Corrective Action Plans

Finding 31194 (2022-001)

Significant Deficiency 2022

Housing Authority of Kansas City, Missouri

MO

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2022 ? 001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Require...

Finding 2022 ? 001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Requirement: Eligibility Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Condition: Exceptions noted in 1 out of 40 files tested for eligibility requirements. The Authority was unable to provide documentation for releases of information or third-party verification of reported family annual income, the value of assets, or expenses related to deductions from annual income. Cause: The Authority did not maintain supporting documentation within the tenant file. Auditor?s Recommendations: Recommend that the Authority implements controls to ensure the tenant files include all required documentation at the time of recertification. Response to Finding 2022-001 The Authority generally concurs with the auditor?s findings and recommendations. The 2022 Audit included the review of 40 HCV files and deficiencies were noted in only one file. The Authority was unable to provide documentation for releases of information or third-party verification of reported family annual income, the value of assets, or expenses related to deductions from annual income. Action Taken: The implementation of a Corrective Action Plan to address the errors to ensure that the tenant files include all required documentation at the time of recertification began on August 1, 2023. To provide consistency, increase staff knowledge and reduce errors, training began immediately and will continue on an annual and as needed basis. In addition, HAKC will increase quality control file reviews and conduct such reviews on a more frequent basis to identify errors sooner and address the cause of errors quickly to prevent systemic errors. Errors will be identified by error type and the person who made the error. Patterns of errors will be monitored, and additional training provided for similar error types that are frequently repeated and persons who are identified as frequently making errors. Quality reviews will be conducted for all files to ensure that all required documents are in the files. It is anticipated it will take one year to complete the initial file review. After the initial review files will be selected randomly and reviewed according to an established quality control schedule. Each team member will be responsible to collect missing documents identified when completing an annual recertification, interim recertification or change of unit. The Director and Supervisor will assist the Deputy Executive Director and Executive Director in overseeing these corrective actions during the next fiscal year. Name of the contact person responsible for corrective action: Edwin Lowndes Executive Director Planned completion date for corrective action plan to be fully implemented: March 1, 2024.

View Audit 28025

Finding 31193 (2022-003)

Significant Deficiency 2022

Peoria Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Eligibility

2022-003 Section 8 Housing Choice Vouchers Recommendation: We recommend the Authority implement controls to ensure all tenant file documentation is accurate and available, and that management review their procedures relating to PIC uploads to ensure compliance with HUD's requirements and timelines....

2022-003 Section 8 Housing Choice Vouchers Recommendation: We recommend the Authority implement controls to ensure all tenant file documentation is accurate and available, and that management review their procedures relating to PIC uploads to ensure compliance with HUD's requirements and timelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: 1. The PHA will implementing a Compliance Team to create and enforce a quality assurance plan. The plan will include a 100% file audit of HCV Participant Files to ensure full compliance, and PHA will process all corresponding corrections. 2. The Quality Assurance employees will continue to complete 10% of monthly internal file audits for recertification and 100% of new admissions, to ensure accurate calculations. The Quality Assurance team will also ensure that all proper documentation is present and accurate in all participant files. 3. In addition, PHA will contract a third-party consultant to complete a one-time 100% file audit, then test 10% of participant files, monthly. 4. The HCV Department Team, except for our inspectors, will complete Rent Calculation Training and obtain the exam certification, with a minimum requisite passing score of 80% Additionally, the third-party consultant will provide the HCV Team with technical support required to reconcile file deficiencies noted during the 100% file audit. Planned completion date for the corrective action plan: December 31, 2023; Ongoing Person Responsible: Armeca Crawford, Chief Executive Officer

View Audit 25746

Finding 31191 (2022-002)

Significant Deficiency 2022

Peoria Housing Authority

IL

Equipment & Real Property Management HUD Housing Programs Significant Deficiency

Finding 2022-002 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with account...

Finding 2022-002 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). The PHA understands the importance of accurately tracking both fixed assets and inventory. The PHA will revise policies around fixed assets and inventory and ensure that they are being followed to provide an accurate representation of what the PHA owns. Corrective Action Plan: The Peoria Housing Authority will do a review of the fixed asset listing and bring the necessary dispositions to be approved by the Board of Commissioners to accurately state fixed assets owned by the PHA. This will become an annual process to be completed by the Finance Department in coordination with PHA staff. An annual inventory count will be completed each year at fiscal year-end to ensure that what is reported reflects what is owned by the PHA. An allowance will be set up for any obsolete inventory. This will be addressed during the 2023 calendar year. Person Responsible: Armeca Crawford, Chief Executive Officer Bedrock Housing Consultants in coordination with the PHA Finance Department. Anticipated Completion Date: December 31, 2023

View Audit 25746

Finding 31190 (2022-001)

Significant Deficiency 2022

Peoria Housing Authority

IL

HUD Housing Programs Reporting Significant Deficiency

Finding 2022-001 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: The Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with acc...

Finding 2022-001 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: The Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Subsequent to December 31, 2022, the PHA procured the services of Bedrock Housing Consultants who have addressed the timeliness and accuracy of bank reconciliations as well as the monitoring of interfund accounts to ensure they are balanced. The PHA will resolve this issue during the 2023 calendar year. Corrective Action Plan: The Peoria Housing Authority (PHA) will continue to ensure timely and accurate financial reports. Bedrock Housing Consultants will continue to work with the Finance Department to ensure timely and accurate bank reconciliations are being performed. Staff will continue to participate in training in Housing Authority financial management to understand better the industry?s policies, procedures, and practices. The PHA will reconcile monthly all accounts, including accurate reconciliation of all bank accounts as well as balancing interfunds, and when possible reimbursing the amounts due. Any audit adjustments will be made in the proper period and in the accounts detailed per the auditor?s adjusting journal entry report. This will be addressed during the 2023 calendar year. Person Responsible: Armeca Crawford, Chief Executive Officer Bedrock Housing Consultants in coordination with the PHA Finance Department. Anticipated Completion Date: December 31, 2023

View Audit 25746

Finding 31189 (2022-003)

Significant Deficiency 2022

Alabama Nursing Home Association Education Foundation

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2022-003 ?Claims Payments Made Based on Incorrect Calculations of Amounts Reimbursed Status: Under completion. Planned Corrective Action: A review was made by the Foundation?s outside accounting firm engaged to process claims and the errors cited in Finding 2022-003 resulted in only one ...

Finding 2022-003 ?Claims Payments Made Based on Incorrect Calculations of Amounts Reimbursed Status: Under completion. Planned Corrective Action: A review was made by the Foundation?s outside accounting firm engaged to process claims and the errors cited in Finding 2022-003 resulted in only one overpayment to a nursing home. This was confined to a single nursing home that received more than that nursing home would have been entitled to receive under the adopted allocation regime. That nursing home was contacted and has promptly refunded the overage. The Foundation plans to redistribute this amount to other nursing facilities with unmet needs on a ratio and proportion basis. Person(s) Responsible: John Matson, Acting Executive Director Completion Date: October 31, 2023

View Audit 25745 Questioned Costs: $1

Finding 31188 (2022-002)

Significant Deficiency 2022

Alabama Nursing Home Association Education Foundation

AL

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.329

Finding 2022-002 ?Internal Control Over Reporting Status: Completed. Planned Corrective Action: Management will retain documentation of review of reports. Person(s) Responsible: John Matson, Acting Executive Director Completion Date: September 26, 2023

View Audit 25745

Finding 31187 (2022-001)

Significant Deficiency 2022

Alabama Nursing Home Association Education Foundation

AL

Period of Performance Significant Deficiency Matching / Level of Effort / Earmarking § 200.203 § 200.303

Finding 2022-001 ?Internal Control Over Allowable Activities/Costs and Period of Performance Status: Plan is being formulated. Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the ?Grantor?) to The Alabama Nursing Home Asso...

Finding 2022-001 ?Internal Control Over Allowable Activities/Costs and Period of Performance Status: Plan is being formulated. Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the ?Grantor?) to The Alabama Nursing Home Association Education Foundation (the ?Foundation?), which permitted the Foundation to rely upon the certifications of nursing home applicants that the applicant had or will have sufficient unmet needs related to qualifying purposes due to the COVID-19 pandemic to support the receipt of the various allocations of the herein described COVID-19 Funds. Under the terms of the certification, each applying nursing home further certified that for ten (10) years it would maintain auditable records supporting the unmet need and use of the COVID-19 Funds. This manner of requiring only a certification for the distribution to health care providers is consistent with the requirements the federal government used when distributing an array of emergency funding (e.g., provider relief funds, rural funds, and infection control funds) to health care providers to meet the unmet needs caused by the COVID-19 pandemic. The term ?COVID-19 Funds? means those funds the Foundation received from the Grantor with respect to (i) The CARES Act Corona Virus Relief Funds for the period from January 31, 2020 through December 31, 2021, and (ii) America Rescue Plan Act (ARPA) funds for unmet needs for qualifying purposes incurred or to be incurred during the period March 11, 2021 through December 31, 2024. To provide further assurance that the COVID-19 Funds were properly applied by the nursing home beneficiaries receiving COVID-19 Funds through the Foundation, the Foundation is working with its outside accountants and legal counsel to develop a look-back review plan. The framework of the look-back review plan will be for each nursing home beneficiary that received COVID-19 Funds to submit during the first month of the third quarter of the calendar year 2024, a worksheet similar to the period reporting worksheets that are required by the federal Health Resources & Services Administration (HRSA) to justify the COVID-19 provider relief funds, rural funds, and infection control funds received by health care providers. In addition to these HRSA type worksheets, a more in-depth examination of a sample of nursing homes will be made by randomly selecting 10 nursing homes from a pool of the 30 nursing homes that received the most COVID-19 Funds through the Foundation, plus another 15 nursing homes from the remainder of the pool of beneficiary nursing homes. These randomly selected nursing homes will be required to supply actual documentation supporting the COVID Funds received. This documentation will include invoices, payroll records, revenue journals, and cost reports. Among the provisions of the certifications submitted by each applying nursing home, is an acknowledgement that (i) the nursing home is subject to audit by the applicable State and federal agencies, and the Foundation, (ii) any COVID-19 Funds received through the Foundation and not properly applied must be refunded, and the nursing home will comply with the requirement that it must maintain for ten (10) years auditable records supporting its use of the COVID-19 Funds it received through the Foundation. In the event that it is determined that one or more nursing homes were unable to properly apply the COVID-19 Funds to an unmet need for a qualifying purpose, those COVID-19 Funds will be recouped and either redistributed to any nursing homes that are able show an unmet need continues to exist using a distribution formula consistent with past distributions of refunded COVID-19 Funds, or returned to the Grantor. This redistribution or return to the Grantor will occur no later than December 31, 2024. Person(s) Responsible: John Matson, Acting Executive Director Completion Date: Adoption of the Look-Back Audit Procedures December 31, 2023

View Audit 25745

Finding 31186 (2022-001)

Material Weakness 2022

South Carolina Regional Housing Authority No. 1

SC

HUD Housing Programs Eligibility Material Weakness

2022-001 - Eligibility: Public Housing Tenant Files Material Weakness in Internal Control, Material Noncompliance Condition: Out of a total tenant population of 1,275, 25 files were selected for testing. Exceptions were noted as follows: ? 6 files where the annual re-examination was not perform...

2022-001 - Eligibility: Public Housing Tenant Files Material Weakness in Internal Control, Material Noncompliance Condition: Out of a total tenant population of 1,275, 25 files were selected for testing. Exceptions were noted as follows: ? 6 files where the annual re-examination was not performed within 12 months. Recommendation: The above-mentioned change will only result in non-timely annual re-examinations for some tenants for one time, and will effectively correct itself in future years. Nonetheless, the Authority should review all annual re-examinations for all tenants and immediately perform annual re-examinations for any remaining tenants that have not already had their next re-examination Action Taken: The Authority concurs with this finding and has begun a review of all files to identify any remaining tenants that have not had a timely annual re-examination and to immediately conduct any needed re-examinations. Effective Date: September 19, 2023 Contact Information Brian Griswell, Executive Director SC Regional Housing Authority No.1 218 Spring Street Laurens, SC 29360 (864) 984-6568

View Audit 25743

Finding 31183 (2022-001)

Material Weakness 2022

Latino Network

OR

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.331

March 6, 2023 CORRECTIVE ACTION PLAN Latino Network respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Kern Thompson 1800 SW First Avenue, Suite 410 Portland, Oregon 97201 Audit Period: 07/01/2021 ? 06/3...

March 6, 2023 CORRECTIVE ACTION PLAN Latino Network respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Kern Thompson 1800 SW First Avenue, Suite 410 Portland, Oregon 97201 Audit Period: 07/01/2021 ? 06/30/2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Finding ? 2022-001 Criteria/Requirement: In accordance with 2.CFR?200.331, a pass-through entity must monitor the activities of subrecipients to ensure that federal awards are used for authorized purposes in compliance with laws, regulations, and the provisions of contracts and grants agreements. Condition/Context: Latino Network passed through $85,311 in funding to subrecipients. During our audit, we noted that the Latino Network did not have documented written controls or procedures to ensure compliance with the U.S. Office of Management and Budget?s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) subrecipient monitoring requirements. Cause: Procedures are not in place to ensure that Latino Network is maintaining adequate monitoring for each federal subrecipient. Effect: Failure to maintain sufficient subrecipient monitoring may result in the wrongful use of federal funds and non-compliance with the provisions of applicable requirements. Questioned Costs: $85,311 Recommendation: The Organization should establish written policies and procedures regarding the monitoring of subrecipients, as well as establish monitoring procedures to ensure that such policies and procedures are being followed. Management?s Response: We agree with the auditors' comments, and the following action will be taken to improve the situation. We will create and document the policies and procedures for effective monitoring of federally granted subrecipients by the end of the fiscal year. We will then perform monitoring of all federally granted subrecipients prior to our FY23 financial audit. Revisions to the users' manual will be made as needed to ensure the manual is current at all times. Grants & Contracts Accountants and Accounting Manager will be trained to perform federally granted subrecipient monitoring.

View Audit 26969 Questioned Costs: $1

Finding 31182 (2022-001)

Material Weakness 2022

Southside Comm Housing CORP - Southside Manor

IL

Internal Control / Segregation of Duties Material Weakness

Views of responsible officials and planned corrective actions: We agree and will continue to monitor monthly financial results and accounting information as correction is not practical.

View Audit 32324

Finding 31181 (2022-001)

Significant Deficiency 2022

Wisconsin Illinois Senior Housing, Inc. and Affiliate

CO

Reporting

Management agrees with and will implement the recommended review as outlined by our auditors to include a review of all program reporting to verify accuracy and appropriateness of information, including comparing all information to source documentation to ensure correct data has been utilized, in ac...

Management agrees with and will implement the recommended review as outlined by our auditors to include a review of all program reporting to verify accuracy and appropriateness of information, including comparing all information to source documentation to ensure correct data has been utilized, in accordance of the terms and conditions of the program. All substantiating documentation for the amounts reported and the correct amounts will be maintained by management.

View Audit 30416

Finding 31179 (2022-001)

Significant Deficiency 2022

Tacoma-Pierce County Chamber of Commerce

WA

Procurement, Suspension & Debarment

Finding One: 2022-001 Procurement, Suspension and Debarment Auditor?s Recommendations: The Organization should adopt Procurement Policy including a section concerning Federal Awards which will include a section regarding the verification of the status of each potential vendor before disbursement...

Finding One: 2022-001 Procurement, Suspension and Debarment Auditor?s Recommendations: The Organization should adopt Procurement Policy including a section concerning Federal Awards which will include a section regarding the verification of the status of each potential vendor before disbursement of Federal funds. CEO, Andrea Reay, will review and approve this policy and the Tacoma-Pierce County Chamber of Commerce (the ?Chamber?) Board of Directors will approve this policy. Response: CEO, Andrea Reay, will update the Chamber?s policies with a Procurement Policy, including a section concerning Federal Awards. Vendors will be verified before disbursement of Federal funds. The new PP will include the following language. The Chamber employees who authorize the use of Federal funds will: -Read and sign a document stating that they are aware of the Federal provisions requiring concerning Suspension and Debarment -Confirm with the CEO, or appropriate delegee that the vendor has been checked prior to fund distribution using the SAM.gov registration. CEO, or appropriate delegee, will develop a process for checking vendor debarment status and include language outlining the process in the procurement policy. CEO, or appropriate delegee, will be responsible for verifying that all vendors being paid using Federal funds, will have been checked for debarment prior to disbursing future Federal funding. Timing of remediation completion: CEO, Andrea Reay, will complete by March 1, 2023.

View Audit 30412

Finding 31178 (2022-003)

Material Weakness 2022

Young Womens Christian Association of Greater Lafayette

IN

HUD Housing Programs Reporting Internal Control / Segregation of Duties

2022-003: REPORTING--STOP Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. Recommendations in the Correc...

2022-003: REPORTING--STOP Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. Recommendations in the Corrective Action Plan were adopted and phased in beginning September 2023. Those recommendations were: ? Confirm best practice approaches with other victim service providers on data collection process and program reports. ? The Chief Executive Officer, Chief Financial Officer and Director are reviewing data collection and program report processes to ensure accuracy and compliance. ? The Director of DVIPP and Client Services Specialist are building a detailed process manual to provide clear guidance on program report process (including, but not limited to, data collection/entry, how to write the narratives and collect numbers for program reports). The detailed process manual will streamline procedures and clarify roles and responsibilities to all involved in program reports.

View Audit 37339

Finding 31175 (2022-002)

Material Weakness 2022

Young Womens Christian Association of Greater Lafayette

IN

HUD Housing Programs Reporting Internal Control / Segregation of Duties

2022-002: REPORTING--VOCA Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. Recommendations in the prio...

2022-002: REPORTING--VOCA Recommendation: Internal controls and procedures should be established and documentation maintained to support all program metrics surrounding each grant reporting. Corrective Actions: YWCA acknowledges discrepancies in data metrics reported. Recommendations in the prior Corrective Action Plans were adopted and phased in beginning September 2023. Those recommendations were: ? Additional staff have been trained to review data entered into the client database monthly for quality assurance prior to running the reports used to complete program reports for grants. Three staff members complete this review monthly. ? Data is being entered into the client database and monitored regularly. ? Standardized reports from the database are used to compile program reports and backup documentation is saved. ? Program reports are reviewed and approved by the Chief Program Officer or the Chief Executive Officer prior to submission to granting agency. ? Program staff are entering client data into the client database in a timely manner. All client data must be entered before monthly reports are compiled. This data is also compiled in a Google doc which the Senior Director compares to output from the database. ? Client bed nights are being tracked in the client database rather than on a paper residential log. ? YWCA has requested an additional field be added to the client database to allow more detailed and accurate reporting. ? The Senior Director has conducted trainings for all staff related to accurate and timely collection and entry of client data into the database. YWCA continues to follow the preceding recommendations and has implemented the following additional internal controls and procedures to ensure data quality: ? Confirm best practice approaches with other victim service providers on data collection process and program reports. ? The Chief Executive Officer, Chief Financial Officer and Director are reviewing data collection and program report processes to ensure accuracy and compliance. ? The Director of DVIPP and Client Services Specialist are building a detailed process manual to provide clear guidance on program report process (including, but not limited to, data collection/entry, how to write the narratives and collect numbers for program reports). The detailed process manual will streamline procedures and clarify roles and responsibilities to all involved in program reports.

View Audit 37339

Finding 31174 (2022-001)

Material Weakness 2022

St. Claire Regional Medical Center, Inc.

KY

Cash Management Material Weakness Reporting

CORRECTIVE ACTION PLAN September 8, 2023 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 East...

CORRECTIVE ACTION PLAN September 8, 2023 U.S. Department of Health and Human Services St. Claire Regional Medical Center, Inc. respectively submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 Audit Period: Year ended June 30, 2022 The findings from the Schedule of Findings and Questioned Costs for the year ended June 30, 2022, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS ? FEDERAL AWARD PROGRAM AUDITS 2022-001 Condition: Untimely disbursement of federal grant funds received: When receiving federal grant funds for the HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program, the Hospital did not disburse federal grant funds received within 3 working days. Action: Management will implement internal control procedures by December 31, 2023 to ensure proper and timely disbursements of federal grant funds to ensure proper cash management of any future HHS Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Plan Program funds. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Chris McClurg, CFO, at (606) 783-6587. Sincerely, Chris McClurg Chief Financial Officer

View Audit 36989

Finding 31173 (2022-002)

Material Weakness 2022

Riverview Hospital

IN

Questioned Costs Allowable Costs / Cost Principles Reporting

Findings Reported by Uniform Guidance ? The following steps have been taken or will be taken to address Finding 2022-002: ? Riverview Hospital plans to monitor controls related to reporting to ensure amounts are appropriately stated. ? Riverview Hospital will prepare internal documentation supporti...

Findings Reported by Uniform Guidance ? The following steps have been taken or will be taken to address Finding 2022-002: ? Riverview Hospital plans to monitor controls related to reporting to ensure amounts are appropriately stated. ? Riverview Hospital will prepare internal documentation supporting reconciled expense amounts which should be retained for a minimum of three (3) years from the date of the final report in accordance with payment terms and conditions.

View Audit 36798 Questioned Costs: $1

Finding 31172 (2022-004)

Significant Deficiency 2022

Housing Authority of St. Louis County

MO

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-004 Public and Indian Housing ? Assistance Listing No. 14.850 ? Declaration of Trusts Recommendation: The Authority should ensure they have all required documentation on file to ensure they are in compliance with HUD requirements regarding declaration of trusts. Explanation of disagreement with...

2022-004 Public and Indian Housing ? Assistance Listing No. 14.850 ? Declaration of Trusts Recommendation: The Authority should ensure they have all required documentation on file to ensure they are in compliance with HUD requirements regarding declaration of trusts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority?s counsel has worked with HUD to develop a Declaration of Trust (DOT) report template. Staff have also increased coordination and communication with legal counsel to ensure all DOTs are up to date. Name(s) of the contact person(s) responsible for corrective action: Katrina Sommer Planned completion date for corrective action plan: December 31, 2023

View Audit 35864

Finding 31165 (2022-003)

Material Weakness 2022

Housing Authority of St. Louis County

MO

Questioned Costs HUD Housing Programs Material Weakness

2022-003 Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? Special Tests ? HQS Inspections Recommendation: The Authority should implement processes to ensure all HQS biennial and re-inspections are completed timely and that there is proper documentation and enforcement of approved ext...

2022-003 Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? Special Tests ? HQS Inspections Recommendation: The Authority should implement processes to ensure all HQS biennial and re-inspections are completed timely and that there is proper documentation and enforcement of approved extensions and abatements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has appointed a new Housing Quality Inspections Manager and filled the vacant position of Housing Quality Inspections Field Supervisor. The Housing Quality management team is currently conducting ongoing training for the department during weekly meetings. The team is also monitoring software dashboards to ensure the Authority meets inspection deadlines. The Authority is in the process of creating customized reports through Yardi, its operations processing software. These reports will enable the Housing Quality Inspections Manager to monitor the timely creation of reinspection appointments and ensure Yardi generates biannual inspections when required. The Authority has made improvements to the process of abatement holds and terminations, ensuring that a hold on Housing Assistance Payments (HAP) is applied when the abatement is initially processed. Each month, the Housing Quality Inspections Manager monitors payment holds to ensure abatement requirements are being met. The Authority provides staff with ongoing training and appropriate oversight to ensure they effectively perform inspections procedures within required timelines. The Housing Quality Inspections Manager has also begun scheduling quality control inspections monthly to ensure they occur within 90 days of the original inspection. The Field Supervisor conducts these inspections and ensures they are completed on time. Name(s) of the contact person(s) responsible for corrective action: Erin Fisher/Katrina Sommer Planned completion date for corrective action plan: On-going

View Audit 35864 Questioned Costs: $1

Finding 31164 (2022-002)

Significant Deficiency 2022

Housing Authority of St. Louis County

MO

HUD Housing Programs Reporting Significant Deficiency

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? PIC Reporting Recommendation: The Authority should implement processes to ensure HUD-50058 submissions are submitted into the PIC system timely and accurately. Explanation of disagreement with audit finding: There is no disagr...

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? PIC Reporting Recommendation: The Authority should implement processes to ensure HUD-50058 submissions are submitted into the PIC system timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since 2022, the Authority has sought comprehensive PIC training from its HUD Field Supervisor, PIC Couch, and EIV Coordinator. During these training events our Authority-HUD team addressed errors dating to 2021 and staff learned to make required corrections in a timely manner. The Authority also has included PIC reporting review as a responsibility for its recently created Housing Choice Voucher (HCV) Floater position. With the assistance of the HCV Floater and oversight by the HCV Director, the Authority addresses any PIC reporting errors effectively and immediately upon receipt. Name(s) of the contact person(s) responsible for corrective action: Nicole O?Dell/Katrina Sommer Planned completion date for corrective action plan: On-going

View Audit 35864

Finding 31163 (2022-001)

Significant Deficiency 2022

Housing Authority of St. Louis County

MO

HUD Housing Programs Eligibility Internal Control / Segregation of Duties

Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? Eligibility Recommendation: The Authority should implement processes to ensure that all documentation is received and that the correct inputs are being accurately reported on the HUD-50058. Explanation of disagreement with audit findin...

Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? Eligibility Recommendation: The Authority should implement processes to ensure that all documentation is received and that the correct inputs are being accurately reported on the HUD-50058. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has made several improvements to the processes in which the staff verify eligibility for the HCV program. In 2021, the Authority created a Director of Program Compliance and Training position to ensure that all HCV staff receive consistent training that is congruent with HUD policies and regulations and the Authority?s Administrative Plan. The Director of Program Compliance and Training instructs staff on HCV processes, procedures, and regulations, and monitors staff progress throughout their development. With the assistance of the Director of Program Compliance and Training, the Authority now provides staff with detailed training regarding calculations of adjusted income, the proper steps to determine and calculate required deductions, and the importance of third-party verification required for HCV program eligibility. The Authority has also taken the initiative to complete its own internal audits at random intervals, at least once a year. The HCV Director completes these audits using HUD?s Section Eight Management Assessment Program (SEMAP) audit template. Following these internal audits, the HCV Director meets with staff to discuss any areas of concern and ensure errors are properly corrected. During this meeting, staff receive training on any errors discovered, and recommendations for additional training. Name(s) of the contact person(s) responsible for corrective action: Nicole O?Dell/Katrina Sommer Planned completion date for corrective action plan: On-going

View Audit 35864

Finding 31162 (2022-001)

None 2022

Village of Woodlawn, Illinois

IL

CFDA number and name: 10.760 ? Water and Waste Disposal Systems for Rural Communities

View Audit 35822

Finding 31160 (2022-001)

Significant Deficiency 2022

Casa Linda, Inc.

CA

HUD Housing Programs

Corrective Action Plan For the Year Ended June 30, 2022 Finding 2022-001 Corrective Action Plan: The Organization is in the process of establishing monthly closing procedures to ensure timely monthly deposits to the replacement reserve account. In addition, the additional monthly deposits were depo...

Corrective Action Plan For the Year Ended June 30, 2022 Finding 2022-001 Corrective Action Plan: The Organization is in the process of establishing monthly closing procedures to ensure timely monthly deposits to the replacement reserve account. In addition, the additional monthly deposits were deposited into the reserve fund subsequent to year-end. Name of Responsible Person: Kim Morrison, CFO Anticipated Completion Date: December 31, 2022 Signed by Kim Morrison on October 12, 2022.

View Audit 35533

Finding 31158 (2022-001)

Significant Deficiency 2022

Kleeman Village Housing Corporation, Nfp

IL

Subrecipient Monitoring Internal Control / Segregation of Duties

U.S. Department of Housing and Urban Development Kleeman Village Housing Corporation, NFP respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit Period: Year...

U.S. Department of Housing and Urban Development Kleeman Village Housing Corporation, NFP respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit Period: Year ended June 30, 2022. The findings from the June 30, 2022 Schedule of Finding and Questioned Costs are discussed below. The findings are number consistently with the number assigned in the schedule. 2022-001 Recommendations: Management agent and sponsor will continue to monitor financial reports and accounting information as correction is not practical. Findings and Questioned Costs - Federal Award Programs Audit: Department of Housing and Urban Development: Supportive Housing for Persons with Disabilities Program (Section 811), Assistance Listing #14.181: See finding 2022-001 Preparation of Financial Statements. If the Department of Housing and Urban Development has questions regarding this plan please call Stephanie Coonce, Kleeman Village Housing Corporation, NFP at (217) 620-9683.

View Audit 33626

Finding 31154 (2022-001)

None 2022

Tolleson Elementary School District No. 17

AZ

Reporting

Finding Number: 2022-001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Dr. Myriam Roa, Executive Director of Business Services (through June 30, 2023) Anita Percell, Executive Director of Business Services (as of July 1, 2023) A...

Finding Number: 2022-001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Dr. Myriam Roa, Executive Director of Business Services (through June 30, 2023) Anita Percell, Executive Director of Business Services (as of July 1, 2023) Anticipated Completion Date: July 31, 2023 Planned Corrective Action: The District has prepared and submitted the ESSER III application to the Arizona Department of Education in May of 2023 and will make any revisions if necessary, in a timely manner. The District has hired new key finance positions with grants management experience to complete all future revisions and submissions.

View Audit 33624

Finding 31153 (2022-002)

Significant Deficiency 2022

Mary Lee Flagship

TX

HUD Housing Programs Internal Control / Segregation of Duties

Reporting Views of Responsible Officials: Management agrees with the finding and will immediately obtain signed HUD Forms 9887 and 9887-A from tenant and family members prior to accessing EIV or obtaining written third-party verification of income. Additionally, management will utilize an external c...

Reporting Views of Responsible Officials: Management agrees with the finding and will immediately obtain signed HUD Forms 9887 and 9887-A from tenant and family members prior to accessing EIV or obtaining written third-party verification of income. Additionally, management will utilize an external consultant to review tenant files for compliance with HUD procedures (i.e.. use of authorized consent and verification forms, EIV reports, etc.) and ensure supporting documentation is maintained in each tenant?s file.

View Audit 33620

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