Corrective Action Plans

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

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

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

Questioned Costs Eligibility HUD Housing Programs

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 Questioned Costs Reporting

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

Internal Control / Segregation of Duties Subrecipient Monitoring Questioned Costs § 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

Finding 575640 (2024-001)

Significant Deficiency 2024

Pro Bono Resource Center of Maryland, Inc.

MD

Questioned Costs Reporting Significant Deficiency § 200.62

Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. ...

Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. Name of Contact Person: Amy M Smitherman, amy.smitherman@gmail.com, 646-240-3185 Projected Completion Date: 9/15/2025

View Audit 365647 Questioned Costs: $1

Finding 575638 (2024-001)

Significant Deficiency 2024

Housing Authority of the County of Santa Barbara

CA

Questioned Costs Special Tests & Provisions HUD Housing Programs

Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standa...

Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least biennially to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussion with management, there was a failed inspection that did not pass reinspection within 30 days without penalty. Context: There were approximately six hundred ninety four (694) failed inspections during the audit period. Of a sample size of twenty-five (25) failed inspections, one (1) unit did not pass reinspection within 30 days. HAP was not abated nor was the tenant transferred. Known Questioned Costs: $5,322 Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor and will make the necessary changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement). Sanford Riggs, Director of Operations, is responsible for implementing this corrective action by December 31, 2025

View Audit 365643 Questioned Costs: $1

Finding 575629 (2024-003)

Significant Deficiency 2024

Newport County Community Mental Health Center, Inc.

RI

Cash Management Questioned Costs Significant Deficiency § 200.302 § 200.303 § 200.305

Finding 2024.003 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur to ensure accuracy. Not a repeat finding. Action Taken Since September 2023, the Center has implemented weekly grants management reviews with the grants team and key exec...

Finding 2024.003 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur to ensure accuracy. Not a repeat finding. Action Taken Since September 2023, the Center has implemented weekly grants management reviews with the grants team and key executives. Action items are tracked through meeting agendas, minutes, and NMH’s project management platform, Monday.com. Meetings include invoice approvals for grant-funded expenditures, and review of allocations, payroll dates, and stipends for drawing down calculations. The meetings going forward will document the amounts for federal grants drawdowns and will be logged within Monday.com and through an external verification spreadsheet. Starting May 2025, an updated verification spreadsheet along with an itemized attestation was implemented.

View Audit 365599

Finding 575545 (2024-004)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Bank Depository Agreements Recommendation: Obtain depository agreements for all bank accounts as required by HUD. Response/Action Taken: we are working directly with our banking institutions to ensure that all accounts holding HUD funds have the required depository agreements. As of August 2025, ...

Bank Depository Agreements Recommendation: Obtain depository agreements for all bank accounts as required by HUD. Response/Action Taken: we are working directly with our banking institutions to ensure that all accounts holding HUD funds have the required depository agreements. As of August 2025, two of the three existing accounts have updated agreements, and the final agreement is currently under legal review and anticipated for completion by the end of Q3 2024. Context from Prior Audit Findings (FY23) The 2023 audit included findings related to documentaion gaps in areas such as Reasonable Rent, Utility Allowance Schedules, Waiting List procedures, and Housing Quality Standards enforcement. HALC took corrective actions in 2024 to address each of these deficiencies. The recurring nature of some 2024 findings indicates an ongoing effort to build stronger internal controls, rather than unresolved issues form the prior year. If the U.S. Department of Housing and Urban Development has questions regardin this plan, please contact Karen Rockwell at 541-265-5326.

View Audit 365535

Finding 575544 (2024-003)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Special Tests & Provisions Eligibility

Tenant Filing Documentation Processes Recommendation: Implement processes to ensure that all required documentation is properly maintained for every tenant. Response/Action Taken: HALC has standardized the documentation process through updated SOPs and training modules. All staff are now required ...

Tenant Filing Documentation Processes Recommendation: Implement processes to ensure that all required documentation is properly maintained for every tenant. Response/Action Taken: HALC has standardized the documentation process through updated SOPs and training modules. All staff are now required to follow a uniform documentation checklist during intake and recertification. Additionally, file reviews are conducted quarterly by supervisors to ensure compliance and identify any gaps in documentation.

View Audit 365535

Finding 575543 (2024-002)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Special Tests & Provisions Reporting

HUD-50058 Listing Review Process Recommendation: Implement a higher-level review of the HUD-50058 forms submitted to the PIC system. Response/Action Taken: To enhance quality control and data integrity, HALC has introduced a supervisory review of HUD-50058 forms before submission to PIC. A new sec...

HUD-50058 Listing Review Process Recommendation: Implement a higher-level review of the HUD-50058 forms submitted to the PIC system. Response/Action Taken: To enhance quality control and data integrity, HALC has introduced a supervisory review of HUD-50058 forms before submission to PIC. A new second-level review process was developed in Q2 2025, and designated staff now review the forms for accuracy and completeness weekly. We are also coodinationg periodic refresher trainings for housing specialists to stay aligned with HUD requirements.

View Audit 365535

Finding 575542 (2024-001)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

Special Tests & Provisions Questioned Costs HUD Housing Programs

Tenant Reasonable Rent Files Documentation Recommendation: Implement internal controls to ensure tenant reasonable rent files are maintained with adequate documentation. Response/Action Taken: The Authority acknowledges the importance of maintaining complete and accurate reasonable rent documenti...

Tenant Reasonable Rent Files Documentation Recommendation: Implement internal controls to ensure tenant reasonable rent files are maintained with adequate documentation. Response/Action Taken: The Authority acknowledges the importance of maintaining complete and accurate reasonable rent documention. We have instituted an internal file review checklist and implemented bi-monthly audits of tenant files to verify compliance. Staff have been restrained on HUD documentation standards, new file retention protocols are in place to ensure all supporting documents are consistently captured and stored electronically.

View Audit 365535

Finding 575513 (2024-001)

Significant Deficiency 2024

Northern Oswego County Health Services, Inc. Dba Connextcare

NY

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Federal Assistance Listing Numbers: 93.224 and 93.527 2024.001 Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review it was determined that a single CDT code within ConnextCare’s practic...

Federal Assistance Listing Numbers: 93.224 and 93.527 2024.001 Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review it was determined that a single CDT code within ConnextCare’s practice management system was not set-up with the proper procedure class and was omitted from the Sliding Fee Program maintenance schedule. The procedure class was corrected in the system. ConnextCare has audited all CDT codes and has determined that there were no other instances. Additionally, ConnextCare audit all D0274 charges back to January 1st, 2024, and determine there were no other occurrences. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Tracy Wimmer, CFO at (315) 298-6569 ext. 2020. Sincerely yours, Tracy Wimmer Chief Financial Officer

View Audit 365508

Finding 575508 (2024-003)

Significant Deficiency 2024

Town of Marblehead

MA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.328

Condition: As of the March 31, 2024, reporting date, the Town reported project amounts voted by the Select Board as obligated rather than purchases, contracts and agreements that met the Federal criteria of an obligation. Corrective Action Plan: Misinterpretation of Federal reporting requirements r...

Condition: As of the March 31, 2024, reporting date, the Town reported project amounts voted by the Select Board as obligated rather than purchases, contracts and agreements that met the Federal criteria of an obligation. Corrective Action Plan: Misinterpretation of Federal reporting requirements regarding the definition of an obligation. Reliance on local budgetary approvals (Select Board votes) rather than federally defined contractual commitments. Lack of documented procedures for distinguishing between appropriations/votes and obligations in Federal reporting. This was primarily due to the many changes by the US Treasury on ARPA Federal Reporting. The Select Board did obligate funds for the Town to hire a compliance accountant as an administrative service which is allowable under ARPA to ensure compliance. In addition, the Town hired a full-time grants coordinator to oversee the grants. All future reports will reflect only qualifying obligations supported by contracts, purchase orders, or agreements. Anticipated Completion Dates: o Completed in 2025: Correction of prior misreporting and adoption of revised obligation reporting practice. o By September 30, 2025: Grant Coordinator additional training and issuance of updated reporting checklist. o Ongoing: Federal obligation reports prepared quarterly, reviewed by the Grant Coordinator prior to submission. Quarterly compliance checks will be performed by the Grant Coordinator to confirm obligations are federally compliant. Contact Information: Donna Cotterell, Grant Coordinator

View Audit 365493

Finding 575507 (2024-003)

Significant Deficiency 2024

Avivo

MN

Questioned Costs Cash Management Reporting § 200.303

Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend the entity evaluate its procedures and implement an additional control to ensure reports are submitted timely and reviewed prior to submission. Exp...

Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend the entity evaluate its procedures and implement an additional control to ensure reports are submitted timely and reviewed prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Avivo will implement an enhanced internal review process to ensure timely report submission and accuracy prior to submission. This will include assigning dedicated personnel to track submission deadlines and conducting pre-submission reviews for completeness and accuracy. Name(s) of the contact person(s) responsible for corrective action: Heidi Kammer-Hodge & Kristen Bewley. Planned completion date for corrective action plan: December 2025.

View Audit 365488

Finding 575491 (2024-002)

Significant Deficiency 2024

Avivo

MN

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no...

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to ensure costs are charged to the grant during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to 2023-2024, we only had one primary HUD contract that we were solely responsible for spending and contract timelines. With the addition of three more COC grants, with different, yet close together end dates, we needed to develop a more formalized process to ensure all expenses are billed to the correct contract for the correct dates. Avivo will implement oversight check-in meetings at least one month prior to each contract end and at least one more before final grant submissions. This meeting will include program leadership, RAA, Director of Housing Compliance, and our Contracts Accountant who oversees eLOCCS pulls. We will discuss all final expenditures and any upcoming expenses that may near the end of the grant term, including staff expenditures like mileage reimbursement. We will create an oversight document that highlights all areas to consider and breaks down roles and responsibilities to drive these meetings ongoingly. Accounting and program leadership will closely monitor spending via Papersave, credit card submission and through Paycom falls within the correct payment periods. Additionally, the RAA and Program Managers in the last quarter of the grant cycle, will meet monthly to work to resolve any outstanding rent balances and oversee any staff reimbursement or other charges that may need to be accounted for. Name(s) of the contact person(s) responsible for corrective action: Courtney Knoll & Lyssa Westling. Planned completion date for corrective action plan: December 2025

View Audit 365488 Questioned Costs: $1

Finding 575475 (2024-001)

Significant Deficiency 2024

Avivo

MN

Questioned Costs HUD Housing Programs Significant Deficiency

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to document rental rate checks are occurring prior to entering into rental contract. Explanation of disagreement with audit finding: T...

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: We recommend the Organization evaluate its procedures and implement an additional control to document rental rate checks are occurring prior to entering into rental contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In March 2024, Avivo created a Rental Assistance Administrator (RAA) role to oversee all rental administration processes for our subsidy housing programs, including paperwork and compliance. The role developed over 2024 and was reviewed and reclassified from purely administrative to leadership and compliance in March 2025, after a year of development. With the new role, we have shifted responsibility off managers for final approval of documentation and have them focusing solely on programming and service provision. The RAA has created standardization across programs, ensures high levels of compliance, ensures no payments are sent without full, accurate documentation and helps to identify common errors early on and areas for training or support. To ensure the most accurate and complete paperwork is uploaded to our electronic health record, we are now submitting all subsidy paperwork through the electronic health system for review and approval. This solidified our process and eliminated managers creating their own processes. Switching to all approvals being electronic ensures that the most accurate and complete paperwork is available and in one place. RAA also approves and processes all rental payments from the service side and if paperwork is not approved, no payments will be released. Program Leadership, RAA and Director of Housing Operations meet bimonthly to review the program manual and policies overall to ensure most accurate policies and practices are reflected. We also updated our checklist cover sheets for all subsidy paperwork changes to reflect the changes from paper to electronic health record and have made several pieces of the subsidy paperwork process available to be completed electronically. In regards to rent reasonableness specifically, Program Leadership, RAA and Director of Housing Operations are planning two work sessions in late August and September, to review policies, current paperwork requirements and to plan additional training and supports for frontline staff to ensure full understanding of rent reasonableness and overall best practices. As part of this, we will review current paperwork and see if there are improvements that could be made, including making documentation fully electronic. We will also be looking at timelines around paperwork submission and sending out payments. Once it is determined what actions are the best solutions, managers will present changes and retrain on rent reasonableness and any other compliance improvements in team meetings in October 2025. Name(s) of the contact person(s) responsible for corrective action: Courtney Knoll, Program Director Planned completion date for corrective action plan: October 2025

View Audit 365488

Finding 575328 (2024-001)

Significant Deficiency 2024

Twenty-Nine Palms Band of Mission Indians

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Description of Finding: Activities Allowed or Unallowed - Significant Deficiency in Internal Controls Over Compliance and Noncompliance · Criteria: Salaries and wages and fringe benefits charged to awards must be supported by reports reflecting the distribution of activity for each employee whose co...

Description of Finding: Activities Allowed or Unallowed - Significant Deficiency in Internal Controls Over Compliance and Noncompliance · Criteria: Salaries and wages and fringe benefits charged to awards must be supported by reports reflecting the distribution of activity for each employee whose compensation is charged to the award. · Condition/Context: For 13 payroll transactions tested for allowability, the auditors noted that the rate charged to the grant differed from the rate the employee was paid. · Cause/Effect: The amount charged to the grant was based on the pay rate included on the employee's timesheet. The rate had not been appropriately updated on the timesheet, which resulted in an incorrect amount being charged to the grant. Statement of Concurrence or Nonconcurrence: Tribe agrees with the finding as stated by the auditors. Corrective Action: All grant awards were reviewed to reconcile salaries, wages and fringe benefits to the correct rate. Adjustments were made to multi-year awards, or updated Federal Financial Reports were prepared where appropriate. In October 2024, the tribe implemented a new payroll system, Paycom, that allows employees to code activity directly to an award. The payroll system allocates salary/wages and benefits based on the employee's current approved rate directly to the grant fund. Paycom will integrate with the Award Management module in the Tribe's new ERP system, Mission Gov beginning July 2025, for direct posting. Persons Responsible: Leslie Williams, Senior Vice President of Finance Wendy Collazo, Executive Director of Accounting - Tribal Government

View Audit 365381

Finding 575327 (2024-003)

Significant Deficiency 2024

Shiloh Home Inc.

CO

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.328

Corrective Action Plan: The Organization has updated its internal review procedures to reflect the need to submit the quarterly Federal Financial Reports within the timeframe prescribed by the terms and conditions of the Federal award.

View Audit 365374

Finding 575313 (2024-001)

Significant Deficiency 2024

Lake Superior Community Health Center, Inc.

MN

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Health and Human Services 2024-001 Consolidated Health Centers – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization investigate the underlying cause of the error, and provide education or incorporate some sort of reconciliation or review process to ...

U.S. Department of Health and Human Services 2024-001 Consolidated Health Centers – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization investigate the underlying cause of the error, and provide education or incorporate some sort of reconciliation or review process to ensure sliding fee adjustments applied match the original determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will provide training to individuals involved with entering sliding fee discounts into EMR and will investigate other review or reconciliation procedures that could be incorporated to reduce risk. Name(s) of the contact person(s) responsible for corrective action: Jake Kuschke, CFO Planned completion date for corrective action plan: 12/31/25 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Jake Kuschke at 715-395-5386.

View Audit 365353

Corrective Action Plans

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