Corrective Action Plans

Finding 1215168 (2025-007)

Material Weakness 2025

Sampson County

NC

Reporting Eligibility

Corrective Action Plan Audit Period: 2025 Audit Finding Reference Number: 2025-07 Description of Deficiency: SEFSA Preparation Finding: During compliance testing, it was noted that certain amounts reported on the Schedule of Expenditures of Federal and State Awards could not be readily reconciled to...

Corrective Action Plan Audit Period: 2025 Audit Finding Reference Number: 2025-07 Description of Deficiency: SEFSA Preparation Finding: During compliance testing, it was noted that certain amounts reported on the Schedule of Expenditures of Federal and State Awards could not be readily reconciled to the general ledger. Corrective Action To address this finding, the County will implement enhanced procedures over the preparation and review of the SEFSA. Specifically, the County will take the following actions: • Maintain more detailed supporting documentation for all SEFSA balances to ensure amounts reported can be traced to the general ledger. • Perform a formal reconciliation of the SEFSA to the general ledger as part of the year-end reporting process. • Conduct an enhanced management-level review of the SEFSA, including verification of reconciliations and significant amounts. • Provide ongoing training and guidance to staff involved in SEFSA preparation to support accurate and complete reporting. This Corrective Action Plan is implemented for the fiscal year ending June 30, 2026 and ongoing thereafter.

View Audit 401835

Finding 1215122 (2025-001)

Material Weakness 2025

St. Louis Housing Authority

MO

Eligibility HUD Housing Programs

Management's Response: The St. Louis Housing Authority (SLHA) accepts the recommendation and acknowledges the excess of failed inspections discovered during the Single Audit. The 24-month inspection cycle is a strict requirement under Federal Regulation 24 CFR § 982.405(a), which mandates that Publi...

Management's Response: The St. Louis Housing Authority (SLHA) accepts the recommendation and acknowledges the excess of failed inspections discovered during the Single Audit. The 24-month inspection cycle is a strict requirement under Federal Regulation 24 CFR § 982.405(a), which mandates that Public Housing Authorities must inspect assisted units at least biennially. Furthermore, SLHA's Administrative Plan incorporates these HUD standards as mandatory operating procedures. Identified Causes of Deficiency: Supervisory Oversight, Operational Monitoring, and Compliance Enforcement The audit identified insufficient oversight in operational monitoring and compliance monitoring, which resulted in missed biennial inspection deadlines for inspections overdue by more than 48 months. This noncompliance with HUD inspection frequency requirements, combined with inadequate staff monitoring, compromised both program integrity and data accuracy. Ensuring that all assisted units meet Housing Quality Standards (HQS) is central to SLHA's mission to provide safe, decent, and sanitary housing. orrective Actions: Contract Assistance, Staffing Adjustments, and Enhanced Database Reviews SLHA has initiated a comprehensive corrective action plan designed to (1) eliminate the current backlog and (2) implement sustainable controls to ensure ongoing compliance. SLHA will engage an external provider to conduct Housing Quality Standards (HQS) inspections for a temporary period of approximately three months to accelerate backlog reduction. Current inspectors may be authorized to work overtime to increase daily inspection capacity during the remediation period. SLHA will also hire two additional inspectors to ensure adequate long-term staffing levels. SLHA will reduce the inspection backlog to zero overdue inspections exceeding 24 months and bring 100% of units into compliance with the biennial inspection requirement within 90 days of implementation. HCV Department leadership will implement mandatory retraining on HUD inspection requirements and perform biweekly inspection schedule reviews and monthly compliance monitoring to track timely inspection completion.

View Audit 401810

Finding 1215066 (2025-001)

Material Weakness 2025

Central Valley School District No. 356

WA

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

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Central Valley School District No. 356 September 1, 2024 through August 31, 2025 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Central Valley School District No. 356 September 1, 2024 through August 31, 2025 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal eligibility requirements. Name, address, and telephone of District contact person: Mathew Knott, Director of Business Services 2218 N. Molter Road Liberty Lake, WA 99019 509-558-5437 Corrective action the auditee plans to take in response to the finding: The District does agree that one school with a poverty rate above 75% was not served. However, OSPI reviewed and approved the District’s Title I application, including our proposed ranking and allocation methodology, and no concerns or comments were raised during that review process. Additionally, the District was able to provide alternative snapshot dates demonstrating that no individual school was truly above the 75% threshold. Once the District became aware of the issue, we proactively contacted OSPI to determine whether any corrective action was necessary for the current year. OSPI’s guidance was that no changes or corrections were required for the current year and that adjustments should instead be implemented in the following year if a school exceeded the 75% threshold. Based on that direction from OSPI, the District did not make current-year corrections. Given these circumstances, including OSPI’s prior approval of the application and subsequent guidance that no corrective action was required, the District respectfully disagrees with the State Auditor’s Office conclusion that this matter rises to the level of a Finding rather than being addressed through a Management Letter. We consider this matter to be resolved as no school going into the 2025-2026 fiscal year was above the 75% threshold. Anticipated date to complete the corrective action: 8/31/2025

View Audit 401770

Finding 1215052 (2025-004)

Material Weakness 2025

Central Minnesota Jobs and Training Services

MN

Allowable Costs / Cost Principles Eligibility

Finding 2025-004: Inadequate Approval Controls Over Adjusting Journal Entries and Invoices Recommendation: We recommend following documented controls to enforce approval for adjusting journal entries. We also recommend ensuring invoice processing workflows include mandatory approvals before payment....

Finding 2025-004: Inadequate Approval Controls Over Adjusting Journal Entries and Invoices Recommendation: We recommend following documented controls to enforce approval for adjusting journal entries. We also recommend ensuring invoice processing workflows include mandatory approvals before payment. We further recommend conducting periodic audits to verify compliance with approval policies. Action Taken: CMJTS migrated to a new accounting software in February of 2025. This software has systematic approval workflows built in to ensure approvals are done on journal entries before they are posted and invoices before they can be paid.

View Audit 401763

Finding 1214917 (2025-002)

Material Weakness 2025

City of Sergeant Bluff, Iowa

IA

Allowable Costs / Cost Principles Cash Management Eligibility § 200.403

Criteria: The Uniform Guidance requires the City to establish and maintain effective internal control over compliance for federal awards, including controls to reasonably ensure that costs charged to federal programs are allowable, properly supported, and comply with applicable federal requirements ...

Criteria: The Uniform Guidance requires the City to establish and maintain effective internal control over compliance for federal awards, including controls to reasonably ensure that costs charged to federal programs are allowable, properly supported, and comply with applicable federal requirements and the terms and conditions of the award. Under 2 CFR 200.403, costs charged to a federal award must be allowable, including that they be adequately documented and not be included as a cost or used to meet cost-sharing requirements of any other federally financed program in the current or a prior period. Condition: The City did not have adequately designed and implemented review controls over certain material project costs included in reimbursement requests submitted to the pass through agency. Our testing identified that the city submitted the same eligible project cost for reimbursement under two different federal grant awards, of which one was denied for reimbursement Cause: The City lacked sufficiently designed or effectively operating controls over the preparation, review, and approval of reimbursement requests for federal awards. In particular, the City's controls did not include an effective reconciliation of expenditure detail by invoice, pay application, or other unique transaction identifier across open grant awards before submission of reimbursement requests. Effect: The absence of effective review controls over material project costs increases the risk that ineligible, unsupported, or incorrectly costs could be included in reimbursement requests without timely detection and correction. The duplicate submission was not reimbursed from both federal awards and therefore does not require repayment or adjustment of reimbursement requests. This deficiency is considered a material weakness in internal control over compliance for the Department of Transportation program. Recommendation: We recommend that the City design and implement formal, documented review procedures over material project costs included in reimbursement requests. These procedures should include defined review responsibilities, documentation of the review performed, review of other federal funding reimbursement request, and supervisory oversight to ensure that all high-dollar or complex transactions are reviewed for eligibility, accuracy, and adequate supporting documentation before submission.Management Response: Management acknowledges the finding and will continue to review and controls to ensure all costs included in reimbursement requests are allowable.

View Audit 401683

Finding 1214907 (2025-001)

Material Weakness 2025

Herkimer County Community College

NY

Subrecipient Monitoring Eligibility

Views of Responsible Officials: The college verbally assigned GLBA responsibilities to an individual in a meeting several years ago regarding GLBA which was attended by all departments affected by its regulations. However, that assignment was not formalized in writing. This individual separated empl...

Views of Responsible Officials: The college verbally assigned GLBA responsibilities to an individual in a meeting several years ago regarding GLBA which was attended by all departments affected by its regulations. However, that assignment was not formalized in writing. This individual separated employment with the college in January 2026. As a result, the college is currently in the process of transitioning its information technology (IT) department under the auspices of the State University of New York Information Technology Exchange Center (SUNY ITEC) where the college has access to a wide range of resources including experts in GLBA. With this transition, SUNY ITEC will appoint the Chief Information Officer / IT Director as the qualified individual (QI) for GLBA compliance. SUNY ITEC’s Security Services will support the Director; informing and advising them of relevant IT Security Program and Security Operations activities and compliance, and the Director will be the signing QI.

View Audit 401665

Finding 1214865 (2025-003)

Material Weakness 2025

Saraland Manor, Inc.

MS

Subrecipient Monitoring Eligibility HUD Housing Programs

We agree with Finding 2025-003 and the recommendations described above. We will provide additional training to staff to ensure annual inspections are completed in a timely manner.

View Audit 401563

Finding 1214864 (2025-002)

Material Weakness 2025

Saraland Manor, Inc.

MS

Subrecipient Monitoring Eligibility HUD Housing Programs

We agree with Finding 2025-002 and the recommendations described above. We will provide additional training to staff to ensure annual recertifications are completed in a timely manner.

View Audit 401563

Finding 1214776 (2025-001)

Material Weakness 2025

Catholic Charities of the Diocese of St. Cloud

MN

Eligibility Significant Deficiency

Foster Grandparent Program – Assistance Listing No. 94.011 Recommendation: The organization should ensure proper eligibility verifications are performed for all current and potential program participants to ensure all program participants are eligible. Explanation of disagreement with audit finding:...

Foster Grandparent Program – Assistance Listing No. 94.011 Recommendation: The organization should ensure proper eligibility verifications are performed for all current and potential program participants to ensure all program participants are eligible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will ensure moving forward that eligibility verifications are performed for all participants in a timely manner as specified by the grant requirements. Name(s) of the contact person(s) responsible for corrective action: Andrew Johannes, CFO Planned completion date for corrective action plan: 12/31/2026

View Audit 401515

Finding 1214697 (2025-005)

Material Weakness 2025

Catholic Charities of the Diocese of Palm Beach County, Inc.

FL

Procurement, Suspension & Debarment Eligibility

U.S. Department of Justice Assistance Listing-No. 16.320 Recommendation: Management should implement a review process requiring eligibility assessments to be reviewed by an individual other than the preparer and update procurement policies to fully comply with Uniform Guidance requirements, includin...

U.S. Department of Justice Assistance Listing-No. 16.320 Recommendation: Management should implement a review process requiring eligibility assessments to be reviewed by an individual other than the preparer and update procurement policies to fully comply with Uniform Guidance requirements, including procedures for procurements exceeding the micro purchase threshold. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Catholic Charities of the Diocese of Palm Beach is strengthening compliance procedures for the U.S. Department of Justice program by implementing a formal secondary review process for participant eligibility determinations and by updating procurement policies and procedures to align with Uniform Guidance requirements. All eligibility determinations will be reviewed by qualified personnel independent of the preparer prior to final approval to confirm compliance with grant eligibility requirements and completeness of supporting documentation. In addition, management will revise procurement policies and related procedures to address procurements exceeding the micro-purchase threshold and to clarify documentation and approval requirements for applicable purchases. These actions are intended to improve compliance with grant eligibility and procurement requirements. Name(s) of the contact person(s) responsible for corrective action: Carol Rodriguez, Program Development & Quality Director; and Marc Hopin, Finance Director Planned completion date for corrective action plan: June 30, 2026

View Audit 401440

Finding 1214694 (2025-003)

Material Weakness 2025

Catholic Charities of the Diocese of Palm Beach County, Inc.

FL

Eligibility Material Weakness

U.S. Department of Health and Human Services-Assistance Listing No. 93.558 Recommendation: Eligibility intake forms should be reviewed by an individual other than the preparer to ensure that only eligible participants are served under the Homeless Challenge Grant. Explanation of disagreement with au...

U.S. Department of Health and Human Services-Assistance Listing No. 93.558 Recommendation: Eligibility intake forms should be reviewed by an individual other than the preparer to ensure that only eligible participants are served under the Homeless Challenge Grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Catholic Charities of the Diocese of Palm Beach is strengthening eligibility determination controls for the Homeless Challenge Grant by implementing a formal secondary review process for participant intake and eligibility documentation. All eligibility determinations will be reviewed by qualified personnel independent of the preparer prior to final approval to confirm compliance with grant eligibility requirements and completeness of supporting documentation. Management will also maintain documentation evidencing the completion of the secondary review. These procedures are intended to strengthen compliance with grant requirements and reduce the risk of ineligible participants being served. Name(s) of the contact person(s) responsible for corrective action: Carol Rodriguez, Program Development & Quality Director; and Rocio Lopez, Program Director Planned completion date for corrective action plan: June 30, 2026

View Audit 401440

Finding 1214652 (2025-001)

Material Weakness 2025

Open Door Community Health Centers

CA

Special Tests & Provisions Eligibility

Name of Contact Person: Sarah Ross, Chief Operating Officer Corrective Action: Under the leadership of Open Door’s Chief Operations Officer and Director of Patient Access, we will implement the following actions to address SFDP compliance findings and reduce the risk of future errors. 1. Staff Retra...

Name of Contact Person: Sarah Ross, Chief Operating Officer Corrective Action: Under the leadership of Open Door’s Chief Operations Officer and Director of Patient Access, we will implement the following actions to address SFDP compliance findings and reduce the risk of future errors. 1. Staff Retraining and Competency Validation Retrain all Office Managers and Front Office staff on SFDP requirements, documentation standards, and processing procedures in collaboration with EMR and Learning & Development. Staff will be required to successfully complete a knowledge check prior to independently handling SFDP documentation. SFDP training will also be incorporated into new-hire onboarding and reinforced through ongoing training as needed. 2. Ongoing Monitoring and Accountability Implement a formal monitoring and accountability process to ensure sustained compliance. SFDP accuracy will be reviewed weekly, with Front Office Managers maintaining an error log to track errors, trends, and corrective actions. Continued or repeated errors will be addressed through expectation conversations and progressive disciplinary action, while accurate and consistent performance will be recognized. 3. Monthly Reporting and Targeted Corrective Training Identify trends and common error types, utilizing monthly SFDP reporting, to inform targeted retraining and process improvements. The reporting infrastructure is currently being developed using the Smartsheet Intelligent Work Management Platform to support leadership oversight and continuous improvement. 4. Leadership Oversight and Site-Level Accountability Administrative Directors at all health centers will actively participate in SFDP oversight by meeting with staff to reinforce program expectations and consequences for non-compliance. Monthly site-level SFDP performance reviews will be conducted with the Director of Patient Access, Administrative Directors, and Office Managers to review findings, trends, and corrective actions. 5. Integration into Performance Evaluations SFDP compliance will be formally integrated into staff performance evaluations. Compliance measures are currently included in Office Manager scorecards and will be added to Receptionist performance evaluations to reinforce accountability and sustain compliance. 6. Process Improvement Through Automation To further reduce the risk of human error, Open Door is planning a transition toward increased SFDP automation within the EMR to standardize determinations and improve documentation accuracy over time. Proposed Completion Date: June 30, 2026

View Audit 401373

Finding 1214593 (2025-001)

Material Weakness 2025

Department of Transportation and Public Works

PR

Internal Control / Segregation of Duties Eligibility Material Weakness § 200.303

Corrective Action: The Finance Director, in coordination with Human Resources, will execute a "Mobility File Standardization Plan." A census of transferred personnel will be conducted to identify missing documents (I-9 forms, tax withholdings, academic certifications, and background checks). A 90-da...

Corrective Action: The Finance Director, in coordination with Human Resources, will execute a "Mobility File Standardization Plan." A census of transferred personnel will be conducted to identify missing documents (I-9 forms, tax withholdings, academic certifications, and background checks). A 90-day term is established to complete the physical and digital archives.

View Audit 401254

Finding 1214511 (2025-005)

Material Weakness 2025

Laurel Public School District No. 7 and 7-70

MT

Eligibility Subrecipient Monitoring

A sample of 28 students receiving targeted Title I services was tested for eligibility compliance. For three students, the district could not provide supporting documentation to verify eligibility. Additionally, discrepancies were noted across multiple District- maintained Title I student listings, ...

A sample of 28 students receiving targeted Title I services was tested for eligibility compliance. For three students, the district could not provide supporting documentation to verify eligibility. Additionally, discrepancies were noted across multiple District- maintained Title I student listings, including inconsistencies and inclusion of students who did not meet established eligibility criteria. Response: In an effort to improve our record retention practices and strengthen internal controls over documentation management, we will implement the following practices and procedures improving our standardized procedures for maintaining and reconciling eligibility records for Title I. Staff training: • Secretary training on the standardized procedures for maintaining Title I eligibility documentation. Each school will have one secretary who will manage the data entry and therefore streamline practices in maintaining our eligibility documentation. • Teacher and administrator training on the standardized procedures for maintaining Title I eligibility documentation. Establishing clarity on which staff member collects the data and can show evidence of eligibility rationale, and then the teacher will communicate the students for record keeping and therefore streamline practices in maintaining our eligibility documentation. Quarterly Checks for accuracy: • Implementation of quarterly checks for eligibility determination to be reviewed at the school level and then verified with the Director overseeing the Title I program. This review will include system-wide documentation and record retention in according to federal requirements. This will ensure accuracy and consistency with data entry, documentation and our ability to correct errors quickly if needed. Systematic Checklist for program oversight: • Development of required evidence collection for Title programs in order to strengthen our internal controls to ensure documentation is complete, accurate, and readily accessible for audit. • Development of eligibility criteria guidance and necessary documentation to be collected at all buildings and communicated through our staff training to ensure documented rationale supporting eligibility.

View Audit 401215

Finding 1214245 (2025-004)

Material Weakness 2025

HABITAT FOR HUMANITY OF KANSAS CITY

MO

Procurement, Suspension & Debarment Eligibility Significant Deficiency

Suspension and Debarment – Assistance Listing No. 21.027 Recommendation: Management should implement a formal process to document and retain evidence of suspension and debarment verification for all applicable vendors, including verification dates. Management should also establish periodic review pr...

Suspension and Debarment – Assistance Listing No. 21.027 Recommendation: Management should implement a formal process to document and retain evidence of suspension and debarment verification for all applicable vendors, including verification dates. Management should also establish periodic review procedures to ensure continued vendor eligibility in accordance with Federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will establish and/or revise policies, procedures, and internal controls to ensure the documentation and retention of evidence of suspension and debarment verification, including periodic review of all applicable vendors. Name of the contact person responsible for corrective action: Lindsay Hicks Planned completion date for corrective action plan: June 30, 2026

View Audit 400970

Finding 1214231 (2025-005)

Material Weakness 2025

ATLANTIC CITY HOUSING AUTHORITY & URBAN REDEVELOPMENT AGENCY

CA

HUD Housing Programs Eligibility Material Weakness

Finding 2025-005: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 and 14.EHV Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness i...

Finding 2025-005: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 and 14.EHV 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 1,056 units. Of a sample size of twenty-four (24) tenant files, the following was noted:  HUD form 9886 was unable to be provided in 6 files - Verification of income was unable to be provided in 2 files - HUD-50058 form was unavailable for review in 4 files - Citizen Declaration Section 214 form was unable to be provided in 9 files - Signed leases were unable to be provided in 8 files - Original application was missing in 2 files - Lead based paint forms were missing 2 files - The Authority was unable to provide 1 tenant file during the time of audit. Known Questioned Costs: $ 149,640 Cause: There is a material weakness in the Housing Voucher Cluster 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 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 Housing Voucher Cluster Programs are in material non-compliance with the eligibility requirements of the 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 in the Housing Voucher Cluster Programs and will train staff on the proper maintenance of tenant files and implement internal control procedures that will ensure compliance with federal regulations. Malcom Isler, HCV Program Director/Interim Deputy Executive Director 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 July 31, 2026.

View Audit 400937

Finding 1214230 (2025-008)

Material Weakness 2025

ATLANTIC CITY HOUSING AUTHORITY & URBAN REDEVELOPMENT AGENCY

CA

HUD Housing Programs Eligibility Material Weakness

Finding 2025-008: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Comp...

Finding 2025-008: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Material Noncompliance 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 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 1,086 units. Of a sample size of twenty-four (24) tenant files, the following was noted: - Citizenship declaration was missing in 1 file - HUD-9886 form was missing in 5 files - Signed lease was missing in 1 file. Our sample size is statistically valid. Known Questioned Costs: $48,870 Cause: There is a material weakness 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 Public and Indian Housing Program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. 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 Housing Program and will train staff on the proper maintenance of tenant files and implement internal control procedures that will ensure compliance with federal regulations. Malcom Isler, HCV Program Director/Interim Deputy Executive Director 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 July 31, 2026.

View Audit 400937

Finding 1214222 (2025-001)

Material Weakness 2025

Community Housing Iii, Inc. Fir Grove Apartments

OR

Eligibility HUD Housing Programs Subrecipient Monitoring

Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures a...

Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that EIVs and recertifications are performed timely, inspections are completed, waitlists are being completed and followed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages at the property continued to have issues with timely completion of income certifications in 2025. In 2026 property management will be outsourced to a third-party management company to address outstanding compliance issues.

View Audit 400934

Finding 1214220 (2025-003)

Material Weakness 2025

Community Housing Ii, Inc. the Maples II Apartments

OR

Eligibility HUD Housing Programs Special Tests & Provisions

Federal Award Findings and Questioned Costs Item 2025-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor com...

Federal Award Findings and Questioned Costs Item 2025-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Action Taken: REACH has policies in place to complete move in inspections but due to tenant noncompliance and staffing issues this inspection was missed. Management scheduled training with staff in March 2026.

View Audit 400933

Finding 1214216 (2025-001)

Material Weakness 2025

Community Housing Ii, Inc. the Maples II Apartments

OR

Eligibility HUD Housing Programs Subrecipient Monitoring

Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor com...

Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that EIVs are performed timely, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete EIVs and recertifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2025. In 2026 property management will be outsourced to third party management company to address outstanding compliance issues.

View Audit 400933

Finding 1214212 (2025-001)

Material Weakness 2025

Powell Boulevard Apartments, Inc.

OR

Eligibility HUD Housing Programs Subrecipient Monitoring

Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities Program Federal Assistance Listing Number: 14.181 Recommendation: Management should establish proc...

Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities Program Federal Assistance Listing Number: 14.181 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications and EIVs in a timely manner but due to staffing shortages at the property continued to have issues with timely completion of income certifications in 2025. In 2026 property management will be outsourced to a third party management company to address outstanding compliance issues.

View Audit 400931

Finding 1214204 (2025-001)

Material Weakness 2025

Community Housing, Inc.

OR

Eligibility HUD Housing Programs Subrecipient Monitoring

Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures a...

Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete EIVs and recertifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2025. In 2026 property management will be outsourced to third party management company to address outstanding compliance issues.

View Audit 400927

Finding 1214169 (2025-034)

Material Weakness 2025

Commonwealth of Massachusetts

MA

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2025-034 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and that this documentation is readily available for audit. Action taken in response to finding: Current...

2025-034 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and that this documentation is readily available for audit. Action taken in response to finding: Currently, when a document is received at a MassHealth Enrollment Center, it is the worker’s responsibility to collect the documentation and send it to the Electronic Document Management Center (EDMC) in New Bedford. Once the document is received it is prepped, scanned, and indexed to enable a worker to process the documentation within our eligibility system. We are proposing a short-term and long-term solution to address the audit finding. Short term solution: This approach involves minimal modifications to the current operational process and can be quickly put into practice across all locations. All staff at the MassHealth document received at a MEC that was submitted by applicants or members. Subsequently, the document must be mailed to EDMC for further processing. Long term solution: Implementing this solution will involve modifications to the current operational processes and workflows within MassHealth Eligibility Operations and the system. To facilitate this, we plan to initiate a comprehensive internal discussion involving different teams to gather insights, understand existing procedures, and identify areas where changes are needed to support the new solution. Once these preliminary discussions are completed, we will work with the relevant stakeholders to begin the development of the specific requirements that the new process will entail. Name(s) of the contact person(s) responsible for corrective action: Tosin Adebiyi, Director of Special Eligibility Programs and Audits, Marco Gonzales, Eligibility Quality Assurance Team Leader, April Aguiar, Director of EDMC, Rosana Senise, Director of MassHealth Eligibility Planned completion date for corrective action plan: Short Term solution: April 1, 2026, Long Term solution: December 2027

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Finding 1214165 (2025-033)

Material Weakness 2025

Commonwealth of Massachusetts

MA

Eligibility Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

2025-033 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation that claims are paid only to eligible providers and that documentation is readily available for audit. Action taken in response to ...

2025-033 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation that claims are paid only to eligible providers and that documentation is readily available for audit. Action taken in response to finding: MassHealth plans to run a quarterly report to identify dental providers who are 3 months away from revalidation. MassHealth plans to share the report with DentaQuest to ensure that the revalidation process begins in a timely manner. Additionally, MassHealth has streamlined the maintenance of revalidation documentation by requiring DentaQuest to upload the documentation directly into MassHealth’s Medicaid Management Information System (MMIS). MassHealth has updated its provider agreement processing procedures and now requires DentaQuest to upload executed provider agreements directly into MassHealth’s MMIS. MassHealth plans to identify any additional dental providers (if any) who may be overdue for revalidation and share such information with DentaQuest and plans to instruct DentaQuest to reach out to the identified providers in order to begin the revalidation process. MassHealth instructed DentaQuest to: (1) generate revalidation letters; and (2) send providers revalidation letters, as appropriate, via email. Name(s) of the contact person(s) responsible for corrective action: Tuyen Vu, Deputy Director, Dental Planned completion date for corrective action plan: MassHealth anticipates implementing the above updated processes in the second quarter of calendar year 2026.

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Finding 1214161 (2025-032)

Material Weakness 2025

Commonwealth of Massachusetts

MA

Eligibility Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

2025-032 Children's Health Insurance Program (CHIP) 93.767 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation that claims are paid only to eligible providers and that documentation is readily available for audit. Action taken in re...

2025-032 Children's Health Insurance Program (CHIP) 93.767 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation that claims are paid only to eligible providers and that documentation is readily available for audit. Action taken in response to finding: MassHealth instructed the Third-Party Affiliation vendor, DentaQuest to: (1) generate revalidation letters; and (2) send providers revalidation letters, as appropriate, via email. MassHealth plans to run a quarterly report to identify dental providers who are 3 months away from revalidation. MassHealth plans to share the report with DentaQuest to ensure that the revalidation process begins in a timely manner. Additionally, MassHealth has streamlined the maintenance of revalidation documentation by requiring DentaQuest to upload the documentation directly into MassHealth’s Medicaid Management Information System (MMIS). MassHealth plans to identify any additional dental providers (if any) who may be overdue for revalidation and share such information with DentaQuest and plans to instruct DentaQuest to reach out to the identified providers in order to begin the revalidation process. MassHealth has updated its provider agreement processing procedures and now requires DentaQuest to upload executed provider agreements directly into MassHealth’s Medicaid Management Information System (MMIS). MassHealth has instructed DentaQuest to complete sanction verifications for all individuals listed on the disclosure forms. MassHealth has updated its provider agreement processing procedures and now requires DentaQuest to: (1) send provider agreements to MassHealth directly for countersigning; and (2) upload executed provider agreements directly into MassHealth’s MMIS. Name(s) of the contact person(s) responsible for corrective action: Tuyen Vu, Deputy Director, Dental Planned completion date for corrective action plan: MassHealth anticipates implementing the above updated processes in the second quarter of calendar year 2026.

View Audit 400886

Corrective Action Plans

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