lutheran Housing Corporation

PA

Questioned Costs Internal Control / Segregation of Duties HUD Housing Programs

2022-002 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Unapproved replacement reserve withdrawal. Condition: The Corporation mistakenly withdrew an unapprove...

2022-002 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Unapproved replacement reserve withdrawal. Condition: The Corporation mistakenly withdrew an unapproved amount from the replacement reserve account in February 2022. Questioned costs: 7,796 Context: Upon receiving proper HUD withdrawal approval, the Corporation mistakenly duplicated the amount of the withdrawal. Upon discover of this mistake, these funds were deposited back into the replacement reserve account in February 2022. Recommendation: The Corporation should ensure all replacement reserve amounts are properly reviewed and approved prior to withdrawal occurs. Action taken in response to finding: Managements acknowledges this finding and is taking steps to correct. Management has counseled HUD building management on the need for appropriate process for handling of the replacement reserve account funds in the future. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 53437 Questioned Costs: $1

Finding 40147 (2022-001)

Significant Deficiency 2022

Chippewa Lutheran Housing Corporation

PA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC t...

2022-001 Federal agency: U.S. Department of Housing and Urban Development Federal program title: Supportive Housing for the Elderly Section 202 CFDA Number: 14.157 Criteria or specific requirement: Expired Project Rental Assistance Contract (PRAC). Condition: The Corporation did not renew the PRAC timely. Context: The PRAC expired September 30, 2021, and was not renewed until February 14, 2022. Recommendation: The Corporation should ensure the PRAC is renewed on a timely basis annually. Action taken in response to finding: Managements acknowledges this finding and is taking steps to correct. Management has counseled HUD building management on the need for timely submissions of proposed budgets and contract completion. A master schedule has been set up and all budget submissions will now be reviewed by the Finance Department prior to submission. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 53437

Finding 40116 (2022-001)

Material Weakness 2022

Cordova Community Medical Center

AK

HUD Housing Programs Material Weakness Reporting

2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Use of the new methodology for calculating net patient revenue for all subsequent reporting periods. Anticipated completion date: Complete as of May 11, 2023 Contact person responsible for corrective action: Denna Sta...

2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: Use of the new methodology for calculating net patient revenue for all subsequent reporting periods. Anticipated completion date: Complete as of May 11, 2023 Contact person responsible for corrective action: Denna Stavig, Director of Finance

View Audit 51015

Finding 40112 (2022-001)

Significant Deficiency 2022

Midmichigan Health Services

MI

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

Finding Number: 2022-001 Condition: The Company has a sliding fee discount policy that is based on income and family size in place. However, management did not follow the Company's policy for all patients during the period under audit. Planned Corrective Action: The Company will maintain a master r...

Finding Number: 2022-001 Condition: The Company has a sliding fee discount policy that is based on income and family size in place. However, management did not follow the Company's policy for all patients during the period under audit. Planned Corrective Action: The Company will maintain a master roster of all eligible and approved sliding fee patients. On a monthly basis the listing of patients who have received a sliding fee adjustment will be compared and verified against the master roster of all eligible and approved sliding fee patients. Any patient who received a sliding fee adjustment and is not on the master roster will be researched and corrected. Contact person responsible for corrective action: William E. Collin Anticipated Completion Date: 6/1/2023

View Audit 51007

Finding 40110 (2022-001)

Significant Deficiency 2022

Therapeutic Living Services, Inc. and Affiliates

NM

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

TLS has implemented the following procedures to ensure a copy of lease agreements as supporting documents for rental assistance payments. The new CoC/HUD Programs Manager has been auditing all rental assistance clients to ensure each client has the proper documentation. TLS utilizes a flowchart to d...

TLS has implemented the following procedures to ensure a copy of lease agreements as supporting documents for rental assistance payments. The new CoC/HUD Programs Manager has been auditing all rental assistance clients to ensure each client has the proper documentation. TLS utilizes a flowchart to document all new rental assistance intakes. In addition, there are checklists in every file and a spreadsheet was created to track all documentation.

View Audit 51005

Finding 40101 (2022-001)

Significant Deficiency 2022

Access Community Health Network

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

Access Community Health Network respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 ? December 31, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consisten...

Access Community Health Network respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 ? December 31, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U. S. Department of Health and Human Services (HHS) ? Health Resources and Services Administration (HRSA) 2022-001 - Allowable Costs Health Center Program Cluster ? Assistance Listing Numbers 93.224/93.527 Recommendation: We recommend management refine its processes and controls over indirect costs to more closely monitor whether indirect costs being allocated to a grant are based on its current federally negotiated indirect cost rate. This may include identifying the expiration date of the current indirect cost rate during the grant budget preparation process and requesting an extension before the rate expires or preparing and submitting a new indirect cost rate proposal at the earliest opportunity. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has refined our processes and controls over indirect costs to more closely monitor whether indirect costs being allocated to a grant are based on its current federally negotiated indirect cost rate. We have identified the expiration date of the current indirect cost rate during the grant budget preparation process and have submitted a new indirect cost rate proposal. Name(s) of the contact person(s) responsible for corrective action: Karen Wesley, Director of Internal Control and Fiscal Management Planned completion date for corrective action plan: Completed. If the HHS has questions regarding this plan, please call Karen Wesley, Director of Internal Control and Fiscal Management, at 773-368-0280. ACCESS COMMUNITY HEALTH NETWORK

View Audit 45527

Finding 40098 (2022-001)

Significant Deficiency 2022

Aids Foundation Houston, Inc.

TX

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

September 26, 2023 AIDS Foundation Houston, Inc. dba Allies in Hope respectfully submits the following corrective action plan in response to our single audit results for the year ended December 31, 2022. Carr, Riggs & Ingram, LLC Two Riverway, 15th Floor Houston, Texas 77056 Audit Period: Fiscal Yea...

September 26, 2023 AIDS Foundation Houston, Inc. dba Allies in Hope respectfully submits the following corrective action plan in response to our single audit results for the year ended December 31, 2022. Carr, Riggs & Ingram, LLC Two Riverway, 15th Floor Houston, Texas 77056 Audit Period: Fiscal Year January 1, 2022 ? December 31, 2022 The finding from the schedule of findings and questioned costs dated September 26, 2023, is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2022-001 Internal Controls over Reporting (Significant Deficiency) Recommendation: The Foundation review its controls and ensure that the copies of the submission emails be part of the Foundation?s grant records. Corrective Action: Effective 10/1/23 we are using a shared system to house and track our reporting to our funders and will save emails sent to funders in this shared system in order to document the submission of the reports. Responsible Parties: Chief Financial Officer, Chief Program Officer, and Director of Compliance Date Expected to be Corrected: 10/1/23 If the U.S. Department of Housing and Urban Development has any questions regarding this plan, please contact Nicholas Williams, CFO at 713-623-6796 x285. Sincerely yours, Nicholas Williams Nicholas Williams Chief Financial Officer

View Audit 48673

Finding 40097 (2022-001)

Significant Deficiency 2022

Advanced Functional Fabrics of America, Inc.

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles

3/28/2023 Board of Directors of Advanced Functional Fabrics of America, Inc.: Advanced Functional Fabrics of America, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: AAFCPAs 160 Federal St. 16th ...

3/28/2023 Board of Directors of Advanced Functional Fabrics of America, Inc.: Advanced Functional Fabrics of America, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: AAFCPAs 160 Federal St. 16th floor Boston, MA 02110 Audit period: July 1, 2021 ? June 30, 2022 The findings from the June 30, 2022, 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 FINDINGS SIGNIFICANT DEFICIENCY 20X2-001 Recommendation: AFFOA should develop and implement policies and controls for monitoring year end transactions as well as funding from the Federal and state governments to identify, document and track accurate expenditures for each year. Action Taken: We concur with the recommendation, particularly as it pertains to credit card transactions. During the current fiscal year, we have increased training and provide weekly reminders to all AFFOA employees that expense reports, including those related to credit card purchases, are to be submitted to Accounting in a timely manner (within 30 days of travel). In addition, we are reconciling the ?Clearing? account monthly. This account bridges the credit card payments and the employees? expense reports. With a monthly reconciliation of this account, we are better able to follow up with employees with overdue expense reports, and we will have a precise basis for any necessary accruals related to credit card purchases at year-end. If the Board has questions regarding this plan, please call Don Nadreau, CFO, at 603-702-3639. Sincerely yours, Don Nadreau, Chief Financial Officer

View Audit 45742

Finding 40066 (2022-005)

Significant Deficiency 2022

Legal Services Alabama, INC

AL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2022-005 ? Internal Control over Reporting (Significant Deficiency) Corrective Action: LSA will resume a review and approval of every grant report and document the review as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@al...

Finding 2022-005 ? Internal Control over Reporting (Significant Deficiency) Corrective Action: LSA will resume a review and approval of every grant report and document the review as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@alsp.org

View Audit 45011

Finding 40065 (2022-004)

Significant Deficiency 2022

Legal Services Alabama, INC

AL

Eligibility Significant Deficiency

Finding 2022-004 ? Eligibility (Significant Deficiency and Non-compliance) Corrective Action: Legal Services Alabama services provided services related to eviction proveedings and other legal services that aided in housing stability. LSA will continue its policies and procedures used for case accep...

Finding 2022-004 ? Eligibility (Significant Deficiency and Non-compliance) Corrective Action: Legal Services Alabama services provided services related to eviction proveedings and other legal services that aided in housing stability. LSA will continue its policies and procedures used for case acceptance and eligility requirements. LSA will review its policies for potential improvements. The review will be conducted by the second quarter of 2023 and any changes will be implemented by the third quarter of 2023. Contact Person: Michael Forton, Director of Advocacy; (256) 551-2671; mforton@alsp.org

View Audit 45011

Finding 40064 (2022-003)

Significant Deficiency 2022

Legal Services Alabama, INC

AL

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.403

Finding 2022-003 ? Allowable Costs (Significant Deficiency and Non-compliance) Corrective Action: The ARPA?s stated purpose is for housing provision, stabilization services, and eviction prevention. The rental assistance funds may be used for arrearage, forward payments, deposits, late fees, and u...

Finding 2022-003 ? Allowable Costs (Significant Deficiency and Non-compliance) Corrective Action: The ARPA?s stated purpose is for housing provision, stabilization services, and eviction prevention. The rental assistance funds may be used for arrearage, forward payments, deposits, late fees, and utilities. The grant provides separate application forms for rental assistance and utilities assistance. The grant does not require maximizing the amount paid on behalf of applicants. Every disbursement involves obtaining documents from the applicant and the landlord. The landlord signs an agreement stating they will allow the client to remain housed by accepting the payment. It is common to negotiate the agreed upon amount because some landlords include fees in their amounts that are not allowable under the grant or ask for more months of assistance that is allowed. The disbursements tested included agreements that were all signed and accepted by the landlords. LSA documented the costs which were reimbursed by the funder. One of the payments included a document that had not been updated. The payment included an additional month?s rent due to the time lag between the start of the application and the completed documents and the revised total amount was included on the signed landlord agreement. In this case, the agreement did not include an additional late fee that would have been expected per the terms of the lease. The landlord accepted the payment less the late fee. LSA staff will document negotiated amounts that are different from the support and provide explanation and the amount included or excluded. A second payment did not include a beginning ledger balance. The landlord charges an insurance fee that is not covered by the grant. Rather than attempting to determine if the balance forward was due to eligible charges or ineligible charges, the amount was excluded from the total. The documentation attached did not specifically mention that the amount was excluded, but a handwritten total of the included charges was included. LSA staff will document negotiated amounts that are different from the support and provide explanation and the amount included or excluded. The third payment was deemed an exception because the reimbursement did not include the client?s utilities charges. Although the charges are eligible under the grant, the applicant and landlord did not request assistance with utilities. LSA staff will document negotiated amounts that are different from the support and provide explanation and the amount included or excluded. Regarding employee time for the program, LSA staff will look for solutions to help prevent time entry errors, and the Finance Department will conduct a review of every grant report. LSA will review if changes can be made in the timekeeping system to restrict certain fund sources from being applied to programs, to enhance controls over time attributed to particular funding. The grant report review will also include a review of program reports when new staff join the program to ensure the time activity is correct and can be allocated as reported. LSA will complete a review of the timekeeping system and procedures by the end of the second quarter 2023 and implement changes by the third quarter of 2023. The grant report review will commence as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@alsp.org

View Audit 45011

Finding 40060 (2022-002)

Significant Deficiency 2022

Legal Services Alabama, INC

AL

Eligibility Significant Deficiency

Finding 2022-002 ? Case Requirements (Significant Deficiency and Non-compliance) Corrective Action: LSA will provide training to all attorneys and support staff on the policies and procedures involved, with a particular emphasis on the documentation requirements. LSA will also be conducting periodic...

Finding 2022-002 ? Case Requirements (Significant Deficiency and Non-compliance) Corrective Action: LSA will provide training to all attorneys and support staff on the policies and procedures involved, with a particular emphasis on the documentation requirements. LSA will also be conducting periodic internal reviews of case files to ensure compliance with all required documentation requirements. These reviews should include a review of financial eligibility documentation, including exceptions, if any. Finally, LSA will review and update any necessary policies and procedures as needed to ensure compliance. Updates to policies and procedires and training will becompleted by the third quarter of 2023. Contact Person: Michael Forton, Director of Advocacy; (256) 551-2671; mforton@alsp.org

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