Corrective Action Plans

Finding 1218700 (2025-004)

Material Weakness 2025

State of Michigan

MI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

Finding 2025-004 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exceptio...

Finding 2025-004 Bridges Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For parts a., b., c., and d., MDHHS implemented the Database Security Application (DSA) on October 2, 2023, which includes documenting incompatible role exception requests and user access request approvals, semi-annual review of privileged users, and annual review for all users. Security management and access control processes will continue to be a standing agenda item for ongoing quarterly training sessions with local office security coordinators (LOSC). For parts a., c., and d., the Access Management Section began implementing a process to conduct quarterly reconciliations of the DSA to the Bridges Integrated Automated Eligibility Determination System (Bridges) during March 2025. Due to the complexity of the reconciliations and time constraints, MDHHS requested the Bridges technical team to develop a consolidated Excel based report to add a level of automation to the process. The report is now available on an ad hoc basis, and the Access Management Section began utilizing it during April 2026 to conduct reviews and provide remediation with the LOSCs and end users. Full automation of the report remains in progress due to significant competing priorities and limited resources. For part b., MDHHS implemented the automated DSA periodic access review process (PAR) during January 2026 to review all users every 90 days, instead of the current 180 days for privileged users. MDHHS updated its policy to require initiation of the PAR in the DSA for all users every 90 days, without exception, to comply with State standards. For part e., MDHHS local office directors, district managers, or designees review a monthly sample of high-risk Bridges transactions to ensure documentation was properly maintained. Beginning September 2024, MDHHS Business Service Centers (BSC) implemented a monitoring process to ensure monthly reviews are completed by the local offices timely and that the documentation is properly maintained. To strengthen compliance, MDHHS will reinforce expectations through manager training and emphasize the requirement to maintain complete records and to sign and date all review reports within 30 days of the report run date. Additional training sessions will be repeated as needed to ensure consistent adherence to documentation and timeliness standards across all local offices. Anticipated Completion Date a., c., and d. Ongoing b. Completed e. September 30, 2026 Responsible Individual(s) a., b., c., and d. Tim Kwast, MDHHS e. Tim Kwast and Veronica Maxson, MDHHS

View Audit 404775

Finding 1218699 (2025-003)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties § 200.303

Finding 2025-003 Bridges Interface Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB will establish a process to verify that the total number of processed, exception, and skipped records matches the number of records read from the data source. DTMB will investiga...

Finding 2025-003 Bridges Interface Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB will establish a process to verify that the total number of processed, exception, and skipped records matches the number of records read from the data source. DTMB will investigate discrepancies identified through this validation process and implement appropriate corrective measures to resolve the issues. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Nathan Buckwalter, DTMB

View Audit 404775

Finding 1218698 (2025-002)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Eligibility Internal Control / Segregation of Duties § 200.303

Finding 2025-002 DTMB, IT General Controls Management Views The Department of Technology, Management, and Budget (DTMB) agrees it did not perform the annual review of privileged accounts for the operating system servers. As stated in the finding, DTMB performed the recertification process after the ...

Finding 2025-002 DTMB, IT General Controls Management Views The Department of Technology, Management, and Budget (DTMB) agrees it did not perform the annual review of privileged accounts for the operating system servers. As stated in the finding, DTMB performed the recertification process after the issue was brought to its attention. Planned Corrective Action DTMB performed its user access recertification processes in November 2025. Anticipated Completion Date Completed Responsible Individual(s) Manny Rosales, DTMB

View Audit 404775

Finding 1218680 (2025-054)

Material Weakness 2025

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Eligibility

Finding 2025-054 Adoption Assistance, ALN 93.659 - Lack of Fingerprint Background Checks Management Views MDHHS disagrees that completion of fingerprint-based background checks within 12 months of adoption finalization are a condition of eligibility for adoption assistance payments. Federal law 42 U...

Finding 2025-054 Adoption Assistance, ALN 93.659 - Lack of Fingerprint Background Checks Management Views MDHHS disagrees that completion of fingerprint-based background checks within 12 months of adoption finalization are a condition of eligibility for adoption assistance payments. Federal law 42 USC 671(a)(20) requires states to complete a fingerprint-based criminal background check before a prospective adoptive parent may be finally approved for placement; however, federal statute does not mandate additional or subsequent fingerprint-based criminal history rechecks after placement approval as a condition of eligibility for adoption assistance payments. Michigan’s Title IV-E State Plan incorporates the safety requirements mandated by federal law 42 USC 671(a)(20) and cites MDHHS policy ADM 0520 (Background Checks, Clearances, Criminal History Checks, and Fingerprinting). ADM 0520 governs all background checks, clearances, criminal history checks, and fingerprinting requirements that MDHHS must complete for foster care and adoptive home providers. The policy establishes the department’s comprehensive safety check framework and is not limited to adoption assistance eligibility determinations. Rather, ADM 0520 outlines the procedures MDHHS uses to meet federal and State safety requirements for approving and supervising foster and adoptive placements, including checks conducted both before placement approval and those completed afterward to ensure the ongoing safety and well being of children under MDHHS supervision. For all cases sampled, fingerprint based clearances were completed within 12 months of the family’s approval for placement, and documentation of these clearances is included in the adoption assistance file. Therefore, MDHHS is compliant with all applicable federal and State requirements for adoption assistance payments. Planned Corrective Action MDHHS will clarify policy to explicitly distinguish safety-driven clearances from federally required placement-approval checks, including clarification that the required prerequisite for adoptive placement and adoption assistance payments is completion of fingerprint-based clearances within 12 months of approval. Anticipated Completion Date December 1, 2026 Responsible Individual(s) Heather Williams, MDHHS Kim Borja, MDHHS Kathonya Triplett, MDHHS

View Audit 404775

Finding 1218661 (2025-051)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Subrecipient Monitoring § 200.516

Finding 2025-051 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action In May 2025, MDHHS issued memo 2025-20, which implemented mandatory training requirements for all eligibility staff and their managers...

Finding 2025-051 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action In May 2025, MDHHS issued memo 2025-20, which implemented mandatory training requirements for all eligibility staff and their managers to address audit-related findings. The State Emergency Relief (SER) training courses occur biannually, in March and August, and cover verification of client income, client contribution payments, and proof of energy crisis. To ensure accuracy of payment processing, in October 2025, MDHHS issued memo 2025-48 which implemented the mandatory SER Reconciliation Report requirement. As part of this updated process, each county office must run the SER Energy Reconciliation Report weekly and review all energy-related payments to ensure accuracy and confirm that required documentation is maintained. In addition, MDHHS will continue to communicate with BSCs and local offices regarding the requirements to maintain sufficient documentation to support SER processing through formal internal communication channels. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Further, MDHHS will explore a potential system enhancement that will provide automated solutions for an added layer of efficiency and compliance. Should such an improvement be identified, it will be submitted through the Departmental Work Intake Process for prioritization and implementation by the Bridges technical team. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the completion date is dependent on the priority assigned to system enhancements as determined by the Departmental Work Intake Process. Responsible Individual(s) Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Julie McLaughlin, MDHHS

View Audit 404775

Finding 1218654 (2025-048)

Material Weakness 2025

State of Michigan

MI

Allowable Costs / Cost Principles Eligibility Questioned Costs § 200.516

Finding 2025-048 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS acknowledges that documentation supporting compliance with refugee c...

Finding 2025-048 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS acknowledges that documentation supporting compliance with refugee cash assistance work registry requirements must be consistently maintained in the electronic case record. The issue identified pertains to documentation of ongoing work registration requirements within the case record to maintain eligibility, noting that the clients were eligible at the time of application approval. Beginning January 2026, MDHHS implemented a monthly manual review of active cases to ensure required documentation is present. MDHHS is also pursuing a Bridges system enhancement to automate generation and storage of the DHS-4785R (Refugee Employment Program Appointment Notice) in the electronic case file. This enhancement will be submitted through the Departmental Work Intake Process for prioritization and implementation by the Bridges technical team. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the priority assigned to the system enhancement as determined by the Departmental Work Intake Process. Responsible Individual(s) Benjamin Cabanaw, LEO Nicole Adams, LEO Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Mariah Schaefer, MDHHS

View Audit 404775

Finding 1218648 (2025-046)

Material Weakness 2025

State of Michigan

MI

Eligibility Questioned Costs Special Tests & Provisions

Finding 2025-046 Temporary Assistance for Needy Families, ALN 93.558 - Child Support Non-Cooperation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA will review each finding with the local offices responsible for the identified error cases. MDHHS ESA will issue a ...

Finding 2025-046 Temporary Assistance for Needy Families, ALN 93.558 - Child Support Non-Cooperation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS ESA will review each finding with the local offices responsible for the identified error cases. MDHHS ESA will issue a memo to local office staff by September 30, 2026, emphasizing the importance of taking appropriate action when clients are either cooperating or not cooperating with child support requirements. Additionally, MDHHS ESA policy staff will collaborate with the Bridges technical team by September 30, 2026, to determine whether system enhancements are needed to ensure sanctions and cooperations are applied in a timely manner. If enhancements are determined to be necessary, a Bridges work request will be developed and scheduled according to established processes and timeframes. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the potential system enhancements identified. Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schultz, MDHHS Brian Sanborn, MDHHS

View Audit 404775

Finding 1218646 (2025-044)

Material Weakness 2025

State of Michigan

MI

Allowable Costs / Cost Principles Questioned Costs Student Financial Aid § 200.516

Finding 2025-044 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF-Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) eligibility after the birth certifica...

Finding 2025-044 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF-Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) eligibility after the birth certificate was received and the youth was determined to be Title IV-E eligible. MDHHS has already reclassified the funds to the appropriate funding source, allowing the department to claim Title IV-E for the eligible placement, and repaying any TANF overpayments. Reconciliations between different fund sources, or recoupments for overpayments, will be created within 30 calendar days of receipt of supporting documentation and approved timely by management. All recoupment and reconciliation records will be approved by management no later than September 30 each fiscal year to ensure compliance with year-end requirements. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Nancy Berger, MDHHS

View Audit 404775

Finding 1218645 (2025-043)

Material Weakness 2025

State of Michigan

MI

Allowable Costs / Cost Principles Eligibility Questioned Costs § 200.516

Finding 2025-043 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will issue a memo to reinforce documentation requirements for TANF eligibility determinations by September 30...

Finding 2025-043 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will issue a memo to reinforce documentation requirements for TANF eligibility determinations by September 30, 2026. The memo will clarify expectations for obtaining, uploading, and retaining all required non-financial eligibility verifications in accordance with federal regulations and MDHHS policy. MDHHS will also address each individual case-specific issue with the appropriate local office. In addition, these findings will be addressed as part of TANF mandatory audit training for local office staff scheduled in July 2026. This training will emphasize the importance of maintaining complete eligibility records, proper use of the Work and Self Sufficiency Rules (DHS-1538) form, verification of age and relationship, and timely completion of the Family Automated Screening Tool. Further, MDHHS ESA policy staff are working with the MDHHS Bridges technical team to implement a system modification during September 2026 that will enhance the application review process. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schulze, MDHHS Brian Sanborn, MDHHS Ashley Soper, MDHHS

View Audit 404775

Finding 1218633 (2025-039)

Material Weakness 2025

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Eligibility § 200.516

Finding 2025-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates and distributes a monthly hospitalization report to adult services supervisors, who then distribute to adult services ...

Finding 2025-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates and distributes a monthly hospitalization report to adult services supervisors, who then distribute to adult services workers as part of the post-payment review process. During February 2025, MDHHS issued an Adult Services Notification to managers and directors reminding local office management of the expectation to thoroughly monitor and review the hospitalization reports to ensure timely and accurate action is taken by adult services workers. MDHHS also reissued the Home Help Recoupment Process training and procedural resources during February 2025 to adult services workers who manage Home Help cases to ensure process steps are consistently followed. In addition, during February 2026, MDHHS issued recoupments for the two clients identified by the Office of the Auditor General as part of the audit finding. During June 2025, MDHHS enhanced the monthly hospitalization report to improve data accuracy for identified service overlaps and ensure timely recovery of payments. However, MDHHS identified timing differences between the report run dates and the weekly schedule updates of CHAMPS hospitalization data that could result in incomplete hospitalization data within the monthly monitoring report. To ensure all relevant records are captured and promptly recover payments to clients hospitalized while receiving Home Help Program services who no longer met eligibility requirements, the timing of the report has been modified. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown, MDHHS

View Audit 404775

Finding 1218632 (2025-038)

Material Weakness 2025

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Eligibility § 200.516

Finding 2025-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing the overpayments, as well as deve...

Finding 2025-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing the overpayments, as well as developing mitigation strategies to temporarily address the overpayment concerns while more permanent system solutions are developed. As part of the Departmental Work Intake Process, MDHHS submitted work requests for prioritization to implement larger system changes that will resolve the remaining synchronization issues. Anticipated Completion Date MDHHS will determine an anticipated completion date after the work requests have been prioritized. Responsible Individual(s) Jamy Hengesbach, MDHHS

View Audit 404775

Finding 1218449 (2025-001)

Material Weakness 2025

Summit County Colorado

CO

Questioned Costs Subrecipient Monitoring Eligibility

Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program FFAL # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: The Federal requirement related to processing of...

Federal Agency Name: U.S. Department of Health and Human Services Passed-through Colorado Department of Health Care Policy and Financing Program Name: Medical Assistance Program FFAL # 93.778 Initial Fiscal Year Finding Occurred: 2024 Finding Summary: The Federal requirement related to processing of an application requires the State to provide notice of its decision concerning eligibility and provide timely and adequate notice of the basis for denial or termination of assistance (42 USC 1320c-7(d)). According to the Colorado Department of Health Care Policy and Financing (HCPF), processing standards 8.100.3.D, the County is required to process an initial application for any program not requiring a disability determination no later than 45 days following receipt of application. Our auditors, Eide Bailly, tested eligibility determination and controls over this process for sixty case files. They noted the following in our testing: • Two instances of non-compliance in which the County did not complete the eligibility determination and approve/deny the case within 45 days, and no notice of action was sent to the client within the required timeframe. • Two instances of non-compliance in which it could not be verified whether the notice of action was sent by the County to the client via mail or email Responsible Individuals: Joanne Sprouse, Human Services Director Corrective Action Plan: Summit County Human Services implemented multiple procedures in response to the prior 2024 findings. Those corrective action responses were still in process for the current 2025 period tested and will continue into 2026. During 2025, Summit County Human Services successfully retrained all case managers on application processing protocols, utilizing stateapproved training modules administered through the Staff Development Department. Summit County Human Services strictly follows state-mandated guidelines for processing Medical Assistance applications to ensure that all cases are approved or denied within the 45-day timeframe established by state regulations. To further enhance the accuracy of eligibility determinations for all household members, case managers have also completed the "Case Wrap-Up Training" through CoLearn, an online training platform developed by the State's Staff Development Department. Completion of this training ensures that eligibility determinations are accurate, and that appropriate client correspondence is issued. In 2025 and continuing into 2026, Summit County Human Services has also implemented a weekly review of the county dashboards, specifically the “HCPF Application Timeliness” and “HCPF Renewal Timeliness” dashboards. These dashboards monitor Medicaid application and renewal processing timelines initiated upon receipt by our office. In addition to the dashboard reviews, management meets weekly with the case managers responsible for monitoring the dashboards to identify trends and determine training needs. Furthermore, an additional line was added to the case comment template to ensure review and verification of correct case correspondence issuance. Anticipated Completion Date: Ongoing

View Audit 404737

Finding 1218424 (2025-002)

Material Weakness 2025

The Salvation Army of the Quad Cities

IA

Eligibility

2025-002 – Home Investments Partnerships Program, Assistance Listing #14.239 Recommendation: The auditors recommend the Division establish procedures to ensure all required documentation is retained in participant files and monitored throughout the year. Corrective Action: The Division will strength...

2025-002 – Home Investments Partnerships Program, Assistance Listing #14.239 Recommendation: The auditors recommend the Division establish procedures to ensure all required documentation is retained in participant files and monitored throughout the year. Corrective Action: The Division will strengthen controls to ensure complete eligibility documentation is obtained, verified, and retained for all program participants. At intake, case managers will verify income and HUD homelessness eligibility by completing required forms, collecting two months of income source documentation, calculating and validating income against applicable AMI limits, and obtaining appropriate homelessness verification with preference for third-party documentation. All required documentation will be maintained in participant files using standardized checklists to ensure completeness. In addition, all new client files will undergo supervisory review for eligibility compliance, and ongoing spot monitoring will be conducted throughout the program period. Responsibility for these reviews has been reassigned to designated staff to ensure consistent oversight and timely correction of any identified deficiencies. Name of Contact Person Responsible: Lee Ann Girard – Divisional Controller Proposed Completion Date: June 30, 2026

View Audit 404690

Finding 1218421 (2025-004)

Material Weakness 2025

Minnesota Prairie County Alliance

MN

Questioned Costs Eligibility Significant Deficiency

CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Depar...

CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the Agency perform case file reviews on a more representative sample of the total clients served and that adequate documentation be retained of those reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Waylon Welvaert, Finance Manager Planned completion date for corrective action plan: December 31, 2026

View Audit 404688

Finding 1218419 (2025-003)

Material Weakness 2025

Minnesota Prairie County Alliance

MN

Questioned Costs Eligibility Significant Deficiency

ELIGIBILITY DETERMINATION Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minneso...

ELIGIBILITY DETERMINATION Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93. 778 Federal Award Identification Numbers and Year: 2505MN5MAP and 2505MN5ADM, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5MAP and 2505MN5ADM Compliance Requirement Affected: Eligibility Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the Agency implement procedures to ensure the citizenship, asset, and income verification documentation in the casefiles be retained and that it matches the METS eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and show staff proper documentation and entry into METS and staff will be reminded to perform reviews. Name of the contact person responsible for corrective action plan: Waylon Welvaert, Finance Manager Planned completion date for corrective action plan: December 31, 2026

View Audit 404688

Finding 1218414 (2025-004)

Material Weakness 2025

Evangeline Booth Residence, Inc., A Florida Corporation

FL

HUD Housing Programs Eligibility Reporting

4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to continue to follow up with HUD to complete activation of their EIV system access. Once access is established, management should implement procedur...

4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to continue to follow up with HUD to complete activation of their EIV system access. Once access is established, management should implement procedures to ensure all required EIV reports are generated, retained, and reviewed in accordance with HUD guidelines. b. Action(s) Taken or Planned on the Finding Management acknowledged the challenges experienced in obtaining EIV access from HUD and stated that follow-up efforts are ongoing. Once access is granted by HUD as already approved, management will generate and maintain all required EIV reports and strengthen controls to ensure compliance with HUD requirements.

View Audit 404683

Finding 1218392 (2025-002)

Material Weakness 2025

Catherine Booth Residence INC A Florida Corporation

FL

Eligibility HUD Housing Programs

Project Legal Name: Catherine Booth Residence, Inc., A Florida Corporation HUD Project No.: 067-EE054-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2024 – 6/30/2025 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory...

Project Legal Name: Catherine Booth Residence, Inc., A Florida Corporation HUD Project No.: 067-EE054-WAH Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2024 – 6/30/2025 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation establish procedures and monitor compliance with those procedures to ensure that tenant eligibility is correctly determined and fully documented, 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. b. Action(s) Taken or Planned on the Finding Management is reviewing the processes and procedures with site personnel to strengthen controls over the maintenance of tenant lease files.

View Audit 404679

Finding 1218340 (2025-001)

Material Weakness 2025

Willow Glen Housing, Inc.

NC

Eligibility HUD Housing Programs

The Organization agrees with the finding. The file in question was corrected January 14, 2026.

View Audit 404599

Finding 1218338 (2025-001)

Material Weakness 2025

Greenpointe Regional Housing, Inc.

NC

Eligibility HUD Housing Programs

The Organization agrees with the finding. The file in question was corrected February 24, 2026.

View Audit 404579

Finding 1218317 (2025-002)

Material Weakness 2025

Housing Authority of the City of Greenville

NC

HUD Housing Programs Questioned Costs Subrecipient Monitoring

Finding 2025-002 – Public and Indian Housing Participant Files – Eligibility – Internal Control over Participant Files – Noncompliance and Material Weakness – Public and Indian Housing Program – ALN 14.850 1. Standardized Eligibility Checklist A comprehensive eligibility checklist will be developed ...

Finding 2025-002 – Public and Indian Housing Participant Files – Eligibility – Internal Control over Participant Files – Noncompliance and Material Weakness – Public and Indian Housing Program – ALN 14.850 1. Standardized Eligibility Checklist A comprehensive eligibility checklist will be developed and required for all participant files. This checklist will ensure all required documents (income verification, identification, citizenship status, etc.) are obtained, reviewed, and properly filed before approval. Please see the above attachment regarding the checklist. 2. File Review & Approval Process All resident files will undergo a two-tier review process: • Initial review by the assigned staff member • Secondary review and approval by a supervisor prior to final eligibility determination No file will Be approved without documented supervisory sign-off. 3. Staff Training All staff responsible for eligibility determinations will receive mandatory training on: • Program eligibility requirements • Proper documentation standards • File organization and recordkeeping procedures Refresher training will be conducted annually or as regulations change. 4. Internal Quality Control Audits Monthly random file audits will be conducted to ensure compliance with eligibility requirements and documentation standards. Findings will be documented, and corrective feedback will be provided to staff by supervisor. 5. Written Policies & Procedures Update The agency has updated its written policies and procedures manual to include: • Step-by-step eligibility determination processes • Documentation requirements • File retention and organization standards • Quality control measures All staff will be required to acknowledge and follow updated procedures. 6. File Organization Standardization All resident files (physical and/or electronic) will follow a uniform structure to ensure consistency, accessibility, and completeness. 7. Tracking & Monitoring System A tracking system (manual log or software-based) will be implemented to monitor: • Missing documents • Pending verifications • File status (intake, review, approved) Person Responsible- Shanetta Moye, Deputy Director/COO Anticipated Completion Date - September 30, 2026

View Audit 404556

Finding 1218215 (2025-004)

Material Weakness 2025

New Phoenix Park I LLC

CA

HUD Housing Programs Questioned Costs Eligibility

Finding 2025-004: Eligibility- Inconsistent Tenant Rent Across Documentation Type: Significant Deficiency Condition: During testing of tenant files, two instances where the tenant rent on the rent roll/rent change notice (Subsidy Adjustment Notice) did not agree to the tenant rent on the Tenant Inco...

Finding 2025-004: Eligibility- Inconsistent Tenant Rent Across Documentation Type: Significant Deficiency Condition: During testing of tenant files, two instances where the tenant rent on the rent roll/rent change notice (Subsidy Adjustment Notice) did not agree to the tenant rent on the Tenant Income Certification. Management agrees with the finding. Management will implement a secondary review process to reconcile tenant rent amounts across all documentation before finalizing rent changes or submitting files to the PHA. A. Management will coordinate with Compliance Manager to establish a review process to ensure tenant rent amounts are reconciled and consistent across the TIC, rent roll, and all subsidy adjustment notices prior to submission to the public housing authority. Contact for Corrective Action: Cornelia Reith anticipated Completion date:12/31/26

View Audit 404487

Finding 1218213 (2025-002)

Material Weakness 2025

New Phoenix Park I LLC

CA

HUD Housing Programs Internal Control / Segregation of Duties Questioned Costs

Finding 2025-002: Eligibility – Untimely Recertifications Type: Significant Deficiency Condition: During testing of tenant files, the auditor identified fourteen instances in which 2025 annual recertifications were not completed in a timely manner. Recertifications were performed in the subsequent y...

Finding 2025-002: Eligibility – Untimely Recertifications Type: Significant Deficiency Condition: During testing of tenant files, the auditor identified fourteen instances in which 2025 annual recertifications were not completed in a timely manner. Recertifications were performed in the subsequent year, and effective dates were backdated to reflect the current year. Management agrees with the finding and acknowledges the need to strengthen internal controls over tenant file compliance. To address this issue, management will implement a formalized tracking system for annual recertifications to ensure they are completed timely with accurate effective dates. Additionally, supervisory review and approval procedures will be enhanced prior to finalizing tenant rent changes. A. The Compliance Manager will oversee the compliance department and ensure staff complete recertifications prior to required effective dates. B. The Property Manager will conduct weekly meetings with staff to review upcoming recertifications and monitor progress to ensure timeliness. C. Management is in the process of hiring additional staff dedicated to processing recertifications to improve timeliness and compliance. Contact for Corrective Action: Cornelia Reith anticipated Completion date:12/31/26

View Audit 404487

Finding 1218179 (2025-001)

Material Weakness 2025

Lake Pepin Plaza LLC

MN

Questioned Costs Eligibility Significant Deficiency § 200.208

Contact Person Patricia Heraty, Accountant Corrective Action Plan Management plans to review its internal control procedures to ensure a quality control review is performed to verify all required documentation and calculations are maintained in the tenant files. Planned Completion Date for CAP Immed...

Contact Person Patricia Heraty, Accountant Corrective Action Plan Management plans to review its internal control procedures to ensure a quality control review is performed to verify all required documentation and calculations are maintained in the tenant files. Planned Completion Date for CAP Immediately.

View Audit 404385

Finding 1218147 (2025-006)

Material Weakness 2025

Columbia Gorge Community College

OR

Questioned Costs Procurement, Suspension & Debarment Student Financial Aid § 200.303

Recommendation: We recommend that the college review its processes and internal controls related to SAP and ensure procedures are in place to ensure students who are not meeting SAP requirements are properly identified and disbursed aid in accordance with the institution’s SAP policy. Explanation of...

Recommendation: We recommend that the college review its processes and internal controls related to SAP and ensure procedures are in place to ensure students who are not meeting SAP requirements are properly identified and disbursed aid in accordance with the institution’s SAP policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since December 2025, the College has worked with the SIS Managed Services team (Anthology now Ellucian) to update its SAP policy and ensure compliance with federal regulations. The new SAP policy was fully implemented effective during the Winter 2026 term. As an internal control, at the end of each term when SAP is evaluated, the results are pre-screened by the Coordinator of Financial Aid with oversight from the Director of Financial Aid to ensure accuracy before results are posted live in the system. Additionally, the College has clarified its understanding of Anthology’s treatment of students who are newly enrolled at the College or who have changed into a different program version. These students are designated with a not-calculated SAP which represents a blank or null status until the conclusion of the term when the students receive a passing or failing grade and can be evaluated by the SAP standards. Steps also have been taken to ensure that prior enrollments are linked to ensure integrity of the application of SAP standards based on the cumulative pace, GPA and maximum timeframe. As a further measure to ensure the integrity of awarding Title IV funds only to eligible students, the College has placed students with prior ineligible SAP statuses in a hold group within the SIS and identified these students as not meeting Disbursement Approval Criteria (DAC) thus causing any attempt to disburse funds to them to fail. Name(s) of the contact person(s) responsible for corrective action: Sarajane Viemeister and Denise Reid-Strachan. Planned completion date for corrective action plan: June 30, 2027.

View Audit 404328

Finding 1218146 (2025-005)

Material Weakness 2025

Columbia Gorge Community College

OR

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility § 200.303

Recommendation: We recommend the College changes its process and controls to ensure exit counseling emails are sent to graduate/withdrawn students throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding...

Recommendation: We recommend the College changes its process and controls to ensure exit counseling emails are sent to graduate/withdrawn students throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since August 2025, the College has taken steps in conjunction with its SIS Managed Services team (Anthology) to establish an automated process to notify graduate/withdrawn students to complete the Exit Counseling requirement. Since then the Director of Financial Aid has been spot-checking the notifications to ensure that the exit counseling notification is being triggered for withdrawn students. Going forward, the Financial Aid Office will use the Task Function in Anthology to confirm that the notification has been sent and close the task which will be timestamped with the name of the reviewer. Name(s) of the contact person(s) responsible for corrective action: Sarajane Viemeister and Denise Reid-Strachan. Planned completion date for corrective action plan: June 30, 2027.

View Audit 404328

Corrective Action Plans

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