Corrective Action Plans

Finding 1226478 (2025-004)

Material Weakness 2025

OR

Eligibility Questioned Costs HUD Housing Programs

Once REACH was notified about this audit finding, Property Management established a new review process to review the HOME units that would be re-classified the next time there is a vacant unit of the corresponding size/type. This is a “next available unit” rule. It will be addressed when the existin...

Once REACH was notified about this audit finding, Property Management established a new review process to review the HOME units that would be re-classified the next time there is a vacant unit of the corresponding size/type. This is a “next available unit” rule. It will be addressed when the existing resident moves out. Our third-party Property Management company will continue to monitor this finding.

View Audit 409109

Finding 1226477 (2025-003)

Material Weakness 2025

Reach Community Development, Inc.

OR

Eligibility Questioned Costs HUD Housing Programs

REACH’s 2024 consolidated audit report was issued in mid-November 2025. Once we were notified about this audit finding, Compliance Management conducted an in-depth review of this finding and determined that one extra 3-bedroom and one fewer 4-bedroom at Covington Commons were incorrectly set up in o...

REACH’s 2024 consolidated audit report was issued in mid-November 2025. Once we were notified about this audit finding, Compliance Management conducted an in-depth review of this finding and determined that one extra 3-bedroom and one fewer 4-bedroom at Covington Commons were incorrectly set up in our Yardi system. REACH have since corrected this issue in the Yardi system. REACH will continue to monitor vacant two-bedrooms at Cascadia Village as they become available. There are only two 2-bedrooms that are not designated as HOME. We noted that unit #72 was not set up properly in our Yardi system. REACH have corrected this issue in the system.

View Audit 409109

Finding 1226476 (2025-002)

Material Weakness 2025

Reach Community Development, Inc.

OR

Eligibility Questioned Costs HUD Housing Programs

REACH’s 2024 consolidated audit report was issued in mid-November 2025. REACH has policies and procedures in place to monitor compliance of recertifications, and correct income verification procedures are performed timely. Once we were notified of this finding, Compliance Management Compliance team ...

REACH’s 2024 consolidated audit report was issued in mid-November 2025. REACH has policies and procedures in place to monitor compliance of recertifications, and correct income verification procedures are performed timely. Once we were notified of this finding, Compliance Management Compliance team conducted a full review of all HOME regulatory agreements in the portfolio, including County, City and Commerce HOME funding. Compliance Management also created a spreadsheet to track which units are due for the appropriate HOME recertification.

View Audit 409109

Finding 1226338 (2025-002)

Material Weakness 2025

Retired Steelworkers Housing and Health Development Corporation

FL

HUD Housing Programs Reporting Eligibility

FINDING No. 2025-002: Section 236 Interest Reduction Payments, ALN 14.103 Recommendation: Management should implement procedures to ensure the Project verifies tenant eligibility through the EIV system. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV repo...

FINDING No. 2025-002: Section 236 Interest Reduction Payments, ALN 14.103 Recommendation: Management should implement procedures to ensure the Project verifies tenant eligibility through the EIV system. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance. If the audit Oversight Agency has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO

View Audit 408975

Finding 1226207 (2025-004)

Material Weakness 2025

Baden Street Settlement of Rochester, Inc.

NY

Eligibility Cash Management § 200.512

Views of Responsible Officials and Planned Corrective Actions: Current staff and new staff will be trained on the importance of keeping accurate records. A checklist will be developed for quarterly internal audits to cross-verify names between applications and attendance records, plus other applicab...

Views of Responsible Officials and Planned Corrective Actions: Current staff and new staff will be trained on the importance of keeping accurate records. A checklist will be developed for quarterly internal audits to cross-verify names between applications and attendance records, plus other applicable records. If discrepancies are identified in the internal audits, they will be corrected promptly.

View Audit 408854

Finding 1226195 (2025-002)

Material Weakness 2025

Opening Doors, Inc.

CA

Questioned Costs Subrecipient Monitoring Eligibility

Auditor's Recommendation: Strengthen controls over eligibility determinations by requiring Program Managers to document and retain evidence of review and approval of all intake forms/applications before services are provided. Management should also implement periodic monitoring procedures to ensure ...

Auditor's Recommendation: Strengthen controls over eligibility determinations by requiring Program Managers to document and retain evidence of review and approval of all intake forms/applications before services are provided. Management should also implement periodic monitoring procedures to ensure review approvals are consistently documented and maintained for audit purposes. Management Response: ODI is diligent in understanding and implementing the steps necessary to review and collect the required documentation to determine client eligibility for programs. Due to the large number of clients serviced and the volume of documents collected and reviewed, many of the programs track eligibility via proprietary on line portals provided by the funders to capture and document the steps performed to determine eligibility. These portals automatically determine whether a client is eligible based on the information provided. The Program Managers see the client eligibility on the portal when they assign caseworkers to the clients, but there is no formal Program Manager signature provided or captured in the portal. Corrective Action: • Regarding the specific program 90ZQ(l}011-01-0 Support for Trauma-Affected Refugees (STAR} referenced in this finding, client eligibility is determined by requirements established by the Office of Refugee Resettlement (ORR} that apply to other programs administered by ODI. To address the auditor's recommendation regarding this program, ODI will set up a procedure to review and retain documentation for clients entering the STAR program or who were referred from other ORR programs showing they are eligible to receive the STAR services. •Regarding the specific program ALSP23-0001 Afghan Legal Services Project (ALSP}, ODI has serviced, and is still servicing, approximately 500 clients. Although ODI asserts that it has and retains the documentation to demonstrate client eligibility for this program, to address the auditor's recommendation, ODI will set up a procedure to track and document that the program manager will approve. Responsible Personnel: Mao Vang, Health & SOT Program Director; Alyssa Eckels, ILS Program Director Implementation Date: Immediate implementation

View Audit 408833

Finding 1226082 (2025-023)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Eligibility California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS wo...

Eligibility California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS would leverage data to monitor application processing times. The data will be used to select counties for focused reviews targeting application processing times and procedures to ensure counties are performing eligibility determinations timely and accurately. DHCS has implemented multiple monitoring activities to address the recommendation and strengthen oversight of county processing of Medi-Cal applications. In May 2024, DHCS issued Medi-Cal Eligibility Division Letter (MEDIL) 24-12, ending the temporary hold harmless provisions and resumed standard county performance accountability. Subsequently, DHCS issued ACWDL 24-17, which established the Department's transition to using system-generated eligibility data, rather than county self-certification, to monitor application timeliness. Under this approach, DHCS evaluates county performance using statewide eligibility data, publishes application timeliness performance through statewide dashboards, and uses the data to identify counties for focused reviews. Focused reviews evaluate both the timeliness and accuracy of county eligibility determinations. Counties that do not meet established performance expectations are subject to corrective actions consistent with the Welfare and Institutions Code (WIC) section 14154 performance monitoring framework, including the application of statutory performance corrective action plans (CAPS), and financial penalties where applicable. Collectively, these actions establish an ongoing oversight process that enables DHCS to monitor county compliance with Medi-Cal application timeliness requirements, identify performance issues, require counties to implement corrective actions to address any deficiencies identified through focused reviews, and promote continued improvement in the timely and accurate processing of Medi-Cal applications. In 2025, DHCS issued MEDIL I 25-19, Reinstatement of the Aid Code Clean-Up Effort, which reinstated the Department's statewide process for identifying beneficiaries assigned to obsolete pre-Affordable Care Act (ACA) aid codes, transitional aid codes, or other records that may require reevaluation of eligibility. As part of this effort, DHCS provides counties with standardized reports on a bi-monthly basis to assist in identifying records that require review and action. Counties are required to review records, and either transition beneficiaries to the appropriate Medi-Cal aid code or discontinue eligibility, as applicable. Through the reinstated Aid Code Clean-Up process, DHCS performs ongoing statewide monitoring of aid code usage, identifies obsolete or inappropriate aid codes, and requires counties to take the appropriate action to ensure these beneficiaries are enrolled under the correct Medi-Cal aid category. Estimated Implementation Date: Fully Implemented Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226080 (2025-022)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Questioned Costs Allowable Costs / Cost Principles § 200.303

Activities Allowed and Unallowed California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL noti...

Activities Allowed and Unallowed California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS would leverage data to monitor application processing times. The data will be used to select counties for focused reviews targeting application processing times and procedures to ensure counties are performing eligibility determinations timely and accurately. DHCS has implemented multiple monitoring activities to address the recommendation and strengthen oversight of county processing of Medi-Cal applications. In May 2024, DHCS issued Medi-Cal Eligibility Division Letter (MEDIL) 24-12, ending the temporary hold harmless provisions and resumed standard county performance accountability. Subsequently, DHCS issued ACWDL 24-17, which established the Department's transition to using system-generated eligibility data, rather than county self-certification, to monitor application timeliness. Under this approach, DHCS evaluates county performance using statewide eligibility data, publishes application timeliness performance through statewide dashboards, and uses the data to identify counties for focused reviews. Focused reviews evaluate both the timeliness and accuracy of county eligibility determinations. Counties that do not meet established performance expectations are subject to corrective actions consistent with the Welfare and Institutions Code (WIC) section 14154 performance monitoring framework, including the application of statutory performance corrective action plans (CAPS), and financial penalties where applicable. Collectively, these actions establish an ongoing oversight process that enables DHCS to monitor county compliance with Medi-Cal application timeliness requirements, identify performance issues, require counties to implement corrective actions to address any deficiencies identified through focused reviews, and promote continued improvement in the timely and accurate processing of Medi-Cal applications. In 2025, DHCS issued MEDIL I 25-19, Reinstatement of the Aid Code Clean-Up Effort, which reinstated the Department's statewide process for identifying beneficiaries assigned to obsolete pre-Affordable Care Act (ACA) aid codes, transitional aid codes, or other records that may require reevaluation of eligibility. As part of this effort, DHCS provides counties with standardized reports on a bi-monthly basis to assist in identifying records that require review and action. Counties are required to review records, and either transition beneficiaries to the appropriate Medi-Cal aid code or discontinue eligibility, as applicable. Through the reinstated Aid Code Clean-Up process, DHCS performs ongoing statewide monitoring of aid code usage, identifies obsolete or inappropriate aid codes, and requires counties to take the appropriate action to ensure these beneficiaries are enrolled under the correct Medi-Cal aid category. Estimated Implementation Date: Fully Implemented Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226073 (2025-020)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Eligibility California Department of Health Care Services DHCS is currently in the process of reevaluating its Medi-Cal Eligibility Data System (MEDS) monitoring process by taking the following steps: Research and Data Collection - DHCS will initiate the revised MEDS alert hierarchy process by condu...

Eligibility California Department of Health Care Services DHCS is currently in the process of reevaluating its Medi-Cal Eligibility Data System (MEDS) monitoring process by taking the following steps: Research and Data Collection - DHCS will initiate the revised MEDS alert hierarchy process by conducting targeted research. This effort will include obtaining the total number of records associated with each MEDS Alert, encompassing the entire universe of MEDS alerts. - As part of this research, DHCS will review the highest volume alerts and identify the root causes. County Staff Workgroup: DHCS will form a workgroup with County Staff to collaborate on refining the MEDS Alerts process. The objectives of this workgroup are to: - Determine whether certain alerts can be streamlined to improve efficiency. - Assess if additional functionality can be added to CalSAWS to address issues that lead to high volume alerts. - Develop strategies to ensure counties have sufficient support to resolve MEDS alerts both accurately and timely. Hierarchy Revision and Implementation - DHCS will use the findings from the research phase and the input provided by the workgroup to revise the MEDS Alerts Hierarchy and ACWDL. - The Program Review Branch will update the BI tool to incorporate all MEDS alerts that affect eligibility, and pertinent high-volume alerts. - We are considering amendments to WIC section 14154.5 to reflect any changes in calculating performance standards for MEDS alerts. - DHCS will postpone posting MEDS Alerts performance data to the public facing dashboard until the end of this process. DHCS does not resolve MEDS Alerts. The purpose of the above process is to reduce the number of MEDS alerts created because of caseworker action by providing additional guidance to counties and potentially adding functionality to CalSAWS that would reduce the number of alerts created due to system discrepancies. This is anticipated to reduce the number of MEDS alerts, which would ease the county staff workload and allow counties to better manage the MEDS alerts workload. Focused reviews will continue to assist the department in identifying counties that do not act upon newly reported information that negatively impacts eligibility. DHCS will require counties to submit a corrective action plan and emphasize implementing ongoing trainings to mitigate inappropriate continuation of benefits. DHCS will continue to monitor progress until the identified issues no longer persist. Estimated Implementation Date: June 2027 Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226049 (2025-010)

Material Weakness 2025

State of California

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.214 § 200.303

Suspension and Debarment California Department of Public Health The California Department of Public Health (CDPH) agrees with this finding. CDPH has implemented interim procedures to verify vendor suspension and debarment status prior to the execution of federally funded procurements, including agre...

Suspension and Debarment California Department of Public Health The California Department of Public Health (CDPH) agrees with this finding. CDPH has implemented interim procedures to verify vendor suspension and debarment status prior to the execution of federally funded procurements, including agreements funded through emergency programs. CDPH is in the process of finalizing department-wide procedures and updating procurement checklists to ensure compliance with federal requirements. Until the formal procedures are published, staff will continue applying the interim procedures to ensure all required verifications are completed and appropriately documented in procurement files. Estimated Implementation Date: July 2026 Contact: - Louise Karsten, Emergency Funding Coordination Branch Manager, Center for Preparedness and Response

View Audit 408731

Finding 1226047 (2025-008)

Material Weakness 2025

State of California

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility § 200.214 § 200.303 § 200.332

Subrecipient Monitoring California Department of Aging Certification: The Department will incorporate a standard suspension and debarment certification clause into all subrecipient agreement templates, requiring each subrecipient to certify it is not suspended, debarred, proposed for debarment, or o...

Subrecipient Monitoring California Department of Aging Certification: The Department will incorporate a standard suspension and debarment certification clause into all subrecipient agreement templates, requiring each subrecipient to certify it is not suspended, debarred, proposed for debarment, or otherwise excluded from participation in federally funded transactions, consistent with 2 CFR §200.214 and 2 CFR Part 180, Subpart C. SAM.gov verification: Prior to executing any covered transaction, program staff will perform and document a search of the subrecipient in the SAM Exclusions database (SAM.gov). A screenshot or printed confirmation of the search results (including the date performed and the staff member who performed it) will be retained in the subrecipient's contract file. Checklist and Desk Procedures: The Department will update the checklist to include both a UEI/registration verification step and a separate Exclusions/Debarment verification step. Desk procedures will be updated to ensure staff follow the checklist and verify both the UEI and Exclusions status on SAM.gov. Retroactive review: For the eight subrecipient agreements identified in this finding, the Department will perform and document SAM.gov Exclusions to confirm suspension/debarment status, in addition to UEI verification, and retain the results in each contract file. Training: Staff responsible for subrecipient monitoring will receive training on the distinction between UEI/SAM registration checks and suspension/debarment exclusion checks, and on where to document each in the file. Estimated Implementation Date: September 2026 Contact: - Han Pham, Section Chief Business Management

View Audit 408731

Finding 1226037 (2025-006)

Material Weakness 2025

State of California

CA

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

Special Tests and Provisions Employment Development Department EDD has current policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the ...

Special Tests and Provisions Employment Development Department EDD has current policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the employee did not follow proper procedure to include the penalty. EDD accepts this oversight and is committed to reviewing its applicable policies and procedures to ensure they are clear, and the penalty requirements are emphasized. Regarding internal controls, EDD leverages a process known as the Field Office Basic Evaluation System (FOBES). This process includes a standardized form that is utilized by leadership to evaluate the quality of their employees’ work in a variety of processes, including overpayment processing. EDD continues to review and modernize the existing assessment form and FOBES process to ensure effectiveness and consistency while evaluating employee compliance with policies and procedures. EDD will enhance current procedures to outline the steps for reviewing claimant eligibility and applying disqualification penalties by: - Updating procedures in the various resources available for our determination false statement processes to include more comprehensive guidance. - Providing updated training for employees on any changes to procedures. Milestones: - Update UI Manuals by 8/14/2026. - Engage with UIB training team to update overpayment-related training and create a new refresher training by 8/14/2026. - Evaluate when a refresher training can be presented to determination trained employees by 8/14/2026. - Provide updated milestone to DOL by 9/30/2026. Estimated Implementation Date: September 2026 Contact: - Diane Underwood, Division Chief, Unemployment Insurance Branch

View Audit 408731

Finding 1226002 (2025-001)

Material Weakness 2025

Meadow Lane Housing Development Fund Company, Inc.

NY

Eligibility Questioned Costs HUD Housing Programs

An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail. Antici...

An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail. Anticipated Completion Date: Pending HUD approval of age waiver

View Audit 408679

Finding 1225991 (2025-001)

Material Weakness 2025

Genesis Nonprofit Housing Corporation

MI

Questioned Costs Eligibility HUD Housing Programs

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the project. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its project and document evidence in the files.

View Audit 408647

Finding 1225989 (2025-002)

Material Weakness 2025

Shawnee Christian Healthcare Center, Inc.

KY

Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking

The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throu...

The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly and proper supporting applications are retained.

View Audit 408644

Finding 1225860 (2025-004)

Material Weakness 2025

Housing Authority of the City of Durham

NC

HUD Housing Programs Questioned Costs Eligibility

Finding 2025-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in...

Finding 2025-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 733 units. Of a sample size of twenty-one (21) tenant files, the following was noted: • Citizenship declaration was missing in 1 file • Original application was missing in 1 file • HUD Form 9886 was missing in 1 file • Lead based paint form was missing in 1 file • HUD form 50058 was missing in 1 file • Verification of income was missing in 1 file • Verification of assets was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: $11,005 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority experienced high turnover and did not properly train employees in the Public and Indian Housing department, which resulted in the Authority having a limited capacity to perform the required maintenance of tenant files, and properly maintain and monitor a system of internal controls that reasonably assures the program is in compliance. Effect: The Authority is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files in the Public and Indian Housing Program. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are hired and trained on tenant file maintenance so that documents are accumulated, stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the deficiencies in the Public and Indian Housing Program and has implemented a quality control program. The Authority will continue to train staff on the proper maintenance of tenant files and implement additional internal control procedures that will ensure compliance with federal regulations. Sean Buchanan, Deputy Operating Officer is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring and is expected to be completed by December 31, 2026.

View Audit 408551

Finding 1225858 (2025-002)

Material Weakness 2025

Housing Authority of the City of Durham

NC

HUD Housing Programs Questioned Costs Eligibility

Finding 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 & 14.879 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in I...

Finding 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 & 14.879 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 2,208 units. Of a sample size of thirty-four (34) tenant files, the following was noted: • HUD form 9886 was unable to be provided in 2 files • Citizen Declaration Section 214 form was unable to be provided in 4 files • Signed lease was unable to be provided in 4 files • Lead based paint form was unable to be provided in 1 file Known Questioned Costs: $19,212 Cause: There is a material weakness in internal controls over the eligibility type of compliance related to the maintenance of tenant files in the Housing Voucher Cluster. The Authority experienced high turnover and did not properly train employees in the HCV department, which resulted in the Authority having a limited capacity to perform the required maintenance of tenant files, and properly maintain and monitor a system of internal controls that reasonably assures the program is in compliance. Effect: The Authority is in material non-compliance with the eligibility requirements of the Housing Voucher Cluster programs. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are hired and trained on tenant file maintenance so that documents are accumulated, stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the deficiencies related to the administration of Housing Voucher Cluster and will train staff on the proper maintenance of tenant files and implement internal control procedures that will ensure compliance with federal regulations. Tonya Crawley, HCV Program Director is responsible for ensuring proper internal controls are in place to prevent material weaknesses from occurring and is expected to be completed by December 31, 2026.

View Audit 408551

Finding 1225595 (2025-001)

Material Weakness 2025

Healthcare for the Homeless - Houston

TX

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Management is Responsible for Obtaining and Retaining Patient Intake Forms to Remain Compliant with Sliding Fee Discount Requirements Management’s view: Management agrees with the condition described. Proposed corrective action: Management will strengthen procedures for obtaining and retaining patie...

Management is Responsible for Obtaining and Retaining Patient Intake Forms to Remain Compliant with Sliding Fee Discount Requirements Management’s view: Management agrees with the condition described. Proposed corrective action: Management will strengthen procedures for obtaining and retaining patient intake documentation to ensure ongoing compliance with sliding fee discount requirements. Front-desk and registration staff will be retrained on intake form completion and annual renewal requirements, with clear accountability assigned for verifying documentation at each patient visit. A weekly compliance monitoring report will be implemented to identify missing or outdated intake forms before they age past the current review period, allowing for timely follow-up. Registration workflows will be refined to build in a review checkpoint at the point of service, and the Organization will add dedicated intake staffing capacity to provide consistent oversight of this function going forward. These steps will strengthen controls and ensure patient intake documentation is properly obtained, updated, and retained in compliance with sliding fee discount requirements. Anticipated correction date: Some corrective action was implemented in Q1 and Q2 2026. This is expected to be fully implemented effective by Q4 2026. Responsible official: Kathryn Rogers, Executive Vice President

View Audit 408476

Finding 1225511 (2025-002)

Material Weakness 2025

Su Casa Community Housing Association

CA

Eligibility Subrecipient Monitoring Cash Management

Finding 2025-002 – Personal Expenses Charged To The Project Recommendation: Management should strengthen expense and invoice review and approval procedures to ensure that all costs charged to the Project are reasonable, necessary, and directly related to Project operations, in accordance with the HU...

Finding 2025-002 – Personal Expenses Charged To The Project Recommendation: Management should strengthen expense and invoice review and approval procedures to ensure that all costs charged to the Project are reasonable, necessary, and directly related to Project operations, in accordance with the HUD Regulatory Agreement. Expense reimbursements should require detailed supporting documentation clearly demonstrating a valid Project purpose. A formal certification should be implemented as part of the approval process to attest that expenses are not personal in nature and have been approved. Internal reviews of Project expenses should be performed to identify and promptly correct any ineligible charges, including reimbursement to the Project where necessary. View of Responsible Officials and Planned Corrective Action: The individuals involved in the issues identified during the audit are no longer associated with the Project. Specifically, the former resident property manager is no longer employed by the Corporation and the composition of the Board has changed since the period under review. Management believes the identified issues resulted from a breakdown in adherence to existing approval, oversight and monitoring controls, including collusion among individuals responsible for reviewing and approving expenditures. The Project’s established policies and procedures were not properly followed. With the turnover in key personnel and Board leadership, management expects improved compliance with existing controls and oversight responsibilities. Management and the Board will continue to monitor Project expenses and ensure that expenditures are reviewed and approved in accordance with Project requirements and fiduciary responsibilities. Management response: Management agrees with the recommendation. Action Taken: The individuals involved in the issues identified during the audit are no longer associated with the Project. Specifically, the former resident property manager is no longer employed by the Corporation, and the composition of the Board has changed since the period under review. Management believes the identified issues resulted from a breakdown in adherence to existing approval, oversight, and monitoring controls, including collusion among individuals responsible for reviewing and approving expenditures. The Project's established policies and procedures were not properly followed. with the turnover in key personnel and Board Leadership, management expects improved compliance with existing controls and oversight responsibilities. Management and the Board will continue to monitor Project expenses and ensure that expenditures are reviewed and approved in accordance with Project requirements and fiduciary responsibilities.

View Audit 408391

Finding 1225492 (2025-001)

Material Weakness 2025

La Pine Community Health Center

OR

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Action taken in response to finding: The organization has worked with appropriate staff to provide further clarification on sliding fee intake and approval process.

View Audit 408356

Finding 1225392 (2025-003)

Material Weakness 2025

Harrington Family Health Center

ME

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was app...

Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was applied Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Billing Team Planned Corrective Action: The Organization revised its sliding fee discount policies, implemented centralized documentation tracking, and enhanced staff training related to eligibility determination and documentation requirements. Monitoring procedures, including periodic supervisory review, were established to ensure compliance. Anticipated Completion Date: Implemented and in progress. Due to the timing of the prior year’s audit completion, the Organization did not have time to complete a full monitoring cycle prior to audit testing.

View Audit 408346

Finding 1225268 (2025-004)

Material Weakness 2025

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Questioned Costs Special Tests & Provisions

Federal Award Finding 2025-004 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Cash Receipts Finding: The Organization maintained cash balances in excess of federally insured limits in financial institutions that did not meet HUD's minimum GNMA rating requirements. Recomm...

Federal Award Finding 2025-004 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Cash Receipts Finding: The Organization maintained cash balances in excess of federally insured limits in financial institutions that did not meet HUD's minimum GNMA rating requirements. Recommendation: The Organization should transfer excess cash balances to financial institutions that meet HUD's GNMA rating requirements or otherwise structure its cash holdings to ensure compliance with federal insurance limits and HUD custodial requirements. Action Taken: Nevins moved to this financial institution with the first HUD loan in 2015. This is a local bank that actively supports Nevin's mission in the community. Given Nevins’ current financial struggles, the balance in the bank seldom exceeds the $250,000 threshold. In addition, the receiver established its own account with East West Bank and was in the process of fully transitioning the operating account to East West Bank at the end of the fiscal year. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: Not started

View Audit 408309

Finding 1225062 (2025-067)

Material Weakness 2025

State of Rhode Island

RI

Allowable Costs / Cost Principles Cash Management Eligibility

To satisfy this audit finding, EOHHS requested a systems solution to process Eleanor Slater Hospital (ESH) claims which would automate a recipient’s TPL, Medicare, and MCO financial obligations before Medicaid is billed. EOHHS, BHDDH, and Gainwell Technologies have been working on said system modifi...

To satisfy this audit finding, EOHHS requested a systems solution to process Eleanor Slater Hospital (ESH) claims which would automate a recipient’s TPL, Medicare, and MCO financial obligations before Medicaid is billed. EOHHS, BHDDH, and Gainwell Technologies have been working on said system modification project (PJ0630 – Other Insurance Edits for Eleanor Slater Hospital Claims) and the Business Design Document was reviewed with all parties on 6/22/2026. Anticipated Completion Date: SFY 2027 Q1 Contact Person: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov

View Audit 408197

Finding 1225061 (2025-066)

Material Weakness 2025

State of Rhode Island

RI

Eligibility Reporting Questioned Costs

2025-066a: In order to address repeat income deficiencies from SWICA, Medicaid added The Work Number (TWN) as a new data source in August 2025. Since then, RI Bridges has been modified to first verify earned income against TWN. With this enhancement, Medicaid has seen an improvement in how earned in...

2025-066a: In order to address repeat income deficiencies from SWICA, Medicaid added The Work Number (TWN) as a new data source in August 2025. Since then, RI Bridges has been modified to first verify earned income against TWN. With this enhancement, Medicaid has seen an improvement in how earned income is verified during the post-eligibility verification (PEV) and annual renewal processes. Medicaid has determined the individuals flagged as being enrolled under the expansion pathway beyond their 65th birthday are the result of exceptions to the mass update eligibility process. Medicaid is working with our system vendor to develop a solution that will bypass this exception and terminate expansion eligibility for those turning 65 years old. RI Bridges appropriately identified the individual in question as requiring verification of citizenship status. However, as noted in the expansion age-out response, the mass update eligibility process exceptioned out, leaving the verification as unresolved and requiring manual review. Medicaid is working with our system vendor to develop a solution that will bypass this exception and terminate eligibility. Effective December 2025, the RI Bridges system receives quarterly matches from the SSA Death Master File (DMF). The DMF is automatically sent to the State as part of the quarterly PARIS data matching process. The State has deployed temporary system measures to process the file and automatically terminate Medicaid eligibility for individuals flagged as deceased on the DMF. As per section 71104 of the Working Families Tax Cut (WFTC) legislation, signed by the President on 7/4/25, the State will be deploying a long-term system enhancement to, “at least a quarterly basis, check the DMF to identify if enrolled individuals are deceased. If an individual is identified as deceased on the DMF, then the state must treat this information as factual, disenroll the individual, and discontinue any payments for items or services furnished after the death of the individual.” This enhancement is scheduled for the March 2027 release. In July 2024, federal partners operating the PARIS interstate match informed the State of a hold on PARIS interstate matching files. PARIS lifted the hold in October 2024. In November 2024, the State identified several defects in the PARIS results and suppressed requests for verification. A temporary system enhancement was logged to address the deficiencies and ensure the process was only requesting residency verification from individuals believed to be receiving Medicaid in another State. Long-term enhancements to the PARIS interstate match process are scheduled for late 2027. 2025-066b: Medicaid will continue to work with the Department of Human Services and HealthSource RI to improve reconciliation and quality assurance monitoring of eligibility and operational processes. Including, but not limited to automated quality control checks on batch processes, manual eligibility reviews of quarterly/annual activities, creating specialized reports, improving task logic, and identifying areas of repeat non-compliance to ensure appropriate controls are in place. 2025-066c: Upon notification from the systems team, Medicaid Finance will return any identified ineligible costs to the federal grantor. Anticipated Completion Dates: 2025-066a: Q4 2026 (exception scenarios) and Q4 2027 (PARIS) 2025-066b: Q4 2026 2025-066c: Ongoing Contact Persons: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov

View Audit 408197

Finding 1225059 (2025-064)

Material Weakness 2025

State of Rhode Island

RI

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s T...

A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s TPL data is not good enough to reject encounter claims from the MCO’s. EOHHS continues to work on improving the TPL process specifically cleaning up the TPL data in the MMIS and eligibility system today. Future system enhancements include a direct TPL vendor and new TPL module which should improve TPL accuracy. Anticipated Completion Date: July 31, 2028 Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov

View Audit 408197

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