Corrective Action Plans

Finding 566892 (2024-003)

Significant Deficiency 2024

WA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.318

Finding 2024-003: TCFB was negligent in two areas for one of their purchases: No record of vendor verification that they were not suspended or disbarred and no WSDA prior approval for the purchase which was over $5,000. This was in violation of both their internal procedures and WSDA requirements. T...

Finding 2024-003: TCFB was negligent in two areas for one of their purchases: No record of vendor verification that they were not suspended or disbarred and no WSDA prior approval for the purchase which was over $5,000. This was in violation of both their internal procedures and WSDA requirements. The Problem: During testing the auditors noted that one instance of purchasing using WSDA funds was made without WSDA prior approval and proper documentation of suspension and debarment or WSDA prior approval. Established Standard: Organization must verify SAM registration and conduct suspension, and debarment checks prior to entering into any sub-agency agreement, contract, purchase, or equipment repair over $5,000. It is recommended that lead agency verifies, at least annually, that sub agencies and vendors are not suspended or debarred. Information about suspension and debarment checks is to be entered onto a spreadsheet of approved vendors. When the lead agency enters into a covered transaction with another agency or vendor, lead agency must verify that the entity with whom business is transacted is registered with SAM and is not excluded or disqualified. There are two methods for verification: A. Checking SAM.GOV exclusions (this method requires saving a copy of the verification search) B. Collecting a signed certification from the vendor. Actions to be taken: • Updated training of TCFB staff on the Policy/Procedures for procurements using WSDA funding. • Create step-by-step instructions for purchases using WSDA funding. • Effective October 1, 2024 WSDA’s threshold for preapprovals changed to $10,000. We will update our purchasing policy to reflect this change. Action Assignments: • Instruction checklist will be created by lead purchaser. • Lead purchaser will ensure that any purchases follow the Policy/Procedures for procurement. • Lead purchaser will be responsible for documenting SAM registration, Suspension and Debarment check, and WSDA pre-approvals. The documentation will consist of a copy of the exclusions page on SAM.GOV, as well as a spreadsheet of approved vendors with a date of last check. Timeline: • Instruction checklist for purchases using WSDA funds will be created by July 1st, 2025. • A spreadsheet has already been created to capture the information concerning Suspension and Debarment checks. A separate folder contains copies of each entities exclusion page from SAM.GOV. Verify Implementation: • In July 2025 Lead Purchaser will submit to the Executive Director: A. A copy of step-by-step instruction checklist. B. A copy of the spreadsheet with Suspension and Debarment checks C. Copies of exclusion pages from SAM.GOV Finance Dept. will verify invoice have received WSDA prior Approvals

View Audit 359751

Finding 566887 (2024-002)

Significant Deficiency 2024

Thurston County Food Bank

WA

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332

Finding 2024-002: TCFB was negligent in monitoring sub-recipients during the grant agreement period. The Problem: During testing, the auditors noted that one of the three sub-recipients tested did not receive a site visit during the grant agreement period. Established standard Three programs requir...

Finding 2024-002: TCFB was negligent in monitoring sub-recipients during the grant agreement period. The Problem: During testing, the auditors noted that one of the three sub-recipients tested did not receive a site visit during the grant agreement period. Established standard Three programs require sub-agency monitoring visits. EFAP (3 sub-agencies) requires each sub-agency to be monitored on site once each biennium (2 year agreement period). TEFAP (40 sub-agencies) requires that a minimum of 10% of sub-agencies be monitored on site once each year. CSFP (3 sub-agencies) requires each agency to be monitored on site once every 2 years. Actions to be taken - While the EFAP requirement was used for the test above, this plan will include monitoring visits for all 3 programs. - An additional staff member will be added to the contract team who will be responsible for on-site monitoring visits once trained. - Plan out which agencies should be visited in which years. - Create a shared calendar that includes the time period visits should take place in, when to reach out to sub-agencies to schedule visits, who will conduct visits. Action assignments - The entire contract team will work together to create the calendar. - Contracts Manager and Commodities Coordinator will plan out which sub-agencies to visit, and when to visit them. - Contracts Manager and new team member will schedule and conduct the first 2 site reviews, after which the new team member will take the lead with support from the others. Timeline - The additional contract team member will be added July 1st, 2025, but will be available for planning meetings before then. - Ordered list of sub-agency visits will be completed by the end of May 2025. - Shared calendar will be fully completed by the end of June 2025. Verify implementation - The Contracts Manager will report progress of monitoring visits to CEO/ED quarterly.

View Audit 359751

Finding 566867 (2024-004)

Material Weakness 2024

Harris-Stowe State University

MO

Subrecipient Monitoring Reporting Cash Management § 200.510

Finding 2024-004 Personnel Responsible for Corrective Action: Director of Sponsored Programs - Eva Kain, Grant Accountant – Charme Benson and Comptroller – Steve Wille Anticipated Completion Date: June 30, 2025 Corrective Action Plan:. The Grant Accountant, in collaboration with the Comptroller...

Finding 2024-004 Personnel Responsible for Corrective Action: Director of Sponsored Programs - Eva Kain, Grant Accountant – Charme Benson and Comptroller – Steve Wille Anticipated Completion Date: June 30, 2025 Corrective Action Plan:. The Grant Accountant, in collaboration with the Comptroller and Director of Sponsored Programs, will compile SEFA data on a quarterly basis and reconcile it against CX reports. The Sponsored Programs Director will verify all Assistance Listing Numbers (ALNs), subrecipient amounts, and accruals. Documentation of all federal awards and drawdowns will be maintained in a centralized repository for internal and audit access.

View Audit 359750

Finding 566865 (2024-007)

Material Weakness 2024

Harris-Stowe State University

MO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.403

Finding 2024-007 Personnel Responsible for Corrective Action: Grant Principal Investigators and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: All expenses must be supported by documentation and comply with Generally Accepted Accounting Princ...

Finding 2024-007 Personnel Responsible for Corrective Action: Grant Principal Investigators and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: All expenses must be supported by documentation and comply with Generally Accepted Accounting Principles (GAAP) standards. A pre-review checklist will be required for all charges against FIPSE grants. Prepaid items must be recorded in the prepaid ledger and amortized appropriately. Documentation will be retained in alignment with the University Record Retention policy. Management will implement a formal review and approval process to ensure that all allowable costs are verified for compliance with applicable regulations and approved by designated personnel prior to reimbursement or payment.

View Audit 359750 Questioned Costs: $1

Finding 566857 (2024-006)

Significant Deficiency 2024

Harris-Stowe State University

MO

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Finding 2024-006 Personnel Responsible for Corrective Action: Director of Sponsored Programs- Eva Kain, Director of Title III – Dr. Neidra Butler and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: Payroll charges to federal programs must mat...

Finding 2024-006 Personnel Responsible for Corrective Action: Director of Sponsored Programs- Eva Kain, Director of Title III – Dr. Neidra Butler and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: Payroll charges to federal programs must match certified time and effort documentation. The Director of Sponsored Programs, the Director of Title III, and the Grant Accountant will jointly review allocations before payrolls are processed. Monthly reports will be generated for review by the Grant Accountant, and discrepancies must be corrected within 30 days. Management will implement a formal review and approval process to ensure that all allowable costs are verified for compliance with applicable regulations and approved by designated personnel prior to reimbursement or payment.

View Audit 359750

Finding 566850 (2024-008)

Material Weakness 2024

Harris-Stowe State University

MO

Subrecipient Monitoring Special Tests & Provisions Material Weakness

Finding 2024-008 Personnel Responsible for Corrective Action: Chief Information Officer - Vacant Anticipated Completion Date: August 31, 2025 Corrective Action Plan: Harris-Stowe State University acknowledges the audit finding regarding noncompliance with the Gramm-Leach-Bliley Act (GLBA) and t...

Finding 2024-008 Personnel Responsible for Corrective Action: Chief Information Officer - Vacant Anticipated Completion Date: August 31, 2025 Corrective Action Plan: Harris-Stowe State University acknowledges the audit finding regarding noncompliance with the Gramm-Leach-Bliley Act (GLBA) and the FTC Safeguards Rule. In response, the University has collaborated with Omega Technical Solutions and ileap Group to execute a comprehensive cybersecurity compliance and modernization initiative. As of the audit period close, over 90% of related deficiencies have been remediated. Specific corrective actions taken or underway include: 1. Written Information Security Program (WISP): A formal WISP has been developed and implemented. It outlines oversight structures, risk management strategies, testing protocols, and required safeguards in alignment with 16 CFR 314.4. 2. Risk Assessment: A comprehensive risk scorecard was created. All Active Directory accounts were reviewed and flagged for deactivation or role reassignment as appropriate. 3. Access and Encryption Controls: Encryption is now deployed across all active endpoints. Logical access control and encryption policies have been adopted and published. Multi-factor authentication (MFA) is enforced for all systems handling student data. 4. Account Management and Role-Based Access: RBAC policies have been established and account provisioning is now formally documented and managed. 5. Retention, Change Management, and Training: A written data retention policy and formal change management procedures are now in place. An onboarding cybersecurity training program has been developed, with full implementation scheduled by August 31, 2025. 6. Legacy Server Risk Mitigation: One legacy Microsoft 2008 server has failed and is decommissioned. The remaining server is isolated, monitored with NIST- and Microsoft Sentinel-aligned tools, and pending full replacement as part of the upcoming infrastructure upgrade. 7. Ongoing Monitoring and Vendor Oversight: TCPM-aligned monitoring practices and vendor oversight protocols are now active and included in the WISP framework. The University’s IT Security SharePoint site houses all related documentation and is structured to support transparency, audit readiness, and continued compliance oversight.

View Audit 359750

Finding 566849 (2024-001)

Significant Deficiency 2024

Pacific Northwest Research Institute

WA

Subrecipient Monitoring Cash Management Allowable Costs / Cost Principles § 200.305

Finding Number 2024-001 Contact Person(s): Dionne Gordon dgordon@pnri.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Although the findings consisted primarily of a small number of late payments that were either ...

Finding Number 2024-001 Contact Person(s): Dionne Gordon dgordon@pnri.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Although the findings consisted primarily of a small number of late payments that were either 1 day late or late as a result of a poorly timed holiday, we fully acknowledge the accuracy of the finding and have added an additional control to account for the impact of weekends and holidays on our AP payment runs. Corrective action planned: Internal control established in AP department to keep track of sub recipients’ request reimbursement to ensure payments are disbursed within 30 calendar days after receipt of request. Anticipated completion date: March 31st 2025

View Audit 359747

Finding 566767 (2024-002)

None 2024

Battelle Memorial Institute

OH

Subrecipient Monitoring Equipment & Real Property Management § 200.508

Reference: Finding 2024-002 Access Restricted to Documentation for Various Compliance Requirements – Research & Development Cluster; Noncompliance – Period of Performance, Procurement (Micro Purchasing), Subrecipient Monitoring, and Equipment and Real Property Management Contact: Erica Classing, C...

Reference: Finding 2024-002 Access Restricted to Documentation for Various Compliance Requirements – Research & Development Cluster; Noncompliance – Period of Performance, Procurement (Micro Purchasing), Subrecipient Monitoring, and Equipment and Real Property Management Contact: Erica Classing, Controller; classinge@battelle.org; 614-424-3372 Views of Responsible Officials: Battelle acknowledges this finding is the result of access restrictions to classified contract documents imposed by federal agencies that are beyond Battelle’s control. Battelle does not have the authority to grant auditor access to classified programs without the proper security clearance and program permissions, rather this authority resides with the federal awarding agency, in accordance with applicable federal security regulations. These restrictions prohibited access to classified contracts for required audit procedures in those areas noted in Finding 2024-002. Classified contracts are a small subset (10%) of Battelle’s total reportable expenditures. Battelle provided all unclassified documentation required to support transactions selected for testing. In addition, Battelle provided all documentation necessary to audit compliance with requirements on all non-classified contracts selected. Management upholds high standards of compliance and transparency and continues to support audit processes to the fullest extent possible. Battelle agrees to explore options to satisfy audit requirements while maintaining compliance with classified contract security regulations. Corrective Action Plan: Summary of finding: During compliance testing of period of performance, procurement (micro purchasing), subrecipient monitoring, and equipment and real property management, access to classified contracts was restricted. The auditor was unable to view federal award documents to confirm the following information: • Period of performance (5 of 50 selections) - unable to confirm the authorized project period • Procurement (micro purchasing) (2 of 40 selections) - unable to review applicable requirement relating to consent to subcontract • Subrecipient monitoring (2 out of 40 selections) – unable to inspect subaward information and applicable terms • Equipment and real property management (3 out of 50 selections) – unable to obtain proof of active use and safeguard of the classified equipment and validate whether the equipment disposal was handled properly in accordance with the contractual terms and conditions. Root cause: Access to classified contracts is subject to confidentiality requirements mandated by external regulators, requiring appropriate security clearance levels and verified need-to-know status. If the classified contract is a special access program, obtaining program-specific approvals from the awarding agency in addition to possessing the appropriate security clearance and need to know is required. There is no guarantee that the federal awarding agency will ultimately grant cleared auditors access to the classified contract. Corrective action: Battelle is taking the following steps to address the finding: • Internal Review: We conducted an internal review of the areas affected by the scope limitation to validate each selection complied with the applicable contractual and regulatory requirements. This action was completed by December 19, 2024 and did not identify any instance of non-compliance with applicable rules, regulations, or contractual requirements. • We have existing monitoring mechanisms in place to ensure compliance in the areas affected by the scope limitation. • Early coordination with external auditor: We are collaborating with our external audit team to identify any classified contract audit selections earlier in the annual audit process. A proactive approach will allow Battelle extra time to engage clients for required approvals to either gain access to the classified information or obtain appropriate alternative audit evidence. In addition, any other related steps that can be completed in advance such as verifying auditor clearance types and levels will be performed early to help mitigate any delays. This corrective action requires the audit firm to provide auditors with the appropriate security clearances. • Engagement with regulatory agencies: We are in dialogue with impacted federal awarding agencies to explore options to provide necessary audit evidence. • Enhanced documentation: We are enhancing our audit support procedures to provide guidelines on how, within the bounds of regulatory restrictions, we can provide access to audit evidence for future audits. Overall Anticipated Implementation Date: December 31, 2025

View Audit 359740

Finding 566117 (2024-002)

Significant Deficiency 2024

Central Rivers Area Education Agency

IL

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency

Management will work to implement controls that will ensure subrecipient monitoring requirements are met.

View Audit 359722

Finding 566044 (2024-003)

Significant Deficiency 2024

Global Communities

MD

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Views of Responsible Officials and Planned Corrective Action: Global Communities experienced staff turnover in the positions responsible for FFATA reporting. Management will ensure those staff now responsible for maintaining compliance with FFATA reporting requirements have received adequate trainin...

Views of Responsible Officials and Planned Corrective Action: Global Communities experienced staff turnover in the positions responsible for FFATA reporting. Management will ensure those staff now responsible for maintaining compliance with FFATA reporting requirements have received adequate training and that supporting documentation of the review and approval of FFATA reports prior to submission are retained in our files.

View Audit 359700

Finding 566043 (2024-002)

Significant Deficiency 2024

Global Communities

MD

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Action: Global Communities policies and procedures did detect these instances of fraud, management of Global Communities took appropriate action ensuring that no unallowable costs were charged to Federal funds. Global Communities will continue th...

Views of Responsible Officials and Planned Corrective Action: Global Communities policies and procedures did detect these instances of fraud, management of Global Communities took appropriate action ensuring that no unallowable costs were charged to Federal funds. Global Communities will continue their due diligence with respect to any items that are considered fraudulent in nature. Any high-risk areas are carefully monitored, additional training and/or resources are provided to ensure that internal controls are functioning as designed to prevent occurrences of misappropriation of assets and procurement fraud.

View Audit 359700

Finding 566042 (2024-001)

Material Weakness 2024

Southern Nevada Regional Housing Authority

NV

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Finding 2024- 001: Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: To reinforce compliance and ensure consistent adherence to policies a specialized team including a Compliance & Training A...

Finding 2024- 001: Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: To reinforce compliance and ensure consistent adherence to policies a specialized team including a Compliance & Training Administrator, a Trainer, and two Senior Occupancy Specialists-has been established to oversee all Housing Choice Voucher (HCV) program training and compliance. This team is responsible for: ■ New hire training to ensure foundational competency. • Refresher trainings to address knowledge gaps and reinforce standards. • Policy & procedure update trainings to keep staff informed of changes. Quality Control: We conduct 100% quality control on all new hires', completed action files and 100% quality control on all contract files. Twenty-five percent (25%) of all Non-provisional employees work product is quality controlled by the compliance team. Department Structure: The entire leadership team completed Nan McKay's HOTMA training to ensure full alignment with the latest Housing Opportunity Through Modernization Act {HOTMA) requirements. This top-down approach guarantees that policy Interpretations and training materials are consistent and up to date. To ensure all required documents are properly retained and accessible, the agency has expedited the transition to a fully digital file system. This will Include standardized naming conventions, centralized storage with access controls, and a documented retention protocol to prevent future discrepancies. Additionally, any staff that falls below the 80 % success rate will be required to actively engage in all mandated trainings and utilize the compliance team as a resource for clarification. Furthermore, staff requiring further reinforcement will be promptly addressed through one-on one coaching or additional training sessions with their immediate supervisor. Anticipated Completion Date: The current staff is attending monthly trainings on the Administrative Plan, best practices and HOTMA policy changes. We anticipate completion of the plan by 12/31/2025. Person Responsible: Ms. Rhonda Jackson, Housing Program Manager II, Ms. Malandria Watson, Housing Program Manager I, -and Ebony Bell, Compliance and Training Administrator will be responsible for reviewing the Quality Control Report and error ratios monthly.

View Audit 359697 Questioned Costs: $1

Finding 566035 (2024-001)

Significant Deficiency 2024

Action, Inc.

MT

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

N/A

View Audit 359680

Finding 566026 (2024-002)

Material Weakness 2024

Lane Community College

OR

Student Financial Aid Reporting Subrecipient Monitoring

2024-002 – Special Tests and Provisions - Enrollment Reporting – Material Weakness in Internal Controls over Compliance Student Financial Assistance Cluster Department of Education Federal Assistance Listing Number: 84.063, 84.268 Federal Program Name: Federal Pell Grant Program, Federal Direct Stu...

2024-002 – Special Tests and Provisions - Enrollment Reporting – Material Weakness in Internal Controls over Compliance Student Financial Assistance Cluster Department of Education Federal Assistance Listing Number: 84.063, 84.268 Federal Program Name: Federal Pell Grant Program, Federal Direct Student Loans Federal Award Number: P063P230357, P268K230357 Award Year: 2023-24 Criteria: The National Student Loan Data System (NSLDS) is the Department of Education’s (ED) centralized database for students’ enrollment information under the Pell Grant and the Direct Loan and Federal Family Education Loan programs. Uniform guidance requires institutions to have internal controls in place to ensure attendance changes for students are reported to NSLDS within at least 60 days of when the student attendance change occurs. It is the College’s responsibility to update students' enrollment information timely and accurately as outlined in 34 CFR § 685.309. Condition/context: The auditors selected a sample of 34 students out of a population of 1,454 who had received Federal aid and had withdrawn or graduated from the College during the 2023-2024 fiscal year. The auditors compared the withdrawal or graduation date per the College’s records to NSLDS. The auditors noted eight students were not reported to NSLDS within the 60-day requirement. In addition, the auditors identified ten students who graduated but were not reported as graduated to NSLDS. Corrective Action: LCC reports enrollment to the National Student Clearinghouse: in the second, sixth and the tenth week of each standard term. There is an error report that the Clearinghouse returns with discrepancies in enrollment status which we respond to and correct within five business days. Once all errors are resolved and the report is accepted the NSC will post the data and report to NSLDS. Lane is an open access institution and therefore does not have a formal withdrawal policy. Two weeks after the end of each term, Lane sends the enrollment report and the “degree verify” extract to NSC. We are in the process of reviewing our NSC reporting strategies and including additional staff who will be supporting the process. We are reviewing NSC reporting times to ensure that we are reporting often enough to meet the required 60 day timeline for NSLDS. We are considering moving the enrollment and degree verify extract to a 30 day reporting period to meet the 60 day timeline. Phase 1: Issue an off cycle report to the NSC by June 6th, which is our next anticipated enrollment reporting cycle (week ten). We will send both the enrollment report and the “degree verify” extract to catch any updates to graduation information that may have changed since our last end of term report. Phase 2: Review updates to NSC processes that were issued through Banner and Ellucian and revise the “degree verify” process to capture regular graduation or withdrawal updates outside our standard reporting window. Unless it is discovered that the 30 day cycle does not meet the requirements of the reporting cycle, we will update our processes to - at a minimum - report every 30 days or in alignment with the weeks two, six and ten current enrollment report to the NSC. Additionally, the students noted in the finding will be reviewed to address any potential anomalies with reporting and to identify the cause of why these were not updated. This will be another consideration during the assessment for any updates to our reporting cycles. Following spring term, we will report graduated and withdrawn students, as is our current practice and after student degree awarding is complete. Name of Contact Person Responsible for Corrective Action: Dawn Whiting Anticipated Completion Date for the Corrective Action: A review process of 90 days should result in refined practices and an implementation of those practices to meet required reporting. All reporting changes will be finalized and followed by Aug 21, 2025.

View Audit 359666

Finding 566024 (2024-007)

Significant Deficiency 2024

Palm Beach County Housing Authority

FL

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility

2024-007 – Eligibility Housing Opportunities for Persons with Aids – Assistance Listing 14.241 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month and to determine if the tenant files were prepared in accordance ...

2024-007 – Eligibility Housing Opportunities for Persons with Aids – Assistance Listing 14.241 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month and to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. We recommend the Authority to hire outside consultants to assist with eligibility requirements 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: All current PBCHA staff responsible for eligibility determinations have received HCV rent calculation training through Nan McKay as of March 21, 2025. The PBCHA will continue to conduct training for program staff on eligibility documentation requirements and program rules to reinforce compliance standards. Through the implementation of intakes, interims and annual recertifications utilizing Yardi’s online workflows, the PBCHA expects to see increased improvement through automated application and documentation processes. The PBCHA will utilize available dashboards, internal audits and formal monitoring protocols to ensure continued compliance and to minimize the risk of recurring deficiencies. 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 eligibility 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: December 31, 2025

View Audit 359660

Finding 566023 (2024-006)

Significant Deficiency 2024

Palm Beach County Housing Authority

FL

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2024-06 – Eligibility Public Housing – Assistance Listing 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month and to determine if the tenant files were prepared in accordance with internal policies and unt...

2024-06 – Eligibility Public Housing – Assistance Listing 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month and to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. We recommend the Authority to hire outside consultants to assist with eligibility requirements 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: All current PBCHA staff responsible for eligibility determinations have received HCV rent calculation training through Nan McKay as of March 21, 2025. The PBCHA will continue to conduct training for program staff on eligibility documentation requirements and program rules to reinforce compliance standards. Through the implementation of intakes, interims and annual recertifications utilizing Yardi’s online workflows, the PBCHA expects to see increased improvement through automated application and documentation processes. The PBCHA will utilize available dashboards, internal audits and formal monitoring protocols to ensure continued compliance and to minimize the risk of recurring deficiencies. 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 eligibility 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: December 31, 2025

View Audit 359660 Questioned Costs: $1

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 566008 (2024-001)

Material Weakness 2024

Palm Beach County Housing Authority

FL

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2024-001 – Eligibility Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management conduct training for program staff on eligibility documentation requirements and program rules. Additionally, we recommend that the Housing Authority implement intern...

2024-001 – Eligibility Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management conduct training for program staff on eligibility documentation requirements and program rules. Additionally, we recommend that the Housing Authority implement internal audits of tenant files to proactively identify and correct documentation issues. A monitoring protocol should also be established to ensure ongoing compliance and to prevent the recurrence of documentation deficiencies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All current PBCHA staff responsible for eligibility determinations have received HCV rent calculation training through Nan McKay as of March 21, 2025. The PBCHA will continue to conduct training for program staff on eligibility documentation requirements and program rules to reinforce compliance standards. Through the implementation of intakes, interims and annual recertifications utilizing Yardi’s online workflows, the PBCHA expects to see increased improvement through automated application and documentation processes. The PBCHA will utilize available dashboards, internal audits and formal monitoring protocols to ensure continued compliance and to minimize the risk of recurring deficiencies. 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 Questioned Costs: $1

Finding 565994 (2024-002)

Material Weakness 2024

Washington Local School District

OH

Subrecipient Monitoring Reporting Material Weakness § 200.328 § 200.330

Create a detailed, step-by-step process for federal procurement to ensure compliance and awareness among all staff responsible for spending and reporting federal funds. Washington Local Schools - Federal Grants Management Process Require training for all staff involved in preparing, reviewing, or...

Create a detailed, step-by-step process for federal procurement to ensure compliance and awareness among all staff responsible for spending and reporting federal funds. Washington Local Schools - Federal Grants Management Process Require training for all staff involved in preparing, reviewing, or certifying federal grant reports, prior to beginning any work. Work with a Financial Program Manager at the Office of Budget and Management (Neal Bucklew was the district’s contact on this particular grant) to ensure that all activity reports are submitted correctly and received on time.

View Audit 359647

Finding 565975 (2024-003)

Significant Deficiency 2024

Taylor County, Texas

TX

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Finding 2024-003 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: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal cont...

Finding 2024-003 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: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Per 31 CFR 19.300, prior to enter in subawards and contracts with award funds, recipients must verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded pursuant to 31 CFR § 19.300. The County did not retain documentation of the verification that 6 vendors were not suspended, debarred, or otherwise excluded prior to entering into a transaction with them. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: The County performed a review of suspended and debarred vendors in October 2024, prior to the submission of the final SLFRF required report. Going forward, Taylor County will continue retaining documentation of the verification of vendors paid with federal funds against the sam.gov suspension and debarment review tool. Anticipated Completion Date: Completed

View Audit 359630

Finding 565947 (2024-003)

Significant Deficiency 2024

Intrahealth International, Inc,

NC

Reporting Subrecipient Monitoring § 200.331 § 200.508 § 200.510

Finding 2024-003: SEFA Preparation – Subrecipient vs. Subcontractor Determinations Name of Responsible Official: Nikolos Oakley, CFAO Anticipated Completion Date: 09/30/2025 Condition: Subcontractor amounts were improperly included in the Amounts Provided to Subrecipients column on the Schedule of ...

Finding 2024-003: SEFA Preparation – Subrecipient vs. Subcontractor Determinations Name of Responsible Official: Nikolos Oakley, CFAO Anticipated Completion Date: 09/30/2025 Condition: Subcontractor amounts were improperly included in the Amounts Provided to Subrecipients column on the Schedule of Expenditures of Federal Awards (SEFA). Context: Management made improper subrecipient vs. subcontractor determinations, resulting in inaccurate SEFA preparation. This resulted in $2.6 million being removed from the Amounts Provided to Subrecipients column in the original SEFA provided to the auditors by management. Views of Responsible Officials and Planned Corrective Action: IntraHealth acknowledges the finding regarding the improper inclusion of subcontractor amounts in the Amounts Provided to Subrecipients column on the Schedule of Expenditures of Federal Awards (SEFA). We will improve our reporting and review processes to ensure subcontractor amounts are not incorporated under Amounts Provided to Subrecipients column in SEFA. Corrective Action: • Implement a more rigorous review process to ensure that only true subrecipients are included in the Amounts Provided to Subrecipients column of the SEFA. Subcontractor amounts will be reported separately as required. We will also improve training for the finance and grants management teams to ensure they fully understand the regulations. IntraHealth is committed to ensuring the accuracy of future SEFA reports and will complete the corrective actions by 09/30/2025. We will also continue to monitor the effectiveness of these changes to prevent future misclassifications.

View Audit 359583

Finding 565946 (2024-002)

Significant Deficiency 2024

Intrahealth International, Inc,

NC

Subrecipient Monitoring § 200.332

Corrective Action Plan Finding 2024-002: Subrecipient Monitoring Name of Responsible Official: Nikolos Oakley, CFAO Anticipated Completion Date: 05/30/2025 Condition: Insufficient monitoring was performed over fixed amount subawards. Context: Fixed amount subawards did not have documented subreci...

Corrective Action Plan Finding 2024-002: Subrecipient Monitoring Name of Responsible Official: Nikolos Oakley, CFAO Anticipated Completion Date: 05/30/2025 Condition: Insufficient monitoring was performed over fixed amount subawards. Context: Fixed amount subawards did not have documented subrecipient monitoring plans based on subrecipient’s risk assessment evaluations. Monitoring of fixed amount subawards was limited to reviewing milestone certification forms against milestone tables included in the subrecipient agreements. Financial audits or reported were not requested for non-US based subrecipients as part of monitoring procedures. Views of Responsible Officials and Planned Corrective Action: Management acknowledges the finding. IntraHealth has a comprehensive sub-recipient monitoring manual and extensive subrecipient monitoring processes, including review of financial audits for all non-fixed price subrecipients. We will expand our monitoring processes and procedures to include requesting and reviewing financial audits and other relevant information for all fixed amount subawards. Corrective Action: • Expand monitoring procedures to include the collection of financial audits or financial reports from fixed amount sub-recipients, as it is required from all other subrecipients InrtaHealth is committed to strengthening its subrecipient monitoring practices and will implement corrective action promptly. We anticipate the completion of these improvements by 05/30/2025.

View Audit 359583

Finding 565843 (2024-003)

Significant Deficiency 2024

The Antirecidivism Coalition

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.328

To address the finding, ARC will strengthen internal controls related to federal reporting by taking the following actions: 1. Enhance Reporting Oversight: The Finance Manager and Grants and Compliance Officer will assume primary responsibility for monitoring and verifying all federal reporting dead...

To address the finding, ARC will strengthen internal controls related to federal reporting by taking the following actions: 1. Enhance Reporting Oversight: The Finance Manager and Grants and Compliance Officer will assume primary responsibility for monitoring and verifying all federal reporting deadlines and submission requirements. 2. Document Retention Procedure: Additional double checks of record retention will take place in monthly reporting meetings, ensuring that centralized record keeping is complete. 3. Compliance Calendar Audit: A quarterly internal audit of the compliance calendar and reporting checklist will be conducted to verify deadlines are met.

View Audit 359567

Finding 565819 (2024-002)

Material Weakness 2024

The Nazareth Project, Inc.

PA

Subrecipient Monitoring Cash Management

Management's Response and Corrective Action Plan: In past experience with USAID reimbursement requests, payment was received 10-14 days after the request for reimbursement was submitted to the office of CFO.CMP Electronic Invoices (USAID). For example, on October 11, 2022, we submitted a request fo...

Management's Response and Corrective Action Plan: In past experience with USAID reimbursement requests, payment was received 10-14 days after the request for reimbursement was submitted to the office of CFO.CMP Electronic Invoices (USAID). For example, on October 11, 2022, we submitted a request for $308,942.22. Payment was received on October 28, 2022 – 17 days after the request for reimbursement. In the specific case of reimbursement received on September 15, 2023, NPI submitted the request for reimbursement on September 13. In this specific case reimbursement was received within only two days. We acknowledge our failure to remit grant funds to the Nazareth Hospital on a timely basis. For future grant reimbursement requests, we have implemented a plan to be more diligent in monitoring the receipt of grant reimbursements to ensure that we can immediately disburse them to the recipient.

View Audit 359527

Finding 565798 (2024-001)

Significant Deficiency 2024

Operation Stand Down Tennessee

TN

Reporting Procurement, Suspension & Debarment Subrecipient Monitoring

Management accepts the recommendation. Corrective Action Taken: • Immediate Correction: The incorrect report was promptly reviewed, corrected and resubmitted to the appropriate entity on 05/28/2025 • Notification: Relevant stakeholders were informed of the error and corrective resubmission. Prev...

Management accepts the recommendation. Corrective Action Taken: • Immediate Correction: The incorrect report was promptly reviewed, corrected and resubmitted to the appropriate entity on 05/28/2025 • Notification: Relevant stakeholders were informed of the error and corrective resubmission. Preventative Measures and Process Improvements: • Dual Review Protocol: A two-step verification process has been instituted, requiring two qualified team members to review and sign off on all critical reports prior to submission. Person Responsible for Corrective Action Plan: Kyle Steffen, COO Date of Correction: 05/28/2025

View Audit 359492

Corrective Action Plans

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