Corrective Action Plans

Finding 1152938 (2024-002)

Material Weakness 2024

NV

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.303

Finding 2024-002 Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the prepa...

Finding 2024-002 Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer of the quarterly financial reports. Corrective Action Plan: Previous reports were compiled by the Foundation’s vendors and submitted by the prior CFO. Future reports will be prepared by the Accountant and reviewed by the CFO prior to submission. Responsible Individuals: Alisha Kinnison, Accountant and Matt Lazar, CFO Anticipated Completion Date: July 2025

View Audit 366274

Finding 1152932 (2024-002)

Material Weakness 2024

Springfield Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Eligibility

FINDING 2024-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency 11 SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2024 FYE audit report. In 2024, the Springfi...

FINDING 2024-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency 11 SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2024 FYE audit report. In 2024, the Springfield Housing Authority Housing Choice Voucher program delineated the following positions to undertake income and rent calculations: one (1) Special Programs Coordinator, four (4) HCV Specialists and one (1) Program Integrity Specialist. Of those six (6) employees, only one had a tenure longer than 12 months. Due to continuing post COVID-19 turnover and lack of qualified workers in the local workforce, the SHA experienced a higher than usual turnover rate in the HCV positions that conduct rent calculations during the majority of FY2024. The Springfield Housing Authority hired third party consultants to assist with annual recertifications in the 3rd Quarter of 2023 that continued through December 31, 2024. The primary function of the Program Integrity Specialist position is to audit and quality control tenant files and rent calculations conducted by HCV Specialists. The HCV Director and/or HCV Manager is responsible for reviewing 3% of recertifications audited by the Program Integrity Specialist position as an additional quality control measure. This error rate was directly attributable to the unprecedented turnover rate of HCV Specialists during the 2024 fiscal year. The Director of HCV, HCV Manager, HCV Specialists, HCV Special Programs Coordinator and Program Integrity Specialist were provided additional internal and external training opportunities in HCV rent calculations and program integrity in June 2025. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Specialist will conduct reviews of 100% of annual and interim recertifications for HCV program participants by December 31, 2025. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the HCV Specialists, monthly. • The HCV Director and/or Manager will review 10% of the recertifications audited by the Program Integrity Specialist as an additional quality control measure by December 31, 2025. • Any newly hired HCV Director, HCV Manager, HCV Specialists and Program Integrity Specialist will be provided with additional external training opportunities in Housing Choice Voucher program income and rent calculations and program integrity within sixty (60) days of employment. • The HCV Director and/or Manager will re-review the files identified with errors during the independent audit and resolve the errors in accordance with the SHA Administrative Plan and HUD rules and regulations by December 31, 2025. Person Responsible: Melissa Huffstedtler Anticipated Completion Date: December 31, 2025

View Audit 366267

Finding 1152931 (2024-001)

Material Weakness 2024

Springfield Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Eligibility

FINDING 2024-001 "Public Housing Tenant Files - Eligibility- Internal Control Over Tenant Files Non-Compliance and Significant Deficiency" SHA RESPONSE • The Springfield Housing Authority acknowledges the five (5) errors as delineated in the full 2024 FYE audit report. The auditors pulled files from...

FINDING 2024-001 "Public Housing Tenant Files - Eligibility- Internal Control Over Tenant Files Non-Compliance and Significant Deficiency" SHA RESPONSE • The Springfield Housing Authority acknowledges the five (5) errors as delineated in the full 2024 FYE audit report. The auditors pulled files from two points in time through the fiscal year. It was noted that the identified errors were from the second half of the fiscal year tenant actions (July- December) when the Springfield Housing Authority experienced a staffing shortage in both the Program Integrity and Asset Manager functions of the Public Housing program. The majority of identified errors were found in instances where the public housing operations was short staffed in five positions (2 Asset Managers, 1 Program Integrity Specialist, 1 Occupancy Specialist and 1 Inspector). Staffing stabilization at the first half of the fiscal year gave way to a higher than usual turnover rate in the positions that conduct rent calculations, file audits and inspections during the latter part of FY2024. The primary function of the Program Integrity Specialist position is to audit and quality control tenant files and rent calculations conducted by Occupancy Specialists. The Asset Managers are responsible for reviewing 3% of recertifications audited by the Program Integrity Specialist position as an additional quality control measure. The Asset Managers, Occupancy Specialists and Program Integrity Specialists were provided additional internal and external training opportunities in low rent public housing rent calculations and program integrity in June 2025. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Specialist will conduct reviews of 100% of annual and interim recertifications for public housing tenants by December 31, 2025. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the Occupancy Specialists, monthly. • The Asset Manager(s) will review 10% of the recertifications audited by the Program Integrity Specialist as an additional quality control measure by December 31, 2025. • Any newly hired Asset Managers, Occupancy Specialists and Program Integrity Specialists will be provided with additional external training opportunities in low rent public housing rent calculations and program integrity within sixty (60) days of employment. • The Asset Managers will re-review the files identified with errors during the independent audit and resolve the errors in accordance with the SHA Admissions and Continued Occupancy Plan and HUD rules and regulations by December 31, 2025. Person Responsible: Melissa Huffstedtler, Deputy Director Anticipated Completion Date: December 31, 2025

View Audit 366267

Finding 1152917 (2024-001)

Material Weakness 2024

Greene County School District

MS

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency

AUDITEE’S CORRECTIVE ACTION PLAN As required by 2 CFR 200.511, the Greene County School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Costs for the year ended June 30, 2024: Finding Correction Action...

AUDITEE’S CORRECTIVE ACTION PLAN As required by 2 CFR 200.511, the Greene County School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Costs for the year ended June 30, 2024: Finding Correction Action Plan Details 2024-001 a. Name of Contact Person Responsible for Corrective Action: George Hedgepeth – Business Manager b. Corrective Action Planned: We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, including compliance with all federal grant requirements. c. Anticipated Completion Date: Immediately.

View Audit 366238

Finding 576314 (2024-004)

Significant Deficiency 2024

Yakama Nation Housing Authority

WA

HUD Housing Programs Material Weakness Significant Deficiency § 200.303

Person responsible for this corrective action plan: Jana Kent, Executive Director Corrective Action Plan: YNHA is developing a policy and procedures to address environmental reviews and ensure that when an environmental review is required that it is conducted and approved prior to beginning work...

Person responsible for this corrective action plan: Jana Kent, Executive Director Corrective Action Plan: YNHA is developing a policy and procedures to address environmental reviews and ensure that when an environmental review is required that it is conducted and approved prior to beginning work on a project. Estimated Completion Date: October 1, 2025

View Audit 366187

Finding 576312 (2024-002)

Material Weakness 2024

Yakama Nation Housing Authority

WA

Allowable Costs / Cost Principles Eligibility HUD Housing Programs § 200.303

Persons responsible for this corrective action plan: Phylistine Alexander, Housing Manager and Jana Kent, Executive Director Corrective Action Plan: YNHA will work with the NwONAP Grant Evaluation Director to evaluate our current tenant file documentation and eligibility determination process an...

Persons responsible for this corrective action plan: Phylistine Alexander, Housing Manager and Jana Kent, Executive Director Corrective Action Plan: YNHA will work with the NwONAP Grant Evaluation Director to evaluate our current tenant file documentation and eligibility determination process and will implement recommendations from HUD. Estimated Completion Date: December 31, 2025

View Audit 366187

Finding 576245 (2024-004)

Significant Deficiency 2024

Opening Doors, Inc.

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.329

Auditor's Recommendation: Strengthen policies and procedures to ensure proper documentation retention for review and approval of all Programmatic Reports prior to grantor submission. Management Response: While ODI does not disagree with the audit finding, the Agency does clarify the context of the ...

Auditor's Recommendation: Strengthen policies and procedures to ensure proper documentation retention for review and approval of all Programmatic Reports prior to grantor submission. Management Response: While ODI does not disagree with the audit finding, the Agency does clarify the context of the finding. ODI has a process for monitoring activities under Federal awards: Program Managers and Directors are responsible for monitoring activities under Federal awards, with the support of the Agency’s Compliance Specialist. The Agency tracks comparisons of program accomplishments to program objectives and reports these data to grantors as required and, where necessary, communicates significant development to the Federal agency and/or pass-through entity. Corrective Action: Establish comprehensive guidelines to retain documentation of quality control and review for programmatic reports through electronic approvals via email and/or approved tracked changes or review notes within software platforms demonstrating review and approval. Responsible Personnel: Jessie Mabry, CEO; Jeremy Huynh, Compliance Specialist Implementation Date: Immediate implementation to assess tracking methods for Federal programmatic reports, and to develop written guidelines for documenting programmatic report quality control.

View Audit 366160

Finding 576167 (2024-001)

Significant Deficiency 2024

Wtia Workforce Institute

WA

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties § 200.303

Apprenti agrees with the finding and acknowledges the importance of maintaining a full audit trail for all disbursement approvals. Apprenti adhered to its internal controls over compliance with allowable costs in accordance with 2 CFR Part 200 for all nonpayroll expenditures and had no findings in p...

Apprenti agrees with the finding and acknowledges the importance of maintaining a full audit trail for all disbursement approvals. Apprenti adhered to its internal controls over compliance with allowable costs in accordance with 2 CFR Part 200 for all nonpayroll expenditures and had no findings in prior Single Audits. However, due to a financial system migration, the audit trail documenting approval workflows for certain transactions was lost and could not be recovered or reconstructed. To prevent similar issues in the future and reinforce compliance, Apprenti has implemented the following corrective action: System Audit Trail Safeguards: Post‐migration, Apprenti implemented robust data retention protocols across both primary and backup financial systems to ensure that all approval workflows are securely preserved and transferable in the event of future system changes or migrations.

View Audit 366081

Finding 576109 (2024-001)

Significant Deficiency 2024

Cote Brilliante Presbyterian Church Housing Corporation

MO

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.403

The Project acknowledges the finding regarding the interproject payable. Management has developed the following corrective action plan: Repayment of Payable - The outstanding payable balance ot the related HUD project will be repaid in full by September 30, 2025. Documentation of repayment will be ...

The Project acknowledges the finding regarding the interproject payable. Management has developed the following corrective action plan: Repayment of Payable - The outstanding payable balance ot the related HUD project will be repaid in full by September 30, 2025. Documentation of repayment will be maintained and made available for audit verification. Elimination of Interproject Borrowing - Effective immediately, the Project has ceased the practice of borrowing funds from other HUD-assisted projects. Future interproject transactions will not be initiated unless expressly authorized by HUD. Polidy Development and Implementation - The Project will adopt a written policy governing cash management and interproject transactions by September 30, 2025. The policy will prohibit interproject loans without HUD approval and establish procedures for timely monitoring of accounts payable. Training and Oversight - Project staff responsible for financial reporting will receive training on HUD requirements and Uniform Guidance within 120 days. In addition, management will review monthly financial reports to ensure no interproject balances exist.

View Audit 366023 Questioned Costs: $1

Finding 576102 (2024-002)

Significant Deficiency 2024

Marshall County

IL

Allowable Costs / Cost Principles Significant Deficiency

2024-002 FINDING Contact Person – Scott Peters, Auditor/Treasurer Corrective Action Plan – Will review procedures over timecard approval. Completion Date – September 30, 2025

View Audit 366011

Finding 576082 (2024-004)

Significant Deficiency 2024

Kanabec County

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency

DOCUMENTATION OF SUSPENSION AND DEBARMENT Recommendation: It is recommended the County retain documentation related to the applicable federal requirements to ensure compliance with said federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit find...

DOCUMENTATION OF SUSPENSION AND DEBARMENT Recommendation: It is recommended the County retain documentation related to the applicable federal requirements to ensure compliance with said federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will retain documentation related to applicable federal requirements. Name of the contact person responsible for corrective action plan: Denise Snyder, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2025

View Audit 365980

Finding 576054 (2024-002)

Significant Deficiency 2024

Public Defender Association

WA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Significant deficiency in internal controls over financial reporting of leases in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action ...

Significant deficiency in internal controls over financial reporting of leases in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: Review lease terms at inception of lease(s) and ensure accounted for correctly in the leasing software and general ledger; review all leases again at year end to ensure any changes to said leases were recorded properly. Anticipated Completion Date: End of 2025 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard, Tara Moss, and Fe LopezGaetke Co-Executive Directors

View Audit 365948

Finding 576053 (2024-001)

Significant Deficiency 2024

Public Defender Association

WA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Significant deficiency in internal controls over financial reporting of net assets with and without donor restrictions in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following co...

Significant deficiency in internal controls over financial reporting of net assets with and without donor restrictions in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: PDA instituted a monthly review of foundation grant spending to ensure spending is in line with assumptions. By the completion of each fiscal year, PDA will have proper information gathered to release funds from restricted net assets accordingly. Anticipated Completion Date: Implemented in 2024 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard, Tara Moss, and Fe LopezGaetke Co-Executive Directors

View Audit 365948

Finding 576045 (2024-004)

Significant Deficiency 2024

Cimarron Watershed Alliance, Inc.

NM

Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management § 200.302 § 200.305 § 200.318

Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible C...

Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible Contact Person: Rick Smith, Executive Director

View Audit 365934

Finding 576029 (2024-002)

Significant Deficiency 2024

Pomona Community Health Center Dba Parktree Community Health Center

CA

Special Tests & Provisions Eligibility Significant Deficiency

2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents ...

2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents are retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on document retention policies in relation to the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review of current patient sliding fee applications to ensure all required documents are maintained and retained for the appropriate length of time as per PCHC Board of Director approved policies. Weekly audits verifying supporting documents for the sliding fee applications are conducted under the supervision of management, and improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025

View Audit 365919

Finding 576025 (2024-001)

Significant Deficiency 2024

Pomona Community Health Center Dba Parktree Community Health Center

CA

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

2024-001 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over demographic data and income verification information entered into the patient billing system in order to ensure the financial classification ...

2024-001 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over demographic data and income verification information entered into the patient billing system in order to ensure the financial classification is correct. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review process of prior period patient sliding fee applications and approved slide adjustment calculations. Weekly audits of patient applications are conducted under the supervision of management to ensure the financial classification is correct. Improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025.

View Audit 365919

Finding 575995 (2024-002)

Significant Deficiency 2024

Young Women's Christian Association of Northeast Kansas

KS

Questioned Costs Subrecipient Monitoring Significant Deficiency § 200.303

Contact person responsible for correction action – Linda Aziz, Chief Financial Officer Anticipated completion date – August 29, 2025 Corrective action YWCA of Northeast Kansas agrees with the finding. An addendum to the Grant Oversight Policy will require quarterly reviews of grant expenditures. The...

Contact person responsible for correction action – Linda Aziz, Chief Financial Officer Anticipated completion date – August 29, 2025 Corrective action YWCA of Northeast Kansas agrees with the finding. An addendum to the Grant Oversight Policy will require quarterly reviews of grant expenditures. The CFO will ensure expenditures are properly coded and reported in the correct period, in collaboration with accounting partners. Discrepancies will be promptly addressed.

View Audit 365889 Questioned Costs: $1

Finding 575951 (2024-001)

Significant Deficiency 2024

Hazelden Betty Ford Foundation and Subsidiaries

MN

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Finding 2024-001: Non-compliance with Special Tests and Provisions: Disbursements Condition For 3 of 25 students selected for testing, the disbursement dates did not agree between the student’s institutional account and the data reported to COD. Each student had disbursements that were later partial...

Finding 2024-001: Non-compliance with Special Tests and Provisions: Disbursements Condition For 3 of 25 students selected for testing, the disbursement dates did not agree between the student’s institutional account and the data reported to COD. Each student had disbursements that were later partially or fully refunded. The sample was not a statistically valid sample. Recommendation It is recommended that policies, procedures and effective controls are put in place to verify that the disbursement dates for federal funds are matching between the student account detail and the COD system. Corrective Action The Foundation will ensure that policies, procedures and effective controls are in place to verify the matching of the disbursement dates for federal funds between the student account detail and the COD system. Anticipated completion date of implementing the corrective action plan will be immediate.

View Audit 365871 Questioned Costs: $1

Finding 575820 (2024-001)

Significant Deficiency 2024

Genesis Nonprofit Housing Corporation

MI

Eligibility HUD Housing Programs Significant Deficiency

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.

View Audit 365801

Finding 575819 (2024-002)

Significant Deficiency 2024

Anita Moreau "food Program Specialist"

TX

Subrecipient Monitoring Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has assigned an employee charged with ensuring monitored visits occur in compliance with 4337 of the Texas Department of Agriculture - Child and Adult Care Food Program - Child Care Centers Handbook. This employee ensures mo...

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has assigned an employee charged with ensuring monitored visits occur in compliance with 4337 of the Texas Department of Agriculture - Child and Adult Care Food Program - Child Care Centers Handbook. This employee ensures monitored visists occur and meals monitored do not include snacks. Monitored visits are based on the meal times with the greatest number of meals served at the centers. These were discovered before the audit and procedures were implemented to rectify these two instances before year-end. Twinkle Wonders Rice: This facility was formely called Kaleidoscope. Because of the change in management, the facility did not have a full program year to be monitored. This is where confusion emerged regarding amount of monitors and monitoring events needed versus what actually occured. Top Leaders: This facility was monitored three times during the year. Two of these monitors were PM snacks. There were monitored August 2024 and a follow-up was scheduled for September 2024. The facility must be given enough time to correct its recommendations. Because the issue was so close to the end fo the program year, there was not enough time to proceed with the follow-up and another monitoring of an additional meal. The facility's next monitoring event was a meal, but it was visited in the following program year.

View Audit 365800

Finding 575797 (2024-001)

Significant Deficiency 2024

Rockingham Planning Commission

NH

Allowable Costs / Cost Principles Significant Deficiency

Planned Corrective Action: Assistant Director to review and initial all Executive Director's timesheets. Planned Implementation Date of Corrective Action: July 2024 Person Responsible for Corrective Action: Annette Pettengill

View Audit 365777

Finding 575781 (2024-001)

Significant Deficiency 2024

City of Chisholm

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency

The City Clerk-Treasurer will attempt to monitor transactions and structure the duties of the office personnel to ensure as much segregation of duties as possible within the City's staffing limitations and funding constraints.

View Audit 365757

Finding 575723 (2024-001)

Significant Deficiency 2024

Oak Street Senior Apartments INC

MI

Questioned Costs HUD Housing Programs Reporting

OAK STREET SENIOR APARTMENTS, INC. HUD PROJECT NO. 048-EE018 CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Oak Street Senior Apartments, Inc. respectfully submits the following corrective action plan for the year end December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave. Suite 1...

OAK STREET SENIOR APARTMENTS, INC. HUD PROJECT NO. 048-EE018 CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Oak Street Senior Apartments, Inc. respectfully submits the following corrective action plan for the year end December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave. Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2024 Corporation Contact Person: Elliott Broderick, Management Agent Representative The finding from the December 31, 2024 schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding – Federal Award Findings and Questioned Costs Finding 2024-001: Considered a significant deficiency in internal control over financial reporting Recommendation: The Corporation should ensure that there are proper internal controls in place over financial reporting to ensure accurate and timely submission of financial transactions, including monthly replacement reserve deposits. Action to be Taken: The Management agent concurs with the facts of this finding and as properly funded the replacement reserve account in 2025.

View Audit 365715 Questioned Costs: $1

Finding 575670 (2024-005)

Significant Deficiency 2024

Indiana Diaper Bank, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...

Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft a new CRM to track benefit limitation and mandatory documentation. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.

View Audit 365678

Finding 575669 (2024-004)

Significant Deficiency 2024

Indiana Diaper Bank, Inc.

IN

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identif...

Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. As a result, three of the sixty transactions tested did not include sufficient documentation to support eligibility determinations, representing instances of noncompliance with the eligibility requirements under the federal program. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.

View Audit 365678 Questioned Costs: $1

Corrective Action Plans

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