Corrective Action Plans

Finding 559033 (2024-001)

Significant Deficiency 2024

Santa Monica Christian Towers, Inc. Hud Project No. 122sh088

CA

Eligibility HUD Housing Programs Significant Deficiency

Management agrees with the finding. The Managing Agent has, at its own expense, contracted with US Inspection Group to complete a full inspection of every unit before April 15, 2025. The Managing Agent has prepared a new internal tasking schedule for enhance tracking of unit inspections by the ma...

Management agrees with the finding. The Managing Agent has, at its own expense, contracted with US Inspection Group to complete a full inspection of every unit before April 15, 2025. The Managing Agent has prepared a new internal tasking schedule for enhance tracking of unit inspections by the maintenance, management and executive teams. The Managing Agent will reinforce the critical importance of annual unit inspection during its annual Maintenance Conference and its annual Management Conference.

View Audit 355300

Finding 559014 (2024-001)

Significant Deficiency 2024

Community Action Agency of St. Louis County, Inc.

MO

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related ...

CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related documentation is contemporaneously completed and appropriately approved to maintain a strong internal control environment. The current intake and eligibility verification procedures was revised to include explicit language requiring staff signatures and approval of eligibility documentation on the date of service. These updated procedures will reflect both in-office and drive-through (if resumed) operations. All relevant staff members will receive updated training on intake documentation requirements, including the importance of contemporaneous staff review and approval. Training materials will be revised to emphasize compliance with federal requirements related to eligibility documentation. While data entry into MIS may still occur post-service, staff will be required to document and date eligibility approvals on the intake fonns at the time of service. Intake forms will now include a section for immediate staff verification with date stamps to reflect real-time approval. Name of Responsible Person: Linda Huntspon, Chief Executive Officer Anticipated Completion Date: Implemented in January 31, 2025

View Audit 355262

Finding 559003 (2024-001)

Significant Deficiency 2024

Indiana Health Centers, Inc.

IN

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

SIGNIFICANT DEFICIENCIES WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 2024.001 Recommendation We recommend that management provide training for those responsible for verifying eligibility to ensure that documentation and inter...

SIGNIFICANT DEFICIENCIES WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 2024.001 Recommendation We recommend that management provide training for those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken The agency Coordinator will have a training session with each clerk in the agency on the importance of documentation and completion of assessing WIC eligibility. This re-training will include step-by-step instructions. Clerks will be instructed to add notes when needed to explain a client's eligibility, (ex. immigrants and eligibility). Demonstration will be required by each clerk to their supervisor. The re-education will be completed by the end of June 2025 and reported on a log with attendees. Ongoing monitoring will be performed by agency supervisors. They will audit five charts twice a month for each clerk/certifier. In the event, there are deficiencies identified, the supervisor will re-train the clerk/certifier at that time. 1. A folder for each clerk will be kept in a locked cabinet by the agency supervisor. It will contain a log that will consist of the clerk's name, household audited and an analysis of the eligibility that was completed at the certification. 2. Ongoing corrections if needed will be addressed by the agency supervisor or coordinator. Retraining may be requested by clerical staff at any time. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335 or email to tnagel@ihcinc.org.

View Audit 355246

Finding 558976 (2024-001)

Significant Deficiency 2024

Community Health Center Dba Alluvion Health, Inc.

MT

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

Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The inform...

Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The information provided for the training will be translated to a process document and provided to all registration staff and billers. Colleagues will be expected to use this document as reference guide to improve program adherence. 4. Registration colleagues will participate in a peer review process where each colleague reviews 5 accounts monthly. They will audit demographics and insurance, as well as slide fee program adherence. Feedback will be provided to the colleagues responsible for errors to make corrections. 5. A leadership team member supervising patient registration colleagues will continue to audit 50 patient accounts each month. The accounts selected will have at least one billable medical, behavioral health, SUD, or dental encounter in the audit month. The audit criteria will include identifying the colleague responsible for inputting income information and application of discounts. Errors identified through the audit process will be sent to the colleage responsible for correction. Supervision and coaching will be provided to colleagues while fixing their errors to improve future performance. Responsible Party(s): Melissa Darko, Revenue Cycle Director and Lisa DeMallie, Associate Vice President of Patient Experience Estimated Completion Date: Applications were streamlined in March 2025; training was provided in April 2025 and will be ongoing; a process document will be provided to staff in May 2025; peer reviews were started in February 2025; and auditing has been ongoing and will continue.

View Audit 355210

Finding 558971 (2024-006)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Student Financial Aid Special Tests & Provisions Eligibility

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system ...

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system (Banner from Ellucian). All students who have withdrawn are being updated through National Student Clearinghouse and from there to NSLDS.

View Audit 355176

Finding 558965 (2024-004)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Internal Control / Segregation of Duties Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Monitor compliance through regular internal reviews and sample audits of personnel records.

View Audit 355176

Finding 558946 (2024-001)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Allowable Costs / Cost Principles Student Financial Aid Cash Management

Update internal financial aid disbursement policies to require annual and mid-year reviews of Pell Grant schedules. Implement a compliance checklist for verifying disbursement amounts.

View Audit 355176

Finding 558727 (2024-029)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Material Weakness Reporting

Finding: The Department of Social and Health Services did not have adequate internal controls to ensure it filed reports timely as required by the Federal Funding Accountability and Transparency Act. Questioned Costs: Assistance Listing # 93.044 93.044 COVID-19 93.045 93.045 COVID-19 93.053 ...

Finding: The Department of Social and Health Services did not have adequate internal controls to ensure it filed reports timely as required by the Federal Funding Accountability and Transparency Act. Questioned Costs: Assistance Listing # 93.044 93.044 COVID-19 93.045 93.045 COVID-19 93.053 Amount $0 Status: Corrective action complete Corrective Action: The Department concurs with the finding. As of January 2024, the Department: • Created a subawards and amendments tracking spreadsheet with the required fields and contract information for reports required by the Federal Funding Accountability and Transparency Act (FFATA). • Assigned two fiscal staff to ensure FFATA reporting activities are submitted in the Federal Funding Accountability and Transparency Subaward Reporting System (FSRS). As of February 2024, the Department: • Ensured federal fiscal year 2024 funded contracts that were executed in December 2023 for the Office of Aging were entered in FSRS. • Added procedures for the Office Chief or designee to review the subawards and amendments tracking spreadsheet monthly for FFATA reporting to ensure federal deadlines are met consistently. As of March 2024, the Department collaborated with the Administration of Community Living and developed a plan to address the FFATA reporting backlog in state fiscal years 2022 and 2023 and ensured all FFATA reports were entered in FSRS for all previous years. The conditions noted in this finding were previously reported in finding 2023-039. Completion Date: March 2024 Agency Contact: Richard Meyer External Audit Compliance Manager PO Box 45804 Olympia, WA 98504-5804 (360) 664-6027 Richard.Meyer@dshs.wa.gov

View Audit 355165

Finding 558661 (2024-067)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Sta...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure monthly foster care maintenance payments to children’s caregivers were adequate and accurate for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action complete Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. As stated in the finding’s Cause of Condition, the Department did not fully implement the prior year’s corrective action plan during the audit period and did not have the reporting capabilities to track rate setting reviews for the entire audit period. To strengthen internal controls and documentation, and as part of the implementation of the new rate assessment process, the Department took the following corrective actions: • Published a new report in FamLink to assist rate assessors in identifying: o Six-month reviews that have not been performed timely. o Cases with upcoming rate assessments and due dates for reviews. • Implemented monthly tracking by supervisors to assist with internal controls and compliance. The Department continues to use the Plan, Do, Check, Act (continuous quality improvement process) to improve the accuracy of the new reports and provide additional training to staff as needed to ensure compliance with the requirement of performing six-month reviews of the reimbursement rates. The conditions noted in this finding were previously reported in finding 2023-067. Completion Date: June 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165

Finding 558660 (2024-066)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Statu...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls to ensure payments to providers for travel and family visits were allowable and adequately supported for the Foster Care program. Questioned Costs: Assistance Listing # 93.658 93.658 COVID-19 Status: Corrective action in progress Corrective Action: The Department is committed to strengthening internal controls and complying with grant requirements. In response to the prior year audit finding, the Department has taken the following actions: • Between April and December 2023: o Filled two vacant contract staff positions dedicated to reviewing child welfare contracts to include family time visit payments. o Developed compliance audit plans for child welfare contracts and began fiscal monitoring of family time visit payments. o Implemented a new process for creating Sprout invoices from family time activity data to include the following:  Utilizing algorithms to identify reimbursements outside of reasonable amounts.  Requiring providers to submit additional documentation or explanation for flagged invoices.  Identifying duplicate billings using a re-run process.  Performing additional review and approval of invoices of the Network Administrator in Eastern Washington prior to release of payment. • Between January and March 2024: o Identified and implemented regional program approvals for Western Washington providers. o Implemented fiscal monitoring controls to ensure payments to providers for travel and family visits are allowable and adequately supported. o Utilized the Plan, Do, Check, Act (continuous quality improvement process) to add additional steps to the process to ensure payments were accurate. In response to the State Auditor’s Office (SAO) recommendations, the Department will: • Reconcile the identified payment exceptions and take appropriate action. • Review the implemented invoice and payment process and update training resources as needed. • Refine the compliance audit plans and update documentation for the contract monitoring process to ensure that SAO can review documentation for monitoring tasks completed. The conditions noted in this finding were previously reported in findings 2023-066, 2022-048, and 2021-040. Completion Date: Estimated July 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165 Questioned Costs: $1

Finding 558637 (2024-043)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over eligibility requirements for child care services paid with the Child Care and Development Fund and Temporary Assistance for Needy Families funds. Questioned Costs: Assistance Listing # 93.55...

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over eligibility requirements for child care services paid with the Child Care and Development Fund and Temporary Assistance for Needy Families funds. Questioned Costs: Assistance Listing # 93.558 93.575 93.575 COVID-19 93.596 Amount $0 Status: Corrective action complete Corrective Action: In response to prior audit findings, the Department developed a corrective action plan to address the internal control deficiencies. This finding was issued due to the corrective action plan not being fully implemented during the audit period. To address the prior years’ eligibility audit findings, the Department has taken the following actions: • As of April 2024, conducted a root cause analysis of internal audit findings, particularly for cases with errors due to household composition and approved activities, and updated the desk aid with corrective actions identified. • As of May 2024: o Improved and published the desk aid outlining simplified eligibility determination process that includes procedures for those families who do not have an approved activity. o Developed updated household composition training for all staff as part of core childcare training. The Department will continue to partner with the Administration for Children and Families and follow our program integrity plan. The conditions noted in this finding were previously reported in findings 2023-059, 2022-036, 2021-035, 2020-039, 2019-032, 2018-030, 2017-026, 2016-023, 2015-026, 2014-026, 2013-017, and 12-30. Completion Date: May 2024 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

View Audit 355165

Finding 558615 (2024-035)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

Finding: The Department of Health did not have adequate internal controls to ensure providers maintained immunization records, control, accountability and safeguarding of vaccines for the Immunization Cooperative Agreements Program. Questioned Costs: Assistance Listing # 93.268 93.268 COVID-...

Finding: The Department of Health did not have adequate internal controls to ensure providers maintained immunization records, control, accountability and safeguarding of vaccines for the Immunization Cooperative Agreements Program. Questioned Costs: Assistance Listing # 93.268 93.268 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department has already taken steps to evaluate current processes to ensure providers maintain immunization records, control, accountability and safeguarding of vaccines for the Immunization Program. As of July 2024, the program implemented a more automated process in the RedCap system to identify the vaccine doses administered outside the age range (DOAR) activities. This process enables adequate reviews and follow up with providers to be performed for the DOAR reports. As of November 2024, the site visit coordinator began the process of closely monitoring site visits due in one month and reaching out to the regional representatives to determine the status of scheduling site visits in order to minimize delays. The Department will continue to conduct monthly site visits and outreach and follow internal policies and procedures to meet DOAR reporting requirements. Completion Date: November 2024 Agency Contact: Jeff Arbuckle External Audit Manager PO Box 47890 Olympia, WA 98504-7890 (360) 701-0798 Jeff.Arbuckle@doh.wa.gov

View Audit 355165

Finding 558461 (2024-008)

Significant Deficiency 2024

State of Washington C/o Office of Financial Management

WA

Subrecipient Monitoring Special Tests & Provisions Internal Control / Segregation of Duties

Finding: The Employment Security Department did not have adequate internal controls to ensure compliance with federal requirements to annually certify that employer tax credits reported under the Federal Unemployment Tax Act are matched against employer contributions paid under the Unemployment Ins...

Finding: The Employment Security Department did not have adequate internal controls to ensure compliance with federal requirements to annually certify that employer tax credits reported under the Federal Unemployment Tax Act are matched against employer contributions paid under the Unemployment Insurance program. Questioned Costs: Assistance Listing # 17.225 17.225 COVID-19 Amount $0 Status: Corrective action complete Corrective Action: The Department is committed to ensuring that the required reports for the Federal Unemployment Tax Act are properly reviewed and in compliance with federal requirements. The Department has a process in place for a secondary review of the employer tax credit reports prior to certification. The two exceptions identified in the audit were isolated incidents where both the preparer and reviewer missed one of the 50 lines on the two reports being reviewed. The Department will ensure management adequately reviews employer account reconciliations performed by staff to ensure the required number of accounts are reviewed for all reports prior to submission. Completion Date: February 2025 Agency Contact: Jay Summers External Audit Manager PO Box 9046 Olympia, WA 98507-9046 (360) 529-6718 Joshua.Summers@esd.wa.gov

View Audit 355165

Finding 558343 (2024-001)

Significant Deficiency 2024

Colorado Youth for A Change

CO

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2024-001: Special Tests and Provisions – CFDA# 94.006 (AmeriCorps State and National): Living Allowance Maximum Threshold Exceeded Audit Finding: Colorado Youth For A Change can only pay AmeriCorps member a living allowance that does not exceed the maximum living allowance threshold per the ...

Finding 2024-001: Special Tests and Provisions – CFDA# 94.006 (AmeriCorps State and National): Living Allowance Maximum Threshold Exceeded Audit Finding: Colorado Youth For A Change can only pay AmeriCorps member a living allowance that does not exceed the maximum living allowance threshold per the Uniform Guidance and grant guidelines. In our audit, we found that twenty AmeriCorps members were paid a living allowance that exceeded the maximum threshold by $1,255 individually, and $25,100 in aggregate. This constitutes a violation of federal grant guidelines and is considered an unallowable cost, requiring corrective action and potential reimbursement to the funding agency. Audit Recommendation: We recommend Colorado Youth For A Change to compare their living allowance calculations to the annual maximum threshold amount to ensure no AmeriCorps members are paid a living allowance in excess of the annual maximum threshold amount. Management’s Response and Corrective Action Plan: Colorado Youth For A Change acknowledges the finding and recommendation. Living allowances for the 25-26 program year have been double-checked against the current NOFA and have been confirmed to be under maximum requirements. An annual process for this action will be instituted. Contact and Completion Date: Mary Zanotti (maryz@youthforachange.org) is the primary contact, and the Executive Director at Colorado Youth For A Change. The correction action is expected to be resolved before the end of the next fiscal year-end of December 31, 2025.

View Audit 355136 Questioned Costs: $1

Finding 558180 (2024-001)

Significant Deficiency 2024

Polk County, Florida

FL

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Department of Homeland Security Hazard Mitigation Grant-Assistance Listing No. 97.039 Recommendation: It was noted that improvements were observed compared to the previous year, however, we advise the County to maintain a review process to ensure quarterly reports are thoroughly examined before su...

Department of Homeland Security Hazard Mitigation Grant-Assistance Listing No. 97.039 Recommendation: It was noted that improvements were observed compared to the previous year, however, we advise the County to maintain a review process to ensure quarterly reports are thoroughly examined before submission to FDEM. Additionally, monitoring procedures should be established to guarantee the proper submission of close-out reports. Implementing a technology solution could aid the grant manager in gathering the necessary reports for the grantor, facilitating easier oversight and monitoring of grant compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will further strengthen oversight of programmatic reporting by developing and implementing a system of monitoring procedures to guarantee that periodic reports contain the appropriate data, have an adequate review performed by the relative Division Director, and are submitted within the timeframe required by the funder. The proper submission of close-out reports will also be accomplished through the developed monitoring procedures. A grant management software will be purchased and implemented and become a foundational component of the County's grant management infrastructure, allowing for more effective oversight by the County grant manager and ensuring greater compliance with all applicable regulations. Additionally, the County will implement mandatory trainings focusing on 2 CFR Part 200, to ensure fiscal and project managers involved with grant projects are fully educated on uniform administrative requirements, including proper reporting and close-out procedures, cost principles, and audit requirements related to federal and pass-through awards. Name(s) of the contact person(s) responsible for corrective action: Terri Saltzman, Grants and Community Investment Manager. Planned completion date for corrective action plan: September 30, 2025. If the Department of Homeland Security has questions regarding this plan, please call Terri Saltzman at 863-519-2049.

View Audit 355088

Finding 558166 (2024-002)

Significant Deficiency 2024

Shenandoah Area Agency on Aging, INC

VA

Reporting Internal Control / Segregation of Duties Significant Deficiency

2024-002: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging – Title III, Part B- Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part C1 – Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting (Sign...

2024-002: Annual Reporting to VDARS, ALN 93.044 Special Programs for the Aging – Title III, Part B- Grants for Supporting Services and Senior Centers, ALN 93.045 Special Programs for the Aging - Title III, Part C1 – Nutrition Services, ALN 93.053 Nutrition Services Incentive Program, Reporting (Significant Deficiency) Condition The 13th Aging Monthly Report required by the pass-through agency, Virginia Department of Aging and Rehabilitative Services (VDARS) contained inaccurate revenue and expenditure data which did not agree to the general ledger. Criteria VDARS requires the annual 13th Month Aging Monthly Report to be submitted by November 15th. The report must contain complete and accurate information as a restating of the monthly reporting for the fiscal year. Cause The 13th Aging Monthly Report was not reconciled to underlying financial records, resulting in unexplained differences between the report and trial balance provided as part of the audit. Inaccurate reporting of such revenues and expenditures did not impact the outcome of requirements of the Agency to meet level of effort metrics as required under the grant awards. Effect The submission of the 13th AMR included data that did not agree to underlying financial records. This should have been caught during the course of a review process before submission. Therefore, it is considered a significant deficiency of internal controls over compliance. Repeat Finding 2013-01 Recommendation Ensure reporting is submitted accurately by the deadline stated by VDARS. Implement a review process for each monthly submission, including documentation of the review. Reconcile the federal, state and local totals reported in the Aging Monthly Report to the underlying financial records as stated in the financial system to ensure accuracy before submission to VDARS. Planned Corrective Action Management agrees with the finding. Management plans to implement a process to ensure that the AMR report will be submitted accurately.

View Audit 355080

Finding 558144 (2024-001)

Significant Deficiency 2024

Nassau Community College

NY

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. Explanation of disagreem...

Student Financial Aid Cluster – Assistance Listing 84.063 and 84.268 Recommendation: The College should review their reporting internal controls and procedures to ensure that they require students' statuses to be reported timely to NSLDS as required by federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We believe that the recent implementation of registration codes for attendance confirmation, along with updates to the eligibility status codes for unofficial and midpoint withdrawals, will effectively reduce delays in reporting enrollment status moving forward. Additionally, we will work closely with the Registrar’s Office and ITS to ensure alignment on their timeline for reporting monthly enrollment status to Clearinghouse. Name(s) of the contact person(s) responsible for corrective action: Patricia Noren Planned completion date for corrective action plan: FY25 If the Department of Education has questions regarding this plan, please call Antoinette Brown 516-572-7743 x24404.

View Audit 355013

Finding 558113 (2024-001)

Significant Deficiency 2024

Metropolitan Development and Housing Agency

TN

HUD Housing Programs Significant Deficiency

Finding: 2024-001 Program Name: Section 8 Project-Based Cluster (14.195/14.249) Federal Awarding Agency: Department of Housing and Urban Development Compliance Requirement: Housing Quality Standards Type of Finding: Significant Deficiency; Nonmaterial Noncompliance Condition: Of the 40 tenant files ...

Finding: 2024-001 Program Name: Section 8 Project-Based Cluster (14.195/14.249) Federal Awarding Agency: Department of Housing and Urban Development Compliance Requirement: Housing Quality Standards Type of Finding: Significant Deficiency; Nonmaterial Noncompliance Condition: Of the 40 tenant files tested, 7 files did not contain documentation that the annual inspection was performed. Auditor Recommendation: We recommend the Agency uilize a tracking system to ensure inspections are completed annually and documentation is maintained regarding the results of the annual inspections. Management’s Response: The Property Management department will coordinate with the Information Technology team to ensure appropriate documentation and tracking of annual inspections.

View Audit 354991

Finding 558105 (2024-008)

Significant Deficiency 2024

Florida Rural Legal Services, Inc.

AL

Significant Deficiency

Upon review of the one case file, it appears that the lapse occurred during a turnover in staff assignment. Both the original attorney assigned to this case and the subsequent attorney left the firm and as a result there was a failure to disclose it to LSC. To address this issue and prevent future o...

Upon review of the one case file, it appears that the lapse occurred during a turnover in staff assignment. Both the original attorney assigned to this case and the subsequent attorney left the firm and as a result there was a failure to disclose it to LSC. To address this issue and prevent future occurrences, we are implementing the following corrective actions within the next 60 days:  Case Transfer Protocol: We are creating a case transfer memo form for Legal Server. We will include an assessment of whether the case needs to be reported during the next LSC Case Disclosure Report.  Case Management System Updates: We are also working on a litigation module for Legal Server that will allow us to track when a case moves from pre-litigation to litigation so that we can easily identify cases that should be included in LSC Case Disclosure Report.  Staff Training: Ongoing training is being provided to ensure all attorneys and advocates understand the importance of timely and accurate disclosures, especially during case transfers.

View Audit 354985

Finding 558103 (2024-006)

Significant Deficiency 2024

Florida Rural Legal Services, Inc.

AL

Subrecipient Monitoring Significant Deficiency Special Tests & Provisions

FRLS is in the process of having its PAI program reviewed through the ABA peer review process to assess options for meeting LSC’s PAI requirements. With respect to the waiver carryover, the CFO had conversations with LSC representatives on the proper computation of this and for 2024 LSC approved our...

FRLS is in the process of having its PAI program reviewed through the ABA peer review process to assess options for meeting LSC’s PAI requirements. With respect to the waiver carryover, the CFO had conversations with LSC representatives on the proper computation of this and for 2024 LSC approved our carryover computation. Upon further consultation with LSC It appears that this information was incorrect and FRLS will revise its computation in consultation with LSC. This change will be made by December 31, 2025.

View Audit 354985

Finding 558102 (2024-005)

Significant Deficiency 2024

Florida Rural Legal Services, Inc.

AL

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

This finding is related to activities on our VOCA grants. This finding is related to Finding 2024-001. 4 invoices were not approved by management. FRLS’s AP policy that was adopted in September 2024 allowed us to skip separate management approval in cases of recurring invoices such as utilities and ...

This finding is related to activities on our VOCA grants. This finding is related to Finding 2024-001. 4 invoices were not approved by management. FRLS’s AP policy that was adopted in September 2024 allowed us to skip separate management approval in cases of recurring invoices such as utilities and in cases where we have approved contracts such as rent payments, software subscriptions etc. This was our policy before September 2024, but it was not formalized before that date. As in the case of 2024-001. FRLS will modify its AP Policy and Procedures to remove this recurring payment exception and will now require all invoices be approved by management by routing invoices to management for approvals through the Teams automated system. Invoices over $5,000 will also be required to be approved by the Executive Director or their temporary designee. Such designation must be made in writing. This change will be made within the next 60 days.

View Audit 354985

Finding 558096 (2024-005)

Significant Deficiency 2024

Housing Authority of the City of Littleton

CO

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Finding 2024-005: U.S. Department of Housing and Urban Development – CFDA #14.155 Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Applicable Federal Award Number and Year – HUD loan under section 207/223(f), HUD Project No. 101-11316 Allowable Costs/ Allowab...

Finding 2024-005: U.S. Department of Housing and Urban Development – CFDA #14.155 Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Applicable Federal Award Number and Year – HUD loan under section 207/223(f), HUD Project No. 101-11316 Allowable Costs/ Allowable Activities Name of contact Person: Renee Gallegos, Finance Manager Anticipated completion date: Completed Planned Corrective Action: • Management has updated internal controls to include that all costs charged to the project are for allowable costs.

View Audit 354976 Questioned Costs: $1

Finding 558095 (2024-004)

Significant Deficiency 2024

Housing Authority of the City of Littleton

CO

Eligibility HUD Housing Programs Significant Deficiency

Finding 2024-004: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 HQS Enforcement Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: In Progress Planned Correct...

Finding 2024-004: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 HQS Enforcement Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: In Progress Planned Corrective Action: • SMHO will provide additional staff training and testing of understanding through a thirdparty training platform for inspections and re-inspections procedures. Management will quarterly review each file that requires re-inspection to ensure all documents are present in the file.

View Audit 354976

Finding 558094 (2024-003)

Significant Deficiency 2024

Housing Authority of the City of Littleton

CO

Internal Control / Segregation of Duties Eligibility HUD Housing Programs

Finding 2024-003: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Ac...

Finding 2024-003: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Action: • SMHO will require managerial file review/approval for income used at new move-ins, port-ins and annual re-exams and the manager/lead will initial the new income line item added to the check sheet for each file to indicate the review/approval has been completed.

View Audit 354976

Finding 558093 (2024-002)

Significant Deficiency 2024

Housing Authority of the City of Littleton

CO

Internal Control / Segregation of Duties Eligibility HUD Housing Programs

Finding 2024-002: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Ac...

Finding 2024-002: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Action: • SMHO will require managerial file review/approval for all new move-ins, port-ins and annual re-exams and the manager/lead will sign the check sheet for each file to indicate the review/approval has been completed.

View Audit 354976

Corrective Action Plans

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