Corrective Action Plans

Finding 481039 (2023-002)

Material Weakness 2023

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

The Emergency Connectivity Fund will not be used again. The funding has ended. The District will ensure they follow best practices on all grants. Anticipated date to complete the corrective action: September 1, 2023

View Audit 317162 Questioned Costs: $1

Finding 481030 (2023-003)

Significant Deficiency 2023

City of Rohnert Park

CA

Reporting Subrecipient Monitoring § 200.328

Finding 2023-003 Reporting – Internal Control and Compliance over Reporting Information on the Federal Program: Assistance Listing Number: 21.027 Federal Program Name: Coronavirus State and Local Fiscal Recovery Fund Federal Agency: Department of Treasury Pass-Through Entity: N/A ...

Finding 2023-003 Reporting – Internal Control and Compliance over Reporting Information on the Federal Program: Assistance Listing Number: 21.027 Federal Program Name: Coronavirus State and Local Fiscal Recovery Fund Federal Agency: Department of Treasury Pass-Through Entity: N/A Federal Award Number and Award Year: N/A - FY22-23 Criteria: Title 2 - Grants and Agreements. Subtitle A - Office of Management and Budget Guidance for Grants and Agreements. Chapter II - Office of Management and Budget Guidance. Part 200 - Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. Subpart D - Post Federal Award Requirements. Performance and Financial Monitoring and Reporting. §200.328 – Financial Reporting (2 CFR 200.328): Unless otherwise approved by OMB, the Federal awarding agency must solicit only the OMB-approved governmentwide data elements for collection of financial information (at time of publication the Federal Financial Report or such future, OMB-approved, governmentwide data elements available from the OMB-designated standards lead. This information must be collected with the frequency required by the terms and conditions of the Federal award, but no less frequently than annually nor more frequently than quarterly except in unusual circumstances, for example where more frequent reporting is necessary for the effective monitoring of the Federal award or could significantly affect program outcomes, and preferably in coordination with performance reporting. The Federal awarding agency must use OMB-approved common information collections, as applicable, when providing financial and performance reporting information. Title 31 – Money and Finance: Treasury. Subtitle A – Office of the Secretary of the Treasury. Part 35 – Pandemic Relief Programs. Subpart A – Coronavirus State and Local Fiscal Recovery Funds. § 35.4 Reservation of authority, reporting. (c) Reporting and requests for other information. During the period of performance, recipients shall provide to the Secretary periodic reports providing detailed accounting of the uses of funds, modifications to a State or Territory’s tax revenue sources, and such other information as the Secretary may require for the administration of this section. In addition to regular reporting requirements, the Secretary may request other additional information as may be necessary or appropriate, including as may be necessary to prevent evasions of the requirements of this subpart. False statements or claims made to the Secretary may result in criminal, civil, or administrative sanctions, including fines, imprisonment, civil damages and penalties, debarment from participating in Federal awards or contracts, and/or any other remedy available by law. Condition: For the Coronavirus State and Local Fiscal Recovery Funds (SLFRF), the City did not submit the reports within the required deadline: Report Type Report Type Period Date Due Date Submitted Project and Expenditure Report Performance Report 1/1/23-3/31/23 4/30/2023 5/3/2023 Project and Expenditure Report Performance Report 4/1/23-6/30/23 7/31/2023 8/25/2023 Four (4) performance reports were tested and two (2) of the reports tested were not submitted by the required deadline. In addition, expenditure information reported on the Project and Expenditure Reports were not supported by the City’s accounting records and did not match expenditures reported on the SEFA. This was due to the City not reporting the Revenue Replacement project expenditures of $4,821,936. The City’s Corrective Action Plan: The City concurs with the auditors’ finding. The City will take steps to improve identification and monitoring of required grantor reporting deadlines. Contact person responsible for corrective action: Betsy Howze, Interim Finance Director Anticipated completion date: June 30, 2024

View Audit 317149

Finding 480998 (2023-001)

Material Weakness 2023

Town of Sutton

MA

School Nutrition Programs Eligibility Internal Control / Segregation of Duties

Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024 Audit Reference: 23-001 Non-Compliance Issue: verification process not completed during school year 22-23 Root Cause Analysis: This was caused by lack of knowledge due to manager change over wi...

Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024 Audit Reference: 23-001 Non-Compliance Issue: verification process not completed during school year 22-23 Root Cause Analysis: This was caused by lack of knowledge due to manager change over with no overlap and managers starting date after verification completion deadline. Corrective Action(s): In planning for next school year, it has been set as a calendar reminder for October 1st to start the verification process with weekly goals set as to what needs to be done each week. As well as a reminder set for November 15th to make sure verification paperwork is submitted prior to the due date of November 17th. 1. Action Item: o Description: Set plans and calendar reminders in place to ensure the verification process is start prior to the end of September and that all is completed to be completed accurately before due date o Responsible Person/Department: Christina Poquette o Expected Completion Date:10/17/2024 Name: Christina Poquette Title: Director of Food and Nutrition Signature: Date: 5/20/2024 Acknowledgement by Responsible Parties: Name: Title: Signature: Date:5/20/2024 Organization Name: Sutton Public Schools Address: 16 Putnam Hill Rd Sutton MA 01590 Issue Date: 05/20/2024

View Audit 317107

Finding 480996 (2023-001)

None 2023

Indiana University Health, Inc. and Subsidiaries

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2023-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...

Finding 2023-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A

View Audit 317105

Finding 480985 (2023-004)

Significant Deficiency 2023

Heartland Alliance for Human Needs & Human Rights

IL

Subrecipient Monitoring

Finding Number: 2023-004 Subrecipient Monitoring - Compliance and Internal Control Summary of Finding: In accordance with §200.331(b) and §200.331(d), Requirements for Pass-Through Entities, the Organization, the recipient of these federal funds) must evaluate each subrecipient’s risk of noncomplian...

Finding Number: 2023-004 Subrecipient Monitoring - Compliance and Internal Control Summary of Finding: In accordance with §200.331(b) and §200.331(d), Requirements for Pass-Through Entities, the Organization, the recipient of these federal funds) must evaluate each subrecipient’s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. During our testing of subrecipient monitoring, we selected two subrecipient samples. We identified the following conditions: • For one of the two samples testing, the Organization was unable to provide documented evidence for the evaluation of the subrecipient’s risk assessment. • For one sample tested, there was no timely evidence that the Organization verified the subrecipient’s audit requirements. Therefore, monitoring activities related to the verification of the audit requirements were not performed in accordance with §200.331(b) and §200.331(d). Response to Finding: Heartland Alliance International acknowledges the findings related to subrecipient monitoring and the non-compliance with §200.331(b) and §200.331(d). We understand the importance of evaluating each subrecipient’s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward to ensure appropriate monitoring. The identified issues were due to lapses in our documentation and verification processes. We are committed to addressing these deficiencies promptly to enhance our compliance and internal control mechanisms. Corrective Action: 2. Improved Documentation Procedures: o Action: Implement a standardized process for documenting the evaluation of each subrecipient’s risk assessment. This will include a checklist and risk assessment template that must be completed and stored in the subrecipient’s file. o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 3. Verification of Audit Requirements: o Action: Establish a formal procedure to ensure timely verification of subrecipients’ audit requirements. This will include setting up reminders and deadlines within our compliance management system to verify audit submissions and review findings promptly. o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 4. Training and Awareness: o Action: Conduct training sessions for all staff involved in subrecipient monitoring to ensure they are aware of the federal requirements and the importance of timely and accurate documentation. Regular refresher courses will be scheduled to maintain high compliance standards. o Responsible Individual: Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 o Internal Audit and Review: o Action: Initiate periodic internal audits to review subrecipient monitoring activities. This will help in identifying any gaps early and ensuring ongoing compliance with §200.331(b) and §200.331(d). o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 5. Enhanced Monitoring System: o Action: Upgrade our subrecipient monitoring system to integrate automated tracking and alerts for compliance-related tasks. This system will ensure that no required actions are overlooked, and that all documentation is securely stored and easily accessible. o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 By implementing these corrective actions, we aim to ensure full compliance with federal requirements and strengthen our internal controls to prevent recurrence of such findings in the future. Individual(s) Responsible for Corrective Action Plan: o Responsible Individual: Rebecca Obrock, Chief Operating Officer o Completion Date: 9/30/2024 o Phone Number: (773) 275-2586 o Anticipated Completion Date: 9/30/2024

View Audit 317091

Finding 480984 (2023-003)

Significant Deficiency 2023

Heartland Alliance for Human Needs & Human Rights

IL

Subrecipient Monitoring

Finding Number: 2023-003 Reporting - Compliance and Internal Control Summary of Finding: Under the requirements of the Federal Funding Accountability and Transparency Act (“FFATA”) (Pub. L. No. 109-282), as amended by Section 6202 of Pub. L. No. 110-252, hereafter referred as the “Transparency Act” ...

Finding Number: 2023-003 Reporting - Compliance and Internal Control Summary of Finding: Under the requirements of the Federal Funding Accountability and Transparency Act (“FFATA”) (Pub. L. No. 109-282), as amended by Section 6202 of Pub. L. No. 110-252, hereafter referred as the “Transparency Act” that are codified in 2 CFR Part 170, recipients (i.e., direct recipients) of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). We were unable to verify that the Organization has established policies and procedures to ensure that the required reports are accurately completed and submitted on a timely basis, we noted the following matters for the subawards tested: • For the two samples tested, the Organization was unable to provide proof of submission of the FFATA reports. Response to Finding: Heartland Alliance International acknowledges the findings related to the FFATA reporting requirements. We recognize the importance of accurate and timely submission of reports to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The identified issue was due to a lack of established policies and procedures for ensuring the submission of FFATA reports. We are committed to rectifying this oversight and enhancing our reporting processes to ensure full compliance with the Transparency Act requirements. Corrective Action: 1. Development of Reporting Procedures: o Action: Develop and implement comprehensive policies and procedures for FFATA reporting. This will include detailed guidelines on the preparation, review, and submission of FFATA reports, ensuring that all necessary documentation is maintained. o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 2. Training for Staff: o Action: Conduct training sessions for staff responsible for FFATA reporting to ensure they are fully aware of the reporting requirements and the importance of timely submissions. Training will cover the use of the FSRS system and the new procedures. o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 3. Internal Monitoring and Verification: o Action: Establish an internal monitoring and verification process to ensure all FFATA reports are submitted accurately and on time. This will involve periodic checks and audits of the reporting process to identify and address any discrepancies promptly. o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 4. Documentation and Record-Keeping: o Action: Implement a standardized system for documenting and storing all FFATA report submissions. This system will ensure that proof of submission is readily available for verification and audit purposes. o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 5. Automated Reminders and Alerts: o Action: Utilize an automated system to set reminders and alerts for upcoming FFATA reporting deadlines. This system will help ensure that reports are submitted on time and that staff are aware of their responsibilities. o Responsible Individual: Carolina Ramazzina Van Moorsel, Sr. Director Global Grant Compliance o Completion Date: 9/30/2024 By implementing these corrective actions, we aim to ensure full compliance with the Transparency Act requirements and strengthen our internal controls to prevent recurrence of such findings in the future. Individual(s) Responsible for Corrective Action Plan: • Name: Rebecca Obrock • Title: Chief Operating Officer • Phone number: (773) 275-2586 • Anticipated Completion Date: 9/30/2024

View Audit 317091

Finding 480980 (2023-002)

Significant Deficiency 2023

Heartland Alliance for Human Needs & Human Rights

IL

Questioned Costs Subrecipient Monitoring

Finding Number: 2023-002 Period of Performance - Compliance and Internal Control Summary of Finding: In accordance with §200.309, a non-Federal entity may charge to the Federal award only allowable costs incurred during the period of performance and any costs incurred before the Federal awarding age...

Finding Number: 2023-002 Period of Performance - Compliance and Internal Control Summary of Finding: In accordance with §200.309, a non-Federal entity may charge to the Federal award only allowable costs incurred during the period of performance and any costs incurred before the Federal awarding agency or pass-through entity made the Federal award that were authorized by the Federal awarding agency or pass-through entity. Unless the Federal awarding agency or pass-through entity authorizes an extension, a non-Federal entity must liquidate all obligations incurred under the Federal award not later than 120 calendar days after the end date of the period of performance as specified in the terms and conditions of the Federal award as required by §200.344(b). During the audit, we identified 1 out of 40 items selected, whereby the expense was incurred after the end of the award period of performance. The expense totaled $1,407. Response to finding: Management agrees with the finding and takes responsibility to comply with period of performance requirements. Management plans to implement additional policies and procedures to ensure compliance with period of performance. Corrective Action: Management is working to implement additional policies and procedures that specifically address period of performance. Management is also making changes within the accounting system that will help ensure expenses are recorded to the proper period. Individual(s) Responsible for Corrective Action Plan: o Name: Melissa Ells o Title: Controller o Phone number: 312-660-1667 o Anticipated Completion Date: September 2023

View Audit 317091 Questioned Costs: $1

Finding 480968 (2023-002)

Significant Deficiency 2023

San Ysidro Health, Inc.

CA

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

Finding 2023-002 Federal Agency: U.S. Department of Health and Human Services, ALN#93.224/93.527 Health Centers Cluster Response: Management acknowledges the finding of the auditors and recognizes the need for improving its Sliding Fee Discount Program systems, processes, and monitoring. In the ...

Finding 2023-002 Federal Agency: U.S. Department of Health and Human Services, ALN#93.224/93.527 Health Centers Cluster Response: Management acknowledges the finding of the auditors and recognizes the need for improving its Sliding Fee Discount Program systems, processes, and monitoring. In the latter half of 2024, the Billing Department leadership and front desk training team will renew its staff training and oversight efforts to improve compliance. Training on San Ysidro Health’s Sliding Fee Discount Program policies and procedures will be planned, scheduled, and provided for all front desk leaders and staff to ensure that the policies and procedures are followed to mitigate the risk of repetitive findings in following years. In addition, the Billing Department will expand the number of sliding fee encounters sampled and tested for compliance monthly. Noncompliance will serve as the basis for additional follow-up training of staff when noted. Monthly compliance reporting will be provided to senior finance and operational leaders to ensure ongoing monitoring of performance and timely resolution of noncompliance. Responsible Party: Charles Nubia, Director of Revenue Cycle; Brian Wallace, CFO Estimated Completion Date: July 22, 2024

View Audit 317089

Finding 480967 (2023-002)

Material Weakness 2023

City of Dillingham

AK

Reporting Subrecipient Monitoring Significant Deficiency § 200.1 § 200.329

Finding 2023-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Anita Fuller, Finance Director Corrective Action Plan: Proposed Completion Date: Immediately

View Audit 317088

Finding 480945 (2023-001)

None 2023

Town of Wilbraham, Ma

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Audit Finding Reference: 2023-001 – Document Policies and Procedures over Federal Awards Planned Corrective Action: The Town is in the process of reviewing Policies and Procedures as they relate to Federal Awards. Name of Contact Person and Completion Date: Derek Geser, Wilbraham Town Accounta...

Audit Finding Reference: 2023-001 – Document Policies and Procedures over Federal Awards Planned Corrective Action: The Town is in the process of reviewing Policies and Procedures as they relate to Federal Awards. Name of Contact Person and Completion Date: Derek Geser, Wilbraham Town Accountant & Nick Breault, Wilbraham Town Administrator - No estimated completion date as of now.

View Audit 317055

Finding 480928 (2023-002)

Material Weakness 2023

The Simple Foundation

NE

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.318 § 200.326

FINDING 2023-002: Procurement Please provide an explanation of how your organization plans to resolve procurement error moving forward The Simple Foundation has implemented a newly developed procurement policy that aligns with the Uniform Guidance procurement standards. Moving forward, this policy w...

FINDING 2023-002: Procurement Please provide an explanation of how your organization plans to resolve procurement error moving forward The Simple Foundation has implemented a newly developed procurement policy that aligns with the Uniform Guidance procurement standards. Moving forward, this policy will be strictly followed for all agreements and transactions under the Federal procurement requirements within Uniform Guidance. Attached below in the procurement policy and the Purchase Justification Form. Reasonable completion date: 08/04/2024 Responsible Party: D&K Financial, Compliance

View Audit 317033

Finding 480921 (2023-009)

None 2023

City of Derby, Connecticut

CT

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Finance Department and/or the Board of Education annually prepare the Schedule of Expenditures of Federal Awards and State Financial Assistance to be presented to the auditor for audit. The auditor can then render an opinion with respect to compliance with and ...

Recommendation: We recommend that the Finance Department and/or the Board of Education annually prepare the Schedule of Expenditures of Federal Awards and State Financial Assistance to be presented to the auditor for audit. The auditor can then render an opinion with respect to compliance with and internal control over compliance with laws, regulations, contracts and grants. This will provide the proper segregation of responsibilities over the preparation of the schedules and the rendering of an opinion of these schedules. Management’s Response: The City and BOE will prepare the Schedules of Expenditures of Federal and State Financial Assistance going forward.

View Audit 317016

Finding 480883 (2023-005)

Significant Deficiency 2023

Anoka County

MN

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Finding Number: 2023-005 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Renee Sande – Manager, Community Development Corrective Acti...

Finding Number: 2023-005 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Renee Sande – Manager, Community Development Corrective Action Planned: Anoka County Community Development staff is implementing procedures to ensure the completion of reports required by Federal Funding Accountability and Transparency Act (FFATA). As part of the procedures, staff will establish and maintain effective internal controls over the federal award to ensure compliance with federal statutes and regulations, along with the terms and conditions of the federal award. Community Development will consult with the U.S. Department of Housing and Urban Development (HUD) on how best to correct reporting. Moving forward, Federal Funding Accountability and Transparency Act (FFATA) reporting will be completed promptly within the required 30 days for applicable subawards of $30,000 or more. This task has been added to the annual contracting process and to assist with tracking, this item has been added to the Community Development Block Grant (CDBG) sub-recipient check list. Anticipated Completion Date: By July 31, 2024, Community Development staff will add required PY 2023 and PY 2022 CDBG recipients of grants or cooperative agreements to the Federal Subaward Reporting System (FSRS) as required for subawards of $30,000 or more per the Federal Funding Accountability and Transparency Act (FFATA).

View Audit 316995

Finding 480840 (2023-002)

Significant Deficiency 2023

Springfield Housing Authority

IL

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

FINDING 2023-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency " SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2023 FYE audit report. In 2023, the Spri...

FINDING 2023-002 "Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance & Significant Deficiency " SHA RESPONSE The Springfield Housing Authority acknowledges the seven (7) errors as delineated in the full 2023 FYE audit report. In 2023, the Springfield Housing Authority Housing Choice Voucher program delineated the following positions to undertake Income and rent calculations: one {l) Special Programs Coordinator, four (4) HCV Specialists and one {1) Program Integrity Specialist. Of those six (6) employees, only onehas a tenure longer than 12 months. Due to continuing post COVID-19 turnover and lack of qualified workers in the local workforce, the SHA expertenced a higher than usual turnover rate in the HCV positions that conduct rent calculations during the majority of FY2023. The Springfield Housing Authority hired third party consultants to assist with annualrecertificationsin the 3rd Quarter of 2023. The primary function of the Program Integrity Specialist position ls to audit and quality control tenant files and rent calculations conducted by HCV Specialists. The HCV Director and/or HCV Manager is responsible for reviewing 3% of recertiflcations audited by the Program Integrity Specialist position as an additional quality control measure. This error rate was directly attributable to the unprecedented turnover rate of HCV Specialists duringthe 2023 fiscal year. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Speclalist will conduct reviews of 100% of annual and interim recertificatlons for HCV program participants by December 31, 2024. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the HCV Specialists, monthly. • The HCV Director and/or Manager will review 10% of the recertifications audited by the Program Integrity Speclallst as an additional quality controlmeasure by December 31, 2024. • The HCV Director, HCV Manager, HCV Specialists and Program Integrity Specialist will be provided with additional internal and external training opportunities in Housing Choice Voucher program income andrent calculations andprogram Integrity by December 31, 2024. • The HCV Manager will re-review the flies Identified with errors during the independent audit and resolve the errors in accordance with the SHA Administrative Plan and HUD rules and regulations by September 30, 2024. Person Responsible: Melissa Huffstedtler, Deputy Director Anticipated Completion Date: December 31, 2024

View Audit 316970

Finding 480839 (2023-001)

Significant Deficiency 2023

Springfield Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

FINDING 2023-001 "Public Hous;ng Tenant Fffes - fllgibility- tnrerno/ Control Over Tenant Files Non-Compliance and Significant Deficiency" SHA RESPONSE The Springfield Housing Authority acknowledges the five (5) errors as delineated in the full 2023 FYE audit report. The identified errors constitut...

FINDING 2023-001 "Public Hous;ng Tenant Fffes - fllgibility- tnrerno/ Control Over Tenant Files Non-Compliance and Significant Deficiency" SHA RESPONSE The Springfield Housing Authority acknowledges the five (5) errors as delineated in the full 2023 FYE audit report. The identified errors constitute a 54% reduction in file errors from fY 2022. In 2023, the Springfield Housing Authority Public Housing program employed three (3} Asset Managers, three (3) Occupancy Specialists and one (1) Program Integrity Specialist. Due to continuing post COVID-19 turnover and lack of qualified workers in the local workforce, the SHA continued to experience a higher than usual turnover rate Ir, the positions that conduct rent calculattons duringthe majority of FY2023. Thepositions began to stabilize by the 4th quarter of 2023. The primary function of the Program Integrity Specialist position is to audit and quality control tenant files and rent calculations conducted by Occupancy Specialists. The Asset Managers are responsible for reviewing 3% of recertifications audited by the Program Integrity Specjalist position as an additional quality controlmeasure. Further, during the auditor's closeout meetingwith the SHA Management team, the auditors indicated that the SHA team conducted necessary file audits and identified deficiencies, however the corrections were not timely. This error rate was directly attributable to the continued high turnover rate of Occupancy Specialists during the 2023 fiscalyear. The SHA will take the following corrective actions to correct the errors and/or prevent the errors moving forward: • The Program Integrity Specialist will conduct reviews of 100% of annual and interim recertiflcations for publlc housing tenants by December 31, 2024. • The Program Integrity Specialist will ensure 100% audited file corrections are completed by the Occupancy Specialists, monthly. • The Asset Manager(s) will review 10% of the recertifications audited by the Program Integrity Specialist as an additional quality control measure by December 31, 2024. • The Asset Managers, Occupancy Specialists and Program Integrity Specialist will be provided with additional internal andexternal trainingopportunities In low rent public housingrentcalculations and program integrity by December 31, 2024. • The Asset Managers will re-review the files identified with erro)J.during the independent audit and resolve the errors in accordance with the SHA Admissions and Cbntl nued Occupancy Plan and HUD rules and regulations by September 30, 2024. Person Responsible: Melissa Huffstedtler, Deputy Director Anticipated Completion Date: December 31, 2024

View Audit 316970

Finding 480730 (2023-001)

Significant Deficiency 2023

Issaquah School District No. 411

WA

Questioned Costs School Nutrition Programs Allowable Costs / Cost Principles

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal allowable activities and allowable costs requirements. Name, address, and telephone of District contact person: Cindy Feng, Controller 5150 220th Avenue S.E. Issaqu...

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal allowable activities and allowable costs requirements. Name, address, and telephone of District contact person: Cindy Feng, Controller 5150 220th Avenue S.E. Issaquah, WA 98029 (425)837-7139 Corrective action the auditee plans to take in response to the finding: The District used SCA funds to pay a vendor for locally produced dairy products for our schools that complied with the funding requirements. Invoices from the vendor show the total amount for each delivery but did not include item level details. With each delivery, a packing slip was provided to the Food Services Department staff members to confirm the receipt of approved items and reconcile for invoice approval. Once invoices were reconciled and properly approved with a signature indicating review, the District used the official invoice statement for payment processing and the delivery packing slip was no longer retained. To assist with the audit, the District provided auditors with the dairy vendor contract, vendor invoice statements, and an attestation letter from vendor stating the items purchased Issaquah School District 5150 220ᵗʰ Ave SE, Issaquah, WA 98029 phone: (425) 837-7000 https://www.isd411.org Page 64 Office of the Washington State Auditor sao.wa.gov conformed to the SCA item list. Unfortunately, these documents were deemed insufficient to allow SAO re-performing our internal controls to test its effectiveness. After SAO communicated the necessity for delivery packing slips in their testing, the District enhanced our current practice and began retaining all packing slips to support SAO’s internal control effectiveness review. We welcome any feedback to further strengthen our overall financial management practices moving forward. Anticipated date to complete the corrective action: June 2024

View Audit 316941 Questioned Costs: $1

Finding 480698 (2023-002)

Material Weakness 2023

Wayne State University Research and Technology Park in the City of Detroit

MI

Subrecipient Monitoring Material Weakness

Finding Number: 2023-002 Condition: The Organization did not have controls in place to ensure required FFATA reports were submitted in the period of time required. Planned Corrective Action: The subrecipient organizations and the amounts of each sub-award were included in the grant application. The ...

Finding Number: 2023-002 Condition: The Organization did not have controls in place to ensure required FFATA reports were submitted in the period of time required. Planned Corrective Action: The subrecipient organizations and the amounts of each sub-award were included in the grant application. The subrecipients were listed in the Organization’s Prime award Specific Terms and Conditions. The organization has implemented an FFATA policy handbook to ensure awareness of the filing timing requirements. This handbook has been included in the Organization’s Grant Award checklist for all federal grant awards. Contact person responsible for corrective action: Diana Goode, Chief Financial Officer, and Norma Jean Zaleski, Director of Grant and Fiscal Compliance Anticipated Completion Date: 12/31/2024

View Audit 316927

Finding 480695 (2023-001)

Significant Deficiency 2023

Southwest Mississippi Regional Medical Center

MS

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303 § 200.430

Finding 2023-001 – Allowable Activities and Costs of Provider Relief Fund Significant Deficiency in Internal Control over Compliance Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Federal Grantor: U.S. D...

Finding 2023-001 – Allowable Activities and Costs of Provider Relief Fund Significant Deficiency in Internal Control over Compliance Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Federal Grantor: U.S. Department of Health and Human Services Pass-Through Entity: None Criteria: Per 2 CFR 200.430(i), personnel costs charged to federal grants are required to be supported by documentation including time records. Per 2 CFR 200.303, a non-federal entity must establish and maintain effective internal control over Federal awards that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and terms and conditions of the Federal award. Condition: Our audit procedures over the calculation of COVID patient days used to allocate the payroll cost to the PRF/ARP federal program disclosed the amounts were not properly calculated. Cause: The Medical Center has controls in place to review the calculation; however, the control did not operate to identify an error in the calculation of COVID patient days. Effect: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Questioned Costs: None Perspective: The error in the calculation resulted in underreporting payroll costs allowed to be charged to PRF/ARP in the amount of $566,272. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Medical Center implement additional internal controls over compliance in order to properly identify any errors in calculation. Management’s Action Plan: The Medical Center will implement additional internal controls over compliance. Such controls will include verification of all calculations used by two parties, the Director of Finance and CFO as well as signoff on calculations. Name of Person Responsible for the Plan: Mallory Ginn, CFO Anticipated Completion Date of the Plan: 7/31/2024

View Audit 316922

Finding 480673 (2023-001)

None 2023

Riordan School Addition Housing Development Fund Company, Inc.

NY

Subrecipient Monitoring Reporting § 200.512

Finding #2023-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Bessie Riordan Addition Apartments agrees...

Finding #2023-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Bessie Riordan Addition Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.

View Audit 316881

Finding 480671 (2023-001)

None 2023

The Carpenter Housing Development Fund Co., Inc.

NY

Subrecipient Monitoring Reporting § 200.512

Finding #2023-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Carpenter Apartments agrees with the aud...

Finding #2023-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Carpenter Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.

View Audit 316880

Finding 480670 (2023-002)

Material Weakness 2023

Arizona Foundation for Human Service Providers

AZ

Subrecipient Monitoring § 200.330 § 200.332

Item: 2023-002 Assistance Listing Number: 21.027 Programs: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Federal Agency: U.S. Department of Treasury Pass-Through Agencies: State of Arizona, Office of the Governor Pass-Through Grantor Identifying Number: EL9HZNBAN1B9 Award Ye...

Item: 2023-002 Assistance Listing Number: 21.027 Programs: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Federal Agency: U.S. Department of Treasury Pass-Through Agencies: State of Arizona, Office of the Governor Pass-Through Grantor Identifying Number: EL9HZNBAN1B9 Award Year: July 1, 2022 – June 30, 2023 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR sections 200.330, .331, and .501(h), pass-through entities must (a) identify the award and applicable requirements, (b) evaluate the subrecipient’s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring related to the subaward (2 CR section 200.332(b), (c) monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals (2 CFR section 200.332(d) through (f), and (d) ensure accountability for any for-profit subrecipients. Condition: In connection with our testing of Arizona Foundation for Human Service Providers (the Foundation) subrecipient monitoring, we noted that the Foundation did not timely or effectively monitor the activities of subrecipients to ensure that the subawards were used for authorized purposes and complied with the terms and conditions of the subaward. Name of Contact Person: Candy Espino, President & CEO Phone Number: (602) 252-9363 Anticipated Completion Date: September 30, 2024 Views of Responsible Officials and Corrective Actions: Arizona Foundation for Human Service Providers will enhance their existing policies and procedures to ensure sufficient controls are in place to properly monitor subrecipients. We will also include specific enhancements to the ongoing post-payment review of subawards and well as supervision and review controls to ensure the procedures are performed in a timely and thorough manner.

View Audit 316869

Finding 480658 (2023-007)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

Action taken in response to finding: ICS will train current and new staff regarding the importance of ensuring all documentation is in the file prior to scanning and that when the file is scanned all documentation is legible. Housing Specialists will continue to be trained on calculating HAP and th...

Action taken in response to finding: ICS will train current and new staff regarding the importance of ensuring all documentation is in the file prior to scanning and that when the file is scanned all documentation is legible. Housing Specialists will continue to be trained on calculating HAP and the importance of reviewing all documentation in the file prior to releasing payments to assure all rent amounts and dates are accurate and match what is being put into the system. RTAs and Leases should always be compared to assure the rent amount provided on the RTA matches the rent amount provided on the executed lease. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately

View Audit 316843

Finding 480653 (2023-006)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles

Action taken in response to finding: ICS will provide additional training for staff regarding how to document family size, voucher size, and citizenship. Proper documentation will be reviewed, and files will continue to be reviewed monthly for compliance. Names of the contact persons responsible f...

Action taken in response to finding: ICS will provide additional training for staff regarding how to document family size, voucher size, and citizenship. Proper documentation will be reviewed, and files will continue to be reviewed monthly for compliance. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately

View Audit 316843

Finding 480648 (2023-005)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Eligibility

Action taken in response to finding: ICS will provide additional training to current and new staff regarding the importance of retaining Authorization For Release of Information documentation and the requirement that there are two Authorization forms saved and scanned with each file. ICS will also ...

Action taken in response to finding: ICS will provide additional training to current and new staff regarding the importance of retaining Authorization For Release of Information documentation and the requirement that there are two Authorization forms saved and scanned with each file. ICS will also request that staff review file as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately

View Audit 316843

Finding 480643 (2023-004)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Eligibility

ICS will provide additional training to current and new staff regarding the importance of retaining asset documentation. ICS will also request that staff review files as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. ICS ...

ICS will provide additional training to current and new staff regarding the importance of retaining asset documentation. ICS will also request that staff review files as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. ICS will also encourage staff provide in writing on the documents how they calculated what was entered. They can either circle the amount they are using or if a calculation is necessary they should write the equation on the verification so all parties know how they came to the amount they are entering into the file. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately.

View Audit 316843

Corrective Action Plans

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