Corrective Action Plans

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Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Developed and implemented a standardized procedures for documenting and retaining support for all grant activity. Reveiwed all grant paperword, reconciled with supportive documentation
Concord’s Compliance Dept has implemented procedures to ensure the tenant security deposits are correctly recorded, tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with HUD’s requirements.
Concord’s Compliance Dept has implemented procedures to ensure the tenant security deposits are correctly recorded, tenant eligibility is correctly determined and that the tenant lease files are properly maintained in accordance with HUD’s requirements.
2023-004 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@har...
2023-004 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will comply with federal employment eligibility requirements by ensuring a Form I-9 is completed for every employee within three business days of their start date. Employees must provide acceptable documentation as...
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will comply with federal employment eligibility requirements by ensuring a Form I-9 is completed for every employee within three business days of their start date. Employees must provide acceptable documentation as required, and completed forms will be securely maintained and retained for the required period. The Financial Analyst will periodically review personnel files to confirm compliance, and any missing or incomplete forms will be addressed promptly with documentation of corrective actions retained. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst by: January 31st, 2024
Finding: 2023-005 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Eligibility – Missing Documentation Documentation for eligibility will be reviewed with staff and files will be reviewed by a supervisor. A supervi...
Finding: 2023-005 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Eligibility – Missing Documentation Documentation for eligibility will be reviewed with staff and files will be reviewed by a supervisor. A supervisor checklist will be used to make sure documents are reviewed. Our IV-E files are also reviewed twice a year by a state IV-E QA team. Anticipated Completion Date: January 2026
Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.01...
Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.019 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements regarding Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2023.
Finding Reference Number: 2023-010 Description of Finding: Documentation of eligibility determination for an applicant could not be located. Response/Corrective Action: The County outsourced the administration of the Emergency Rental Assistance Program to several third parties over the duration of t...
Finding Reference Number: 2023-010 Description of Finding: Documentation of eligibility determination for an applicant could not be located. Response/Corrective Action: The County outsourced the administration of the Emergency Rental Assistance Program to several third parties over the duration of the Federally-funded program. Due to several administration changes, it is apparent that one of the files was either commingled with another record, misfiled, or misplaced. There is no evidence to suggest authorization and disbursement of funds occurred at the time of processing without a complete file supporting the activity was qualified and released was so approved. The County will be more diligent in the management and storage of required records for contact guideline requirements moving forward.
FINDING 2023-003 - Sliding Fee Discount Program MATERIAL WEAKNESS; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93.224/93 .527, Health Center Program Cluster Compliance Requirement: Special Tests & Provisions Criteria: Section ...
FINDING 2023-003 - Sliding Fee Discount Program MATERIAL WEAKNESS; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93.224/93 .527, Health Center Program Cluster Compliance Requirement: Special Tests & Provisions Criteria: Section 330 of the Public Health Service Act and the HRSA Health Center Program Compliance Manual require health centers to maintain and operate a board-approved Sliding Fee Discount Program that adjusts patient charges based on income and family size using the current Federal Pove1ty Guidelines, applies uniformly to all patients and all in-scope services, and is supported by adequate documentation of eligibility determinations. In addition, Uniform Guidance requires nonfederal entities to establish and maintain effective internal controls over federal programs to provide reasonable assurance of compliance with federal statutes, regulations, and award terms. Condition: During testing of the Sliding Fee Discount Program within the Health Center Cluster, the Center could not provide documentation of the appropriate sliding fee discounts for certain patients in accordance with federal requirements. Context: The condition was identified through testing of the Health Center Cluster as pa1i of the single audit, which included testing patient fee assessments and sliding fee discount application as a special test required under the program. Controls were determined to be ineffective in 2 of 40 test items. Noncompliance was noted in 2 of 25 test items. Statistical sampling was not utilized. Cause: The condition was caused by inadequate internal controls over the implementation and monitoring of the Sliding Fee Discount Program, including limited supervisory review to ensure all sliding fee applications are maintained, reviewed, and properly applied. Effect or Potential Effect: The Center's failure to maintain documentation surrounding sliding fee discounts in accordance with federal requirements increases the risk of noncompliance with Health Center Program requirements and may result in patients being charged amounts not aligned with their ability to pay. The condition also increases the risk of adverse findings during HRSA oversight or other federal monitoring activities. Questioned Costs: No questioned costs were identified as a result of this finding. Repeat Finding: This is not a repeat finding. Recommendation: The Center should enhance internal controls over the Sliding Fee Discount Program by ensuring consistent documentation of income and family size, timely reassessment of eligibility in accordance with policy, consistent application of the board-approved sliding fee discount schedule to all applicable in-scope services, and periodic monitoring and supervisory review to ensure ongoingcompliance. Views of Responsible Officials: Neighborhood Medical Center has implemented quarterly SFDP internal audits and training for the intake staff to improve compliance oversight and documentation accuracy. A standardized audit tracking log documenting charts are reviewed, findings identified and corrective actions completed. An annual refresher for the staff has been implemented. A quick-reference eligibility checklist has also been developed for staff use. Person Responsible for Corrective Action: Ronica Mathis and Shenika Mathews Anticipated Completion Date for Corrective Action: This practice has already been implemented.
"Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Pe...
"Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations"
The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify they meet the grant eligibility requirements. September 2026 Al Agpoon, Golden State Division Controller
The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify they meet the grant eligibility requirements. September 2026 Al Agpoon, Golden State Division Controller
Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards,...
Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards, and updated procedures Ongoing Monitoring - Quarterly internal audits; COO and Board Finance Committee review of compliance - ongoing Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to finance committee - ongoing
Fund Account - Deposited back to the replacement reserve account - October 16, 2025 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - M...
Fund Account - Deposited back to the replacement reserve account - October 16, 2025 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - May/June 2026 Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to Finance Committee - Ongoing
Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards,...
Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards, and updated procedures Ongoing Monitoring - Quarterly internal audits; COO and Board Finance Committee review of compliance - ongoing Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to finance committee - ongoing
The County acknowledges deficiencies related to the availability and completeness of supporting documentation for one federal program expenditures and reporting. In some instances, supporting documentation was not readily available at the time of review or required additional follow-up. The County i...
The County acknowledges deficiencies related to the availability and completeness of supporting documentation for one federal program expenditures and reporting. In some instances, supporting documentation was not readily available at the time of review or required additional follow-up. The County is strengthening documentation and record retention practices, improving coordination with program staff, and reinforcing expectations for maintaining complete and timely supporting records. These actions are intended to ensure documentation is available to support reporting and compliance requirements.
Special Tests and Provisions - Waiting List Public and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of...
Special Tests and Provisions - Waiting List Public and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenants who were admitted i nto the Public Housing Program. Specifically, required records demonstrating waiting list position, selection order, and eligibility determinations were not available for review. As a result, we were unable to verify that applicants were admitted in accordance with HUD waiting list and tenant selection requirements. Auditor Recommendations: We recommend that management perform a reconciliation of the waiting list and reconstruct missing documentation where possible to support applicant selection and admission into the program. Management should update and formalize waiting list procedures in accordance with HUD regulations and the Authority's ACOP, i mplement supervisory review controls to verify completeness of waiting list documentation prior to tenant admission, and ensure records are retained in accordance with HUD and federal record-retention requirements. In addition, management should provide training to staff responsible for waiting list administration to promote consistent compliance with HUD requirements. Action Taken: HACM's Lease and Compliance department has done additional training with their staff since 2023 on Occupancy, Eligibility, Income and Rent Calculation. In addition, the Director has provided additional onboarding training to new employees and has provided YARDI Aspire training in how to perform certain tasks in YARDI software, i ncluding waitlist selection. We believe that the error rate will decrease in future years from 2023. In addition, between March 2026 and June 2026, the Lease and Compliance Director will work with all staff that maintain waitlists or perform waitlist selection to reiterate the proper documentations of how to maintain records that demonstrate waitlist positions, selection order and proper selection. Name of Responsible Person: Marquetta Treadway, Lease and Compliance Director Projected Completion Date: June 30, 2026
Eligibility P ublic and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: Out of an approximate population of 2,150 tenants from the Public and Indian Housing program, we tested 43 tenants and the following deficiencies were noted: • 16 files were m...
Eligibility P ublic and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: Out of an approximate population of 2,150 tenants from the Public and Indian Housing program, we tested 43 tenants and the following deficiencies were noted: • 16 files were missing a flat rent option form, • 14 files were missing 214 forms, • 10 units did not have the required inspection performed, • 9 files had incorrect income or missing income support, • 8 files incorrectly contained prior year information in the current year recertification, • 6 files were missing valid 9886 forms, • 2 files were missing identification for adults in the household, and • 1 file was missing birth certificate or other documentation for minors receiving income credits. A uditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor's sample. Action Taken: HACM's Lease and Compliance department has done additional training with their staff since 2023 on Occupancy, Eligibility, Income and Rent Calculation. In addition, the Director has provided additional onboarding training to new employees and has provided YARDI Aspire training in how to perform certain eligibility tasks in YARDI. We believe that the error rate will decrease in future years from 2023. In add ition,between March 2026 and June 2026, the Lease and Compliance Director will work with all staff that perform initial eligibility or recertifications to reiterate the major topics that HACM has had deficiencies and the proper way to treat those items. Name of Responsible Person: Marquetta Treadway, Lease and Compliance Director Projected Completion Date: June 30, 2026
2023-004 Special Tests and Provisions - Waiting List Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenan...
2023-004 Special Tests and Provisions - Waiting List Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenants who were issued housing vouchers. Specifically, required records demonstrating waiting list position, selection order, and eligibility determinations were not available for review. In addition, 8 of the 40 new admissions tested lacked support for the auditor to complete testing in this area. A uditor Recommendations: We recommend that management perform a reconciliation of the waiting list and reconstruct missing documentation where possible to support applicant selection and voucher issuance. Management should update and formalize waiting list procedures in accordance with HUD regulations and the Authority's Administrative Plan, i mplement supervisory review controls to verify completeness of waiting list documentation prior to voucher issuance, and ensure records are retained in accordance with HUD and federal record-retention requirements. In addition, management should provide training to staff responsible for waiting list administration to promote consistent compliance with HUD requirements. Action Taken: On the same note and based on a HUD review of operations, HACM entered into a SEMAP Corrective Action Plan with HUD with the goal to improve the SEMAP performance indicator scores. Via a nationwide Request for Proposal, HACM hired the contractor, CVR Associates, Inc. (CVR) to manage and operate the entire Housing Choice Voucher program for HACM, effective January 2, 2025. This contract is currently overseen by the Acting Secretary- Executive Director and will be overseen by the Chief Operations Officer once a new one is hired. CVR was selected as the contractor in part due to their extensive experience in managing similar voucher programs nationwide and on their tools/software that they have developed to manage items, such as quality control testing in the areas such as the items noted above. This included wait list oversight and wait list selection. CVR provided additional training to staff, prepared new standard operating procedures i ncluding those over waiting lists, and perform quality control testing over the course of the entire year. Many of the SEMAP indicators have improved, but some have additional improvement still needed based on the 2025 SEMAP results. When there a re issues, the CVR Quality Control team follows up with the staff person to correct the issue, and to provide guidance or additional training with the goal to reduce the error rate in the future. We believe that HACM will be back to being a standard performer or higher in 2026. In addition, the self-reported 2025 SEMAP testing was showing good scores in the area of Waiting List. Name of Responsible Person: Ken Barbeau, Acting Secretary-Executive Director; Chief Operations Officer (once hired); Projected Completion Date: December 31, 2026
Contact Name: Patrick Johndrow Contract Phone Number: 479-271-6781 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2023 Finding #2023-002 – Statement of Condition: The City did not maintain documentation supporting the underlying information included in its quarterly performance report. Sp...
Contact Name: Patrick Johndrow Contract Phone Number: 479-271-6781 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2023 Finding #2023-002 – Statement of Condition: The City did not maintain documentation supporting the underlying information included in its quarterly performance report. Specifically, source records and supporting schedules used to compile reported information were not retained or made available for audit. Response: The Organization concurs with the finding and related adjustments made during the audit. Management will implement additional internal controls related to program reports. The completion date for the above-mentioned corrective action was January 2026.
A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and iss...
A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and issue weekly progress reports to the Director of Asset Management. c. Non-compliant files will be flagged for immediate follow-up with tenants. d. PMCS, a third-party group, will assist with recertifications. 2. Enforcing Timely Recertifications: a. Recertifications must be completed no later than 30 days before expiration. b. Staff will receive monthly reminders, and escalation measures will be implemented for delays. 3. Quarterly Internal Audits: a. PMCS and internal staff will conduct random file audits every three months to ensure adherence. b. Deficiencies will be addressed in real-time, and corrective steps will be logged. B. Ensuring EIV System Compliance 1. Standardizing EIV Compliance Procedures: a. A formal checklist will be created for EIV report reviews, ensuring all required reports are generated before lease renewals. b. EIV data will be cross-referenced with tenant files every quarter to ensure completeness. 2. Internal Monthly EIV Reviews: a. The Senior Housing Specialist will generate and review EIV reports on the 1st of each month. b. The Director of Asset Management, Third-Party Compliance Officer (PMCS), and Senior Housing Specialist will verify compliance before reports are finalized. 3. Quarterly Compliance Reports: a. The Compliance Officer will submit a quarterly compliance report documenting completion rates and deficiencies. C. Enhancing Staff Training and Accountability 1. Mandatory Quarterly Training: a. Staff will undergo quarterly compliance training covering HUD Handbook 4350.3, recertifications, and EIV compliance. b. Training sessions will be documented, and staff performance assessed. 2. Clarification of Responsibilities: a. Staff roles will be clearly outlined in a Standard Operating Procedure (SOP) document. b. Staff will be required to acknowledge their roles in compliance processes. 3. PMCS Involvement for Training Support: a. PMCS will offer supplementary training sessions as needed. D. Documentation and Oversight Enhancements 1. Maintaining Complete and Auditable Files: a. All lease and EIV documentation will be stored both physically and digitally. b. A real-time compliance dashboard will track completion rates. 2. Routine Management Reviews: a. The Senior Housing Specialist and Director of Asset Management will conduct monthly spot checks to verify document accuracy and completion. b. Non-compliance will result in formal corrective actions.
We have reviewed the sliding fee calculations calculated by the system and have implemented internal control procedures to ensure the discount fees are calculated and applied correctly. Implementation date: June 16, 2025
We have reviewed the sliding fee calculations calculated by the system and have implemented internal control procedures to ensure the discount fees are calculated and applied correctly. Implementation date: June 16, 2025
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