Corrective Action Plans

Finding 575628 (2024-002)

Significant Deficiency 2024

Newport County Community Mental Health Center, Inc.

RI

Procurement, Suspension & Debarment

Finding 2024.002 – Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compli...

Finding 2024.002 – Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Not a repeat finding Action Taken Beginning in FY26, NMH has formally adopted the following policy and procedure to address uniform guidance requirements for suspension and debarment. This policy updates and clarifies the Center’s internal procedures, building upon the initial check process and the sporadic exclusion of monthly suspension and debarment checks conducted in FY24. See policy and procedure below: NMH POLICY & PROCEDURE FOR UNIFORM GUIDANCE REQUIREMENTS FOR SUSPENSION AND DEBARMENT To ensure that Newport Mental Health (NMH) is not doing business with vendors who have been suspended or debarred from doing business with the federal government, prior to contracting/purchase, the Vice President of Finance, or designee, will ensure the vendor/contractor is not on the List of excluded Individuals and Entities (LEIE) in the Office of Inspector General (OIG) Exclusion Database before creating a purchase order or making a payment. Procedures for Accounts Payable: New vendors or contractors must complete a current W-9 and debarment attestation form. Accounts Payable will verify that the vendor is not suspended or debarred. If a vendor or contractor is found to be suspended or debarred, Accounts Payable will flag them in NXT. This alert notifies invoice processors that federal funds cannot be used for this vendor. Any NMH Department who detects a suspended or debarred vendor should notify Accounts Payable to ensure proper flagging in the system. Procedures for Ongoing Checks: The Finance Department will generate a list of all vendors and employees paid with Federal funds and review it monthly against the LEIE using Verify Comply, an OIG Exclusion Search Software. If a vendor is found to be suspended or debarred, the Finance Department will reclassify purchases off the Federal grant and notify Accounts Payable to flag the vendor in NXT. Accounts Payable must keep documentation of each check. The Vice President of Finance oversees these processes to ensure compliance.

View Audit 365599

Finding 575610 (2024-001)

Significant Deficiency 2024

Western Landowners Alliance

CO

Reporting § 200.508

Auditee Corrective Action Plan Finding 2024-001: Schedule of Federal Awards (SEFA) Preparation – Significant Deficiency Audit Finding: During our audit, we noted that the Schedule of Expenditures of Federal Awards (SEFA) initially prepared by Western Landowners Alliance did not include the required...

Auditee Corrective Action Plan Finding 2024-001: Schedule of Federal Awards (SEFA) Preparation – Significant Deficiency Audit Finding: During our audit, we noted that the Schedule of Expenditures of Federal Awards (SEFA) initially prepared by Western Landowners Alliance did not include the required Assistance Listing Numbers (formerly CFDA numbers) for each federal program, and the amounts of federal expenditures reported contained inaccuracies. We understand this was Western Landowners Alliance’s first year preparing a SEFA and that staff are still becoming familiar with the detailed requirements of the Uniform Guidance (2 CFR Part 200). As the SEFA is a critical component of the Single Audit reporting package and serves as the basis for major program determination and compliance testing, it is essential that it be prepared accurately and in accordance with Uniform Guidance. We recommend that management enhance its understanding of SEFA preparation requirements, consider additional training on Uniform Guidance, and implement review procedures to help ensure the completeness and accuracy of the SEFA in future reporting periods. Audit Recommendation: We recommend that management enhance its understanding of SEFA preparation requirements, consider additional training on Uniform Guidance, and implement review procedures to help ensure the completeness and accuracy of the SEFA in future reporting periods. Management’s Response and Corrective Action Plan: Western Landowners Alliance (WLA) acknowledges and agrees with the finding, and have taken the following corrective actions to address the issue: (1) Implementation of SEFA Template: given the diversity of awards WLA receives (primary, subawards, and awards with both federal/non-federal funding), a standardized template has been developed and implemented to ensure accurate tracking and reporting of awards, funding sources, and expenditures. (2) Proactive Collection of Assistance Listing Numbers: WLA will proactively request and document the Assistance Listing Numbers (formerly CFDA numbers) from funding agencies upon receipt of awards to ensure compliance, and complete and accurate reporting. (3) Documentation of Expense Allocation Process for Awards with Federal and Non-Federal Funding: WLA’s financial policies and procedures have been updates (as of August 2025) to document the process for allocating expenses on awards that include both federal and non-federal resources. Documentation of this process will ensure consistent and appropriate allocation in accordance with federal requirements. (4) Per recommendation from RGO, Robinson has enrolled in two trainings: Uniform Guidance Training Part 1 and Part 2-Single Audit Training-the importance of the SEFA, hosted by Illumeo, to augment knowledge to support future compliance. Contact and Completion Date: Rachael Robinson, 505-466-1495, rrobinson@westernlandowners.org, is the primary contact, and the Chief Operating Officer at Western Landowners Alliance. The corrective action is currently in effect and trainings will be completed by August 31, 2025, to ensure compliance with the current fiscal year. Please reach out with any questions. Rachael Robinson Chief Operating Officer Western Landowners Alliance 505-466-1495

View Audit 365598

Finding 575592 (2024-001)

None 2024

Firstmed Health and Wellness Center

NV

Special Tests & Provisions Eligibility

The Center will - Provide immediate re-training to staff on issues identified, and - Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing, and - Ha...

The Center will - Provide immediate re-training to staff on issues identified, and - Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing, and - Has updated procedures for the Sliding Fee Discount Program approval process in which all sliding fee required documents are first reviewed and approved by a Clinic Supervisor or Center Manager for program compliance. This process was implemented in July 2025, which was at the mid-point of the current fiscal year and will assist in addressing any issues and training proactively, and - Will continue ongoing Sliding Fee Audit Tracers and Chart Audits to assess staff knowledge, provide feedback, and offer guidance, as needed

View Audit 365587

Finding 575582 (2024-002)

Material Weakness 2024

City of East Chicago

IN

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.328

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur ...

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: To ensure proper implementation of the policies and procedures in place related to SLFRF reporting, in the future, no submittal of reports will be approved without the City Controller and a Senior Staff Accountant reviewing and approving the P&E reports. This will ensure policies and procedures are followed and possibly added to, if needed, to ensure compliance over SLFRF reporting. Anticipated Completion Date: Corrective action is now in effect as of August 18, 2025.

View Audit 365567

Finding 575581 (2024-001)

Material Weakness 2024

City of East Chicago

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2024-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Offici...

FINDING 2024-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Valeriano Gomez, City Controller Contact Phone Number and Email Address: (219) 391-8220, vgomez@eastchicago.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: A Suspension and Debarment policy was adopted at the conclusion of the 2023 audit, however, the policy was not presented to and officially adopted by the East Chicago Board of Works until the August 22, 2024, meeting. This oversight resulted in a delay of the anticipated enactment of the policy resulting in there being sufficient time to enact the new policy for the current audit year of 2024. The current summary schedule of prior audit findings reflects the issue as partially corrected, providing the supporting documents consisting of Board of Works actions in regard to the policy. Going forward, all steps are in place for correction of the situation. See policy below. CITY OF EAST CHICAGO SUSPENSION/ OR DEBARMENT POLICY FOR VENDOR WHEN FEDERAL FUNDS/ ASSISTANCE INVOLVED: The following specific provisions to be followed under the City of East Chicago purchasing policy and procedure for determining Suspension and Debarment status of any vendor doing business with the City for which federal funds and/ or federal assistance are to be utilized by City. A. SAM search, verification by contracted vendor or contractual provision. Prior to any purchase for which federal funds or federal assistance is to be utilized by the City, the purchasing agency, or its designee, shall: 1. Examine and verify the status of any vendor participating in or to be contracting for business with the City utilizing federal funds and or federal assistance for debarment and suspension status to determine whether the vendor is qualified to participate. The check or verification for debarment and suspension shall be performed using the System for Award Management (SAM) or any similar system currently approved for such purpose. The City Departments/ Boards responsible for facilitating, coordinating and utilizing federal funds will be required to conduct and complete the SAM search, or its approved equivalent, as such procedures and methods are amended, on all vendors with whom the City intends to conduct business utilizing federal funds. Further the City or entity responsible shall provide a hard copy proof and verification of each SAM search for record keeping. 2. Require each contracted vendor utilizing federal funds to certify that the contracted vendor was not suspended or debarred; or 3. Add a clause to appropriate contract to ensure that the contracted vendors were not suspended or debarred. 4. Further these policy requirements for determination of suspension and/ or debarment status of any vendor doing business with the City of East Chicago, in which federal funds and/or federal assistance are utilized shall pertain to "Covered Transactions" under 2 C.F. R. pt. 180, subpt. 8 which include those government contracts for goods and services awarded under a non-procurement transaction (e.g. grant or cooperative agreement) that are expected to equal or exceed $25,000, or meet certain other specified criteria. B. No business with a debarred or suspended entity. It is specifically directed and required that the City of East Chicago, shall not conduct any business with any firm, individual, or entity that has been identified as having been debarred or suspended for such purposes, in conformance with applicable law; in particular, 2CFR 180.300 a. 2 CFR 180.300 states: When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified. You must do this by: 1. Checking SAM Exclusions; or 2. Collecting a certification from that person; or 3. Adding a clause or condition to the covered transaction with that person. Anticipated Completion Date: Corrective action is now in effect as of August 18, 2025.

View Audit 365567

Finding 575580 (2024-005)

Significant Deficiency 2024

Survivor Advocacy Outreach Program

OH

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332

New policy was to be implemented by August 31, 2025 that will include written agreements with subaward programs and the Grants Manager will monitor the plan, with additional monitoring to be completed by the Exective Director periodically.

View Audit 365566

Finding 575579 (2024-004)

Significant Deficiency 2024

Survivor Advocacy Outreach Program

OH

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The policy for SAOP was updated to include proper approvals for related to Federal program. This policy was to be approved by the Board of Directors by August 31, 2025

View Audit 365566

Finding 575578 (2024-002)

Significant Deficiency 2024

National Sorghum Producers Association

TX

Reporting Allowable Costs / Cost Principles

2024-002 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Allowable Costs/Cost Principles: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA is strengthening budgeting and recordkeeping to properly allocate payroll costs between federal and nonfederal funding. Estimat...

2024-002 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Allowable Costs/Cost Principles: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA is strengthening budgeting and recordkeeping to properly allocate payroll costs between federal and nonfederal funding. Estimated Completion Date: September 2025 Management Contact: Tim Lust, CEO

View Audit 365562

Finding 575577 (2024-001)

Significant Deficiency 2024

National Sorghum Producers Association

TX

Subrecipient Monitoring

2024-001 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Subrecipient Monitoring: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA will establish a policy and implement procedures for subrecipient monitoring and risk assessment and a record will be maintained of all ...

2024-001 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Subrecipient Monitoring: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA will establish a policy and implement procedures for subrecipient monitoring and risk assessment and a record will be maintained of all award agreements identifying or documenting subrecipients’ compliance obligation. Estimated Completion Date: September 2025 Management Contact: Tim Lust, CEO

View Audit 365562

Finding 575567 (2024-001)

Material Weakness 2024

Town of Middleborough

MA

Procurement, Suspension & Debarment § 200.303 § 200.318

The School Department Failed to Check Vendors for Suspension and Debarment Before Contracting Name of Contact Person: Michael Perrone, Director of Business & Finance Corrective Action Plan: The District will apply procedures, and or processes, to document all contracts with vendors that exceed $25,0...

The School Department Failed to Check Vendors for Suspension and Debarment Before Contracting Name of Contact Person: Michael Perrone, Director of Business & Finance Corrective Action Plan: The District will apply procedures, and or processes, to document all contracts with vendors that exceed $25,000 to include verification that the vendor is not subject to suspension/debarment prior to contracting. It is important to note, that on every Middleborough Public School purchase order contains the language “The offerer certifies that they and any principals are not presently debarred, suspended, proposed for debarment,or declare ineligible for the award of contracts by any federal agency” The District believed that a vendor honoring our purchase order (Contract) was in essence certifying that they were compliant with the language on our purchase order. Proposed Completion Date: The District will immediately make the necessary changes to comply with the aforementioned finding. It would be helpful if your team would supply the District with examples from other municipalities with acceptable practices.

View Audit 365559

Finding 575557 (2024-002)

Material Weakness 2024

City of Grafton

ND

Reporting

Contact Person – City Administrator Corrective Action Plan – The City will implement procedures to ensure all required reports are prepared and submitted by their due dates. Completion Date – September 1, 2025

View Audit 365546

Finding 575554 (2024-001)

None 2024

Juneau Economic Development Council

AK

Reporting Subrecipient Monitoring § 200.512

Finding 2024-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Sam Muse, Finance and Administration Director Corrective Action: JEDC will implement a policy in which, whenever Federal or State dollars are transferred to JEDC, JEDC will obtain written clarific...

Finding 2024-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Sam Muse, Finance and Administration Director Corrective Action: JEDC will implement a policy in which, whenever Federal or State dollars are transferred to JEDC, JEDC will obtain written clarification from the entity transferring the money expressly indicating whether JEDC is a contractor or a subrecipient of the monies. Additionally, JEDC will use a “checklist” to confirm and verify that determination and will seek additional clarification if there is any disagreement in the classifications. Proposed Completion Date: July 1, 2024.

View Audit 365538

Finding 575545 (2024-004)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

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

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

View Audit 365535

Finding 575544 (2024-003)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Special Tests & Provisions Eligibility

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

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

View Audit 365535

Finding 575543 (2024-002)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

HUD Housing Programs Special Tests & Provisions Reporting

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

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

View Audit 365535

Finding 575542 (2024-001)

Significant Deficiency 2024

Housing Authority of Lincoln County

OR

Special Tests & Provisions HUD Housing Programs Significant Deficiency

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

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

View Audit 365535

Finding 575513 (2024-001)

Significant Deficiency 2024

Northern Oswego County Health Services, Inc. Dba Connextcare

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

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

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

View Audit 365508

Finding 575512 (2024-002)

Significant Deficiency 2024

Five Towns Community Center INC

NY

Questioned Costs Allowable Costs / Cost Principles

FTCC concurs with the finding and will make every attempt to create time studies and maintain labor distributions reports to support salary allocations in the future. FTCC anticipates to complete the corrective action plan by the year end December 31, 2025.

View Audit 365496 Questioned Costs: $1

Finding 575509 (2024-004)

Material Weakness 2024

Town of Marblehead

MA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.214

Condition: Suspension and debarment compliance was not verified for three covered transactions. Corrective Action Plan: The Town will implement the following: • Have the Grant Coordinator review and understand compliance with the Town’s Federal Grant Awards Policy. • Have the Grant Coordinator in...

Condition: Suspension and debarment compliance was not verified for three covered transactions. Corrective Action Plan: The Town will implement the following: • Have the Grant Coordinator review and understand compliance with the Town’s Federal Grant Awards Policy. • Have the Grant Coordinator in conjunction with the compliance accountant develop a standard reporting checklist to be used by all staff preparing or reviewing Federal project submissions. • Implement a two-level review process requiring: o Department-level preparation with supporting documentation. o Grant Coordinator final review and approval before submission of Federal reports. • Require quarterly reconciliations between project expenditures and Federal reporting to ensure accuracy. Anticipated Completion Dates: o By September 30, 2025: Grant Coordinator training completed, and checklist distributed. o Ongoing: Reports will be reviewed and certified quarterly by the Grant Coordinator prior to submission. Contact Information: Donna Cotterell, Grant Coordinator

View Audit 365493

Finding 575508 (2024-003)

Significant Deficiency 2024

Town of Marblehead

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.328

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

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

View Audit 365493

Finding 575507 (2024-003)

Significant Deficiency 2024

Avivo

MN

Cash Management Reporting Significant Deficiency § 200.303

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

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

View Audit 365488

Finding 575491 (2024-002)

Significant Deficiency 2024

Avivo

MN

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

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

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

View Audit 365488 Questioned Costs: $1

Finding 575475 (2024-001)

Significant Deficiency 2024

Avivo

MN

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

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

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

View Audit 365488

Finding 575471 (2024-003)

Material Weakness 2024

Lutheran Social Services of Central Ohio

OH

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring

Condition: During the year, the Organization did not have appropriate review procedures and controls in place related to cash management and reporting over federal programs Planned Corrective Action: Finance has recent changes in leadership roles and with the change in leadership, has put into plac...

Condition: During the year, the Organization did not have appropriate review procedures and controls in place related to cash management and reporting over federal programs Planned Corrective Action: Finance has recent changes in leadership roles and with the change in leadership, has put into place improvements in oversight of cash management and reporting. LSS has a philosophy of continuous improvement and with the current management LSS will ensure that all guidelines and requirements for cash management and reporting for federal programs are met. Contact person responsible for corrective action: Julie Fratianne, CFO Anticipated Completion Date: September 30, 2025

View Audit 365486

Finding 575468 (2024-002)

Material Weakness 2024

Lutheran Social Services of Central Ohio

OH

Subrecipient Monitoring Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Condition: During the current year, a lack of control procedures surrounding the review of payroll costs resulted in improper amounts of payroll to be charged to the grant. Planned Corrective Action: Finance is working with IT and HR to integrate the payroll system with LSS’ accounting system to e...

Condition: During the current year, a lack of control procedures surrounding the review of payroll costs resulted in improper amounts of payroll to be charged to the grant. Planned Corrective Action: Finance is working with IT and HR to integrate the payroll system with LSS’ accounting system to eliminate manual processes in the creation of the payroll journal entry. There will also be periodic internal audits performed to test payroll allocations. Contact person responsible for corrective action: Julie Fratianne, CFO Anticipated Completion Date: September 30, 2025

View Audit 365486

Corrective Action Plans

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