Corrective Action Plans

Finding 566020 (2024-005)

Significant Deficiency 2024

FL

HUD Housing Programs Reporting Significant Deficiency

2024-005 – PIC Reporting Housing Voucher Cluster – Assistance Listing 14.781 and 14.879 Recommendation: We recommend that the Authority designate an individual to ensure the HUD-50058s are uploaded into the PIC system accurately and timely. Explanation of disagreement with audit finding: There is...

2024-005 – PIC Reporting Housing Voucher Cluster – Assistance Listing 14.781 and 14.879 Recommendation: We recommend that the Authority designate an individual to ensure the HUD-50058s are uploaded into the PIC system accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented that completion of all reexaminations within its Yardi resident portal. Reexaminations within Yardi provide online workflows that maximize efficiency, streamline compliance, reduce errors, and increase reporting accuracy. As such, the PBCHA has seen improvement in this area. PIC submissions are completed weekly to ensure compliance with eVMS and encourage timely correction of fatal errors. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Yvette Bembry Planned completion date for corrective action plan: December 31, 2025

View Audit 359660

Finding 566017 (2024-004)

Significant Deficiency 2024

Palm Beach County Housing Authority

FL

HUD Housing Programs Subrecipient Monitoring Eligibility

2024-004 – Selection from the Waiting List Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend management that designates an induvial to maintain the waiting list and track all correspondence with potential tenants. We recommend that the Authority’s waitlist...

2024-004 – Selection from the Waiting List Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend management that designates an induvial to maintain the waiting list and track all correspondence with potential tenants. We recommend that the Authority’s waitlist tracking software be monitored to ensure tenants are removed from the wait list timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented the completion of all waiting lists generation/selection and intakes for eligibility within its Yardi resident portal. Intakes within Yardi automates applications, increases efficiency and ensures compliance with program requirements. Utilizing this technology, the PBCHA has seen improvement in this longstanding finding. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance and that correspondence with potential tenants is properly documented and tracked. Additionally, PBCHA will implement procedures to regularly monitor its waitlist tracking software to confirm that applicants are removed from the wait list in a timely and compliant manner. Name(s) of the contact person(s) responsible for corrective action: Yvette Bembry Planned completion date for corrective action plan: December 31, 2025

View Audit 359660

Finding 566014 (2024-003)

Significant Deficiency 2024

Palm Beach County Housing Authority

FL

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2024-003 – Rent Reasonableness Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend management that designates an individual to review tenant filles to determine if a rent reasonableness has been performed and was completed in a timely manner. We recommend t...

2024-003 – Rent Reasonableness Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend management that designates an individual to review tenant filles to determine if a rent reasonableness has been performed and was completed in a timely manner. We recommend the authority to hire outside consultants to assist with reasonable rent determination or increase staffing in this area. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PBCHA will continue to instruct staff members to review tenant files to ensure rent reasonableness determinations have been completed accurately and in a timely manner, in accordance with HUD requirements. With this instruction, the PBCHA has seen vast improvement in this area. The PBCHA will continue to assess current staffing levels and evaluate the feasibility of hiring outside consultants or increasing staffing to support consistent and compliant rent reasonableness determinations while being cognizant of current funding uncertainties. Name(s) of the contact person(s) responsible for corrective action: Yvette Bembry Planned completion date for corrective action plan: August 30, 2026

View Audit 359660

Finding 566011 (2024-002)

Significant Deficiency 2024

Palm Beach County Housing Authority

FL

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2024-002 – Annual HQS Inspection Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management implement a centralized tracking system to monitor inspection due dates and follow-up timelines, ensuring all inspections are completed within HUD- mandated...

2024-002 – Annual HQS Inspection Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management implement a centralized tracking system to monitor inspection due dates and follow-up timelines, ensuring all inspections are completed within HUD- mandated timeframes. Additionally, we recommend that PBCHA evaluate current staffing levels and consider hiring additional inspectors or contracting with third-party providers to meet inspection demands. Ongoing training should also be provided to staff on Housing Quality Standards (HQS) protocols and compliance expectations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA has seen vast improvement in this area. The PBCHA will continue to monitor its third-party inspection vendor to ensure continued adherence for the provision of inspection reports. The PBCHA will utilize centralized tracking systems within Yardi and other systems to improve oversight of inspection due dates and follow-up timelines, ensuring timely completion of all inspections in accordance with HUD requirements. The PBCHA will assess current staffing levels and evaluate the feasibility of hiring internal inspectors or contracting with additional third-party inspection services to meet demand while being cognizant of current funding uncertainties. Additionally, training will be provided to staff to reinforce Housing Quality Standards (HQS) protocols and compliance expectations. Name(s) of the contact person(s) responsible for corrective action: Yvette Bembry Planned completion date for corrective action plan: August 30, 2026

View Audit 359660

Finding 566003 (2024-001)

Significant Deficiency 2024

Beaumont Senior Citizens Housing, Inc.

TX

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

CORRECTIVE ACTION PLAN Name of the Project: Beaumont Senior Citizens Housing, Inc. FHA/CONTACT NO. 114-11227 Audit Firm: M Group, LLP Audit Period: The year ended June 30, 2024 Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our aud...

CORRECTIVE ACTION PLAN Name of the Project: Beaumont Senior Citizens Housing, Inc. FHA/CONTACT NO. 114-11227 Audit Firm: M Group, LLP Audit Period: The year ended June 30, 2024 Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING #2024-001: Section 8 Housing Assistance Payments Program, Assistance Listing: 14.195 and Mortgage Insurance Section 223(f) Insured Loan, Assistance Listing: 14.155 CORRECTIVE ACTION TO BE COMPLETED: The Corporation completed and submitted the financials for audit for the years ended June 30, 2024 and 2023. The financial data was submitted into the FASSUB and FAC system. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Stewart Grounds, Chief Financial Officer.

View Audit 359651

Finding 565996 (2024-001)

Significant Deficiency 2024

Independent Living Place, Inc.

TX

HUD Housing Programs Significant Deficiency

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2024 Compliance Review: A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our audi...

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2024 Compliance Review: A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING #2024-01: Section 202 Supportive Housing for the Disabled, Assistance Listing 14.157 and Section 8 Housing Assistance Payments Program, Assistance Listing 14.195 CORRECTIVE ACTION COMPLETED: CLEARED. The Corporation submitted the audited financials for the year ended September 30, 2023 on September 25, 2024. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Stewart Grounds, Chief Financial Officer of Arnold-Grounds Apartment Management & Affordable Housing Specialists, LLC.

View Audit 359648

Finding 565992 (2024-003)

Significant Deficiency 2024

Central Virginia Legal Aid Society, Inc.

VA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Corrective Action Taken or Planned: The Organization will implement a review process to ensure that reports to LSC are filed timely. This review process will consist of the Executive Director and the Director of Finance independently reviewing the Oversight section of Grantease (LSC’s web-based p...

Corrective Action Taken or Planned: The Organization will implement a review process to ensure that reports to LSC are filed timely. This review process will consist of the Executive Director and the Director of Finance independently reviewing the Oversight section of Grantease (LSC’s web-based platform) monthly to ensure compliance. The Organization already has calendared all report deadlines for LSC and has a good track record of meeting those deadlines. The Organization believes the missed deadline identified in the audit was due to changes in job responsibilities following organizational restructuring and will not occur again. Name of Contact Person: Steve Dickinson, Executive Director Phone Number of Contact Person: (804) 200-6049 Projected Completion Date: April 30, 2025

View Audit 359640

Finding 565976 (2024-001)

Significant Deficiency 2024

Young Men's Christian Association of Middle Tennessee

TN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-001 – Significant Deficiency in Internal Controls over Reports Submitted to Grantors – Child Care and Development Block Grant – 93.575 Recommendation: YMCA management should strengthen its controls related to the review and approval of information on grant reporting ensuring proper evid...

Finding 2024-001 – Significant Deficiency in Internal Controls over Reports Submitted to Grantors – Child Care and Development Block Grant – 93.575 Recommendation: YMCA management should strengthen its controls related to the review and approval of information on grant reporting ensuring proper evidence is maintained of the control over compliance with financial reporting requirements. Corrective Action: Management will ensure reviews of documents submitted to grantors will be reviewed and documented such that evidence of such reviews will be retained. Person Responsible for Corrective Action: Chief Financial Officer Anticipated Completion Date for Corrective Action: The Corrective Action was implemented effective June 22, 2024. If there are questions regarding this corrective action plan, please call Marcy Towns, Chief Financial Officer, at (615) 259-9622.

View Audit 359631

Finding 565974 (2024-001)

Significant Deficiency 2024

Taylor County, Texas

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding 2024-001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not revie...

Finding 2024-001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: Taylor County implemented a control process for the last quarter of fiscal year 2024 to have the County Auditor prepare the performance reports, with a mechanical review of the report performed by an individual within the Auditor’s Office. Anticipated Completion Date: Completed

View Audit 359630

Finding 565818 (2024-002)

Significant Deficiency 2024

City of Beaumont

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

For required reporting offirm deadlines (such as those tied to portals or systems), we already have a practice of submitting a bit earlier when deadlines fall on weekends or holidays to avoid timing issues. However, for this specific grant, the reports are submitted via email to a consultant managin...

For required reporting offirm deadlines (such as those tied to portals or systems), we already have a practice of submitting a bit earlier when deadlines fall on weekends or holidays to avoid timing issues. However, for this specific grant, the reports are submitted via email to a consultant managing the ARPA funds on behalf of Riverside County. These deadlines are somewhat flexible, as the consultant collects data from all subrecipients and submits it to the County as a consolidated package. Effective immediately, the Grants Analyst will submit these earlier rather than later. The Finance Director will assess compliance with timely filing requirements to ensure the establishment of internal controls over financial reporting.

View Audit 359523

Finding 565807 (2024-004)

Significant Deficiency 2024

Human Services of Faribault and Martin Counties

MN

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

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2405MN5MAP and 2405MN5ADM, 2024 Pass-Through Agency: Minnesota Department of Human Ser...

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2405MN5MAP and 2405MN5ADM, 2024 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2405MN5MAP and 2405MN5ADM Compliance Requirement Affected: Allowable Costs/Allowable Activities Award Period: Year-Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the Agency implement control procedures to ensure Income Maintenance Random Moment Study (IMRMS) and Social Services Time Study (SSTS) listings are accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and implement changes as needed to ensure going forward that the IMRMS and SSTS listings are accurate. Name of the contact person responsible for corrective action plan: Chera Sevcik, Human Services Executive Director Planned completion date for corrective action plan: December 31, 2025

View Audit 359512

Finding 565806 (2024-003)

Significant Deficiency 2024

Metropolitan Economic Development Association

MN

Procurement, Suspension & Debarment Significant Deficiency § 200.303

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.033 Program Name: Community Development Financial Institutions Equitable Recovery Program Finding Summary: MEDA does not have a formal process to search for suspension and debarment of entities prior to entering into a loan ...

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.033 Program Name: Community Development Financial Institutions Equitable Recovery Program Finding Summary: MEDA does not have a formal process to search for suspension and debarment of entities prior to entering into a loan agreement. Corrective Action Plan: MEDA has an extensive underwriting process that reviews all borrowers from a variety of state and national databases for fraud, debt, and money laundering activities. In our current underwriting process, we search SAM. gov for SBA loan requests. As of May 1, 2025, we are searching SAM. gov for all of our loan requests. Furthermore, we have added this requirement to our loan underwriting manual, as evidenced by Section 10, Letter D for the search list of legal, financial and personal documents that are required to approve a loan at MEDA. Responsible Individuals: Adrian Ruddock – VP of Lending & Business Consulting, Raynette Buerke – Sr. Loan Administration Manager Anticipated Completion Date: May 1, 2025

View Audit 359504

Finding 565772 (2024-003)

Significant Deficiency 2024

Boys & Girls Club of Huntington County, Inc.

IN

Allowable Costs / Cost Principles Cash Management Significant Deficiency

2024-003 Twenty-First Century Community Learning Centers -Assistance Listing No. 84.287 Significant Deficiency in Internal Control Over Compliance and Noncompliance - Appropriate Internal Control Structure Related to Compliance Requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost...

2024-003 Twenty-First Century Community Learning Centers -Assistance Listing No. 84.287 Significant Deficiency in Internal Control Over Compliance and Noncompliance - Appropriate Internal Control Structure Related to Compliance Requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, and C. Cash Management Recommendation: The Auditor recommends the policies in accordance with §200.302 Financial Management paragraph (b) (6) and (b)(7) be written by the Organization, approved by the Board of Directors, and included in the permanent files of the Organization. Planned Corrective Action: We agree with the recommendation, and updated our policies in accordance with §200.302 Financial Management paragraph (b) (7) in December 2024 and will update our policies in accordance with (b) (6) by August 2025.

View Audit 359460

Finding 565731 (2024-002)

Significant Deficiency 2024

Community Action Agency of Jackson, Lenawee, and Hillsdale

MI

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.328

2024-002 - Late submission of reports Auditor Description of Condition and Effect: The Agency failed to submit the required report for the federal grant within the stipulated deadlines as outlined in the grant agreement and Uniform Guidance. During reporting testing, it was noted that the Final FFR ...

2024-002 - Late submission of reports Auditor Description of Condition and Effect: The Agency failed to submit the required report for the federal grant within the stipulated deadlines as outlined in the grant agreement and Uniform Guidance. During reporting testing, it was noted that the Final FFR report was not submitted into the Payment Management Services (PMS) prior to the required due date. Late submission of reports results in noncompliance with federal regulations, potentially leading to administrative actions such as withholding of future grant funds, increased monitoring, or other penalties as deemed appropriate by the Federal awarding agency. The Agency did not comply with contractual reporting requirements. Auditor Recommendation: We recommend the Agency implement procedures to ensure timely submission of all required reports. Corrective Action: The Agency will implement a system of reviewing the semi-annual and annual federal financial reporting which would include the reports being prepared by the Financial Grants Manager, reviewed by the Chief Financial Officer and submitted by the Chief Executive Officer, all of whom will be aware of the reporting due dates as to ensure they are filed timely. Responsible Person: Anthony J Samon, CFO Anticipated Completion Date: Immediately, the Agency’s next FFR due date is September 30th.

View Audit 359441

Finding 565672 (2024-001)

Significant Deficiency 2024

Boys & Girls Clubs of Southeastern Michigan

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Delinquent Filing of Reports Auditor Description of Condition and Effect: The Organization failed to submit certain reports for the federal grant within the stipulated deadlines as outlined in the grant agreement and Uniform Guidance. Late or delinquent submission of reports results in noncompliance...

Delinquent Filing of Reports Auditor Description of Condition and Effect: The Organization failed to submit certain reports for the federal grant within the stipulated deadlines as outlined in the grant agreement and Uniform Guidance. Late or delinquent submission of reports results in noncompliance with federal regulations, potentially leading to administrative actions such as withholding of future grant funds, increased monitoring, or other penalties as deemed appropriate by the Federal awarding agency. The Organization did not comply with certain contractual reporting requirements. Auditor Recommendation: We recommend the Organization implement procedures to ensure timely submission of all required reports. Corrective Action: BGCSM leadership agrees with the audit finding noted above. BGCSM will establish and document clear grant administration policies and procedures. The processes will include steps to ensure a thorough understanding of the reporting requirements to ensure timely and accurate reporting. Responsible Person: Resource Development – Julia Callis and Gregory McPherson Anticipated Completion Date: 6/30/2025

View Audit 359350

Finding 565660 (2024-002)

Significant Deficiency 2024

Housing Authority of the City of Greenville

NC

HUD Housing Programs Subrecipient Monitoring Eligibility

Finding 2024-002 – Continuum of Care Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end ...

Finding 2024-002 – Continuum of Care Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end September 30, 2025: a. Program Coordinators will maintain all Continuum of Care Tenant files in individual file folders designated by special purpose voucher programs. All loose documents will be anchored in tenant files. b. An action plan has been developed for the Continuum of Care programs to ensure that all program files are HUD, State, and HACG compliant starting with October 1, 2024, files through the current. c. Continuum of Care fiscal year 2024 (October 2023-September 2024) re- exams and interims will be caught up and completed as they become effective. All tenant files will be reviewed and compliant by FYE2024. d. All late/overdue re-exams will be compliant by FYE2024. e. During FYE2024, the Housing Choice Voucher Director will perform quality controls on all Continuum of Care tenant files processed each month prior to initialization (25th-30th of each month). f. File checklist sheets will be placed in each file upon quality control review to be signed off by the Housing Choice Voucher Director. g. Additional training will be required and ongoing for Program Coordinators. h. Other internal control measures will be implemented as deemed necessary by the Deputy Executive Director/COO, to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2025

View Audit 359338

Finding 565659 (2024-001)

Significant Deficiency 2024

Housing Authority of the City of Greenville

NC

HUD Housing Programs Subrecipient Monitoring Eligibility

Finding 2024-001 – Housing Choice Voucher Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year...

Finding 2024-001 – Housing Choice Voucher Tenant Files – Eligibility – Internal Control over Tenant Files – Noncompliance and Significant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fiscal year-end September 30, 2025: a. Housing Choice Voucher tenant files will be reviewed and quality controlled each month prior to initialization (25th-30th of each month) by the Housing Choice Voucher Director. b. An action plan has been developed for the Housing Choice Voucher department to ensure that all Housing Choice Voucher files are HUD and GHA compliant starting with October 1, 2024 files through the current. c. Housing Choice Voucher calendar-year 2024 (October 2023-September 2024) re-exams are substantially complete, as they become effective. All tenant files will be reviewed and HUD-compliant by FYE2024. d. During FYE2024, the Housing Choice Voucher Director will perform 40% quality controls of the monthly re-exams processed by the Housing Specialists. e. File checklist sheets will be placed in each file upon quality control review to be signed off by the Housing Choice Voucher Director. f. Additional training has been and will be made available as necessary. g. Other internal control measures will be implemented as deemed necessary by the Deputy Executive Director/COO, to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2025

View Audit 359338

Finding 565484 (2024-037)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-037 Opioid-STR - Assistance Listing No. 93.788 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit year. It should establish procedures and internal controls to ensure that all required subawards are ...

DEPARTMENT OF PUBLIC HEALTH 2024-037 Opioid-STR - Assistance Listing No. 93.788 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit year. It should establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: All subrecipient FFATA information will be batched and uploaded to FSRS within 30 days of execution of subcontracts. Each month the FFATA submission receipt and all additional records pertaining to the upload will be saved. The internal Fiscal Compliance Auditor will review FFATA monthly submissions for compliance. Uploads will be made monthly by The Grants team. The Grants team at BSAS has created a Standard Operating Procedure (SOP) to make sure this process is repeated every month. Name(s) of the contact person(s) responsible for corrective action: Windy Senecharles Planned completion date for corrective action plan: July 1, 2025

View Audit 359283

Finding 565479 (2024-035)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

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

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-035 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it promptly follows up with participants whose eligibility...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-035 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it promptly follows up with participants whose eligibility review identifies errors and that ineligible participants are terminated from the program. Action taken in response to finding: The State will implement the following corrective actions to enhance the oversight within the Eligibility Quality Assurance (EQA) program: • Annual refresher training for supervisory staff The State will perform an annual refresher training for all Team Leaders and Supervisors who are responsible for reviewing and correcting tasks identified by the Eligibility Quality Assurance unit. • Comprehensive training for new supervisory workers The State will ensure that all newly appointed Team Leaders and Supervisors receive a comprehensive training that will include a detailed overview of the eligibility review and correction process established by the Eligibility Quality Assurance unit. • Review of corrections The State will establish a process to assist and remind managers and supervisors that they are expected to review and approve all corrections made by the eligibility workers in response to the Eligibility Quality Assurance Unit findings. Documentations of such corrections will be maintained for audit and monitoring purposes. • Standardized member outreach process for incomplete Employee Sponsored Insurance forms (ESI). The State will develop and implement a standardized process for timely outreach to members whose ESI form is identified as incomplete. Name(s) of the contact person(s) responsible for corrective action: Tosin Adebiyi, Assistant Director of Special Eligibility Programs and Audits Marco Gonzalez, Eligibility Quality Assurance Team Leader Planned completion date for corrective action plan: All corrective actions are targeted for full implementation by December 31st, 2026.

View Audit 359283

Finding 565475 (2024-034)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Eligibility Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-034 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it properly monitors high-risk providers and that it maint...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-034 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it properly monitors high-risk providers and that it maintains documentation that claims are paid only to eligible providers. Action taken in response to finding: Providers who are identified as high risk, are sent for fingerprinting. Once the fingerprinting results are received, they are scheduled for a site visit. Business Support Services have reinforced with staff that the site visit must follow the fingerprinting results. Additionally, a checklist will be created for all high-risk providers to ensure that all required steps in the process are completed at enrollment, revalidation or when they are identified as having a credible allegation of fraud or appropriate overpayment. Name(s) of the contact person(s) responsible for corrective action: Janice Wadsworth, MassHealth Director Provider Operations Keith West, Director Special Projects Business Support Services and Chris Silva, Manager Provider Enrollment Business Support Services. Planned completion date for corrective action plan: The checklist will be complete by July 2025.

View Audit 359283

Finding 565471 (2024-033)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-033 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: We recommend that the Department enhance its procedures and controls to ensure that the calculation of the federal share of overpayment...

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 2024-033 Medicaid Cluster, COVID-19 – Medicaid Cluster - Assistance Listing No. 93.775, 93.777, 93.778 Recommendation: We recommend that the Department enhance its procedures and controls to ensure that the calculation of the federal share of overpayments to be returned is accurate and is properly reported on the CMS-64. Action taken in response to finding: In response to the finding, MassHealth will: ▪ Add additional validation checks where possible to flag discrepancies or potential errors. ▪ Continue to automate and improve the importation of data to allow more time for quality control review. ▪ Continue to work with staff and provide additional training and guidance ▪ Continue to work with staff to develop additional check points to ensure the correct federal share is reported and returned. Name(s) of the contact person(s) responsible for corrective action: Janet Chin, Director Federal Revenue Claiming, Title XIX & XXI Planned completion date for corrective action plan: Immediate and ongoing

View Audit 359283 Questioned Costs: $1

Finding 565465 (2024-029)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

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

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-029 Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Recommendation: We recommend that the Department review and enhance its procedures and internal controls to ensure that special reports are submitted accurately, and that th...

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-029 Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Recommendation: We recommend that the Department review and enhance its procedures and internal controls to ensure that special reports are submitted accurately, and that the information reported agrees to supporting documentation. Action taken in response to finding: The Executive Office of Housing and Livable Communities (EOHLC), which was formerly the Department of Housing and Community Development (DHCD or Department), has implemented the recommended measures and will continue them going forward. EOHLC has reviewed their policies and procedures for LIHEAP reporting requirements and is committed to making any enhancements that are necessary to ensure the reports are submitted timely and accurately, and that the information reported agrees to the supporting documentation. In addition, EOHLC Management or their designees will review deadlines and other requirements for LIHEAP reports on an ongoing basis. Name(s) of the contact person(s) responsible for corrective action: Edward Kiely Planned completion date for corrective action plan: October 1, 2024

View Audit 359283

Finding 565464 (2024-028)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-028 Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Recommendation: We recommend the Department review and enhance its procedures and internal controls to ensure that all required subawards are reported timely and accurately ...

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2024-028 Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Recommendation: We recommend the Department review and enhance its procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Executive Office of Housing and Livable Communities (EOHLC), which was formerly the Department of Housing and Community Development (DHCD or Department), has implemented the recommended measures and will continue them going forward. As a result of the original finding, 2022-018, EOHLC had previously put policies and procedures in place to ensure that all required subawards are reported timely and accurately to FSRS, and the Federal Funding Accountability and Transparency Act (FFATA) reports are reported timely and accurately. EOHLC’s FFATA report procedure was developed in September of 2023 and submitted on November 20, 2023. EOHLC notes that policies and procedures have already been put in place to remedy this issue. Name(s) of the contact person(s) responsible for corrective action: Frederique P. Phanor Planned completion date for corrective action plan: FFATA report procedure developed September 12, 2023 and LIHEAP submitted November 20, 2023

View Audit 359283

Finding 565463 (2024-027)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Eligibility Special Tests & Provisions Significant Deficiency § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-027 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls to ensure that information used to verify work participation is complete, accurate, ...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-027 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls to ensure that information used to verify work participation is complete, accurate, and agrees with supporting documentation. Action taken in response to finding: A. Program requirements on work hours self-attestation for self-employed The Department will work on guidance that complies with the federal rules and develop instructions for staff on how to determine hours of work for those who are self-employed. B. Accuracy of reported hours of work Quality Control (QC) managers will initial the unsubsidized hours field and the corresponding supporting documentation to indicate that a thorough review has been completed. The current procedure requires QC managers to review all cases, which 250 to 300 cases per month. Further, QC staff will also be reminded of the importance of accurately coding unsubsidized employment hours and will be instructed to double-check their work to minimize errors and maintain data integrity. QC management maintains the practice of reviewing a random 20% sample of all unsubsidized employment hours coded prior to quarterly transmission to ACF, to ensure ongoing accuracy and compliance. QC management will work with IT to explore the possibility of developing a management report or error report using backend BEACON data that would show specifics of errors corrected by QC managers or QC management to assist management in providing targeted training to QC staff. Name(s) of the contact person(s) responsible for corrective action: Megan Nicholls, Associate Commissioner of Family and Economic Assistance Carlos Rosado, Director of Quality Control | Quality Management Planned completion date for corrective action plan: September 30, 2025 – Issue instruction and guidance that complies with the federal rules October 30, 2025 – Implement enhanced procedures accuracy of reported work hours

View Audit 359283

Finding 565462 (2024-026)

Significant Deficiency 2024

Commonwealth of Massachusetts

MA

Questioned Costs Special Tests & Provisions Student Financial Aid § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-026 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls over Child Support Non-Cooperation to ensure that sanctions are applied timely. Acti...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-026 Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Recommendation: We recommend the Department evaluate its procedures and internal controls over Child Support Non-Cooperation to ensure that sanctions are applied timely. Action taken in response to finding: The Department will utilize existing training opportunities, including but not limited to new hire training, monthly supervisor webinars and ad hoc guest training from DOR to address this topic as needed. Further, the Department is working on building out a quality control program on sampling of TAFDC cases in the Quality Management organization. When built out, this program would include a sample review of child support non-cooperative cases to ensure sanctions are applied timely and appropriately. In the interim, ad hoc targeted reviews on this topic will be performed annually at minimum as a compensating control for risk mitigation. Reviews will be performed on a sample basis. Name(s) of the contact person(s) responsible for corrective action: Megan Nicholls, Associate Commissioner of Family and Economic Assistance - Training Lily Kuo, Director of Internal Controls – Ad hoc Targeted Reviews Planned completion date for corrective action plan: September 30, 2025 and forward – Facilitate training March 30, 2026 and forward – Perform ad hoc targeted reviews

View Audit 359283 Questioned Costs: $1

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