Corrective Action Plans

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Corrective Action Plan It was found that four cases did not contain evidence in the case record that would indicate the participant’s categorical eligibility. A memo will be distributed to all staff as a reminder on the need to adequately document the case record to support the eligibility determina...
Corrective Action Plan It was found that four cases did not contain evidence in the case record that would indicate the participant’s categorical eligibility. A memo will be distributed to all staff as a reminder on the need to adequately document the case record to support the eligibility determination to ensure compliance with state and federal regulations and the need to scan all documents to IEDR in a timely manner. A separate memo will be distributed to all supervisory staff as a reminder on their need to ensure the case is properly documented and stored in IEDR when reviewing the case record for eligibility determination. The agency will monitor training classes offered by OTDA throughout the year to assign staff to attend to reinforce and strengthen their knowledge on properly documenting and determining eligibility for program. Action Date 9/14/2026 Final Implementation Date 9/30/2027 Name And Phone No. Of Person Responsible For Implementation Bryan Bogad – 631-854-9880
Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Annette Ange, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program elegibility requirements. Mange...
Corrective Action Plan Section III - Federal Award Findings and Questioned Costs Finding 2025-001 Name of Contact Person: Annette Ange, Executive Director Corrective Action: We will implement proper internal control procedures for the Public and Indian Housing program elegibility requirements. Mangement has established a checklist for applications and will establish checklists for move-ins and move-outs. Proposed Completion Date: Immediately
Contact Person Derek Johnson, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2026
Contact Person Derek Johnson, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2026
Finding 2025-004: Temporary Assistance for Needy Families (TANF), Assistance Listing No. 93.558, U.S. Department of Health and Human Services Passed through Colorado Department of Human Services Compliance Requirement: Eligibility, Special Tests and Provisions Grant No.: Not applicable Type of findi...
Finding 2025-004: Temporary Assistance for Needy Families (TANF), Assistance Listing No. 93.558, U.S. Department of Health and Human Services Passed through Colorado Department of Human Services Compliance Requirement: Eligibility, Special Tests and Provisions Grant No.: Not applicable Type of finding: Internal Control (material weakness) Recommendation: The County should develop, document, and implement a formal TANF case file review process, including supervisory review and retention of evidence of reviews performed, to help ensure compliance with program requirements. Action Taken: Costilla County DSS will develop and fully document a formal TANF case review process that will include supervisor reviews. Costilla County DSS will retain evidence of reviews completed monthly, to ensure program requirements. If there are questions regarding this plan, please call the responsible parties listed below. Sincerely yours, Julie Albert Chief Financial Officer Costilla County, Colorado Najondine Placek County Clerk Costilla County, Colorado Tommy Vigil County Social Services Director Costilla County, Colorado
FINDING 2025-008 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Contact Person Responsible for Corrective Action: Dr. Bo Yan, Ahnaf Tahmid & Marlaina Johns Contact Phone Number and Email Address: 574-393-6000, byan@sbcsc.k12.in.us, atahmid@sbcsc.k12.in.us, mjohns2@sbcsc....
FINDING 2025-008 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Contact Person Responsible for Corrective Action: Dr. Bo Yan, Ahnaf Tahmid & Marlaina Johns Contact Phone Number and Email Address: 574-393-6000, byan@sbcsc.k12.in.us, atahmid@sbcsc.k12.in.us, mjohns2@sbcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: • Centralized enrollment/withdrawal document management with weekly accuracy audits. • Updated Internal Control Manual to mandate a 12-item list of enrollment documents (birth certificates, residency proof, immunizations, etc.). • Established a formal "Summary of Attempts" process requiring at least 3 documented attempts to secure residency proof before submitting signed summaries. • Standardized documentation for general transfers, mandatory 16–17-year-old exit interviews, and Title I ESSA graduation cohort tracking. Anticipated Completion Date: January 1, 2027 (Note: Specific student mobility updates corrected April 1, 2026).
Name of the Contact Person Responsible for Corrective Action Jacqueline Guilfoyle, Corporate Controller Planned Corrective Action: In alignment with management's commitment to ensuring complete and accurate grant reporting, internal control procedures for grant expenditure reviews will be enhanced. ...
Name of the Contact Person Responsible for Corrective Action Jacqueline Guilfoyle, Corporate Controller Planned Corrective Action: In alignment with management's commitment to ensuring complete and accurate grant reporting, internal control procedures for grant expenditure reviews will be enhanced. To mitigate the risks associated with complex or commingled invoices, reviewers are now required to perform a detailed, line-item analysis of any invoice containing multiple service types or charges. For invoices that include both allowable and unallowable costs, the reviewer must document the specific segregation of these costs. This updated procedure will ensure that only the direct, incremental, and eligible costs are approved for reimbursement, thereby strengthening compliance with granting agency requirements. We will also repay FEMA for the amount claimed in error. Planned Completion Date: October 30, 2026
Finding 1238773 (2025-003)
Material Weakness 2025
Finding Number: 2025-003 Finding Title: Eligibility - MAXIS Program: Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Karen Amundson, Social Services Supervisor Corrective Action Planned: Clay County Social Services will provide targeted training addre...
Finding Number: 2025-003 Finding Title: Eligibility - MAXIS Program: Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Karen Amundson, Social Services Supervisor Corrective Action Planned: Clay County Social Services will provide targeted training addressing the areas identified in the 2025 audit, with particular emphasis on Social Security number documentation and the accurate verification, documentation, and entry of asset information in MAXIS. Policy updates and related documentation expectations will continue to be reviewed during monthly staff meetings. The lead eligibility worker will continue conducting random internal reviews of MAXIS cases. Review results will be discussed directly with each worker so identified errors can be corrected, expectations clarified, and individualized coaching or additional training provided. Results will also be monitored for recurring error patterns that may require broader training, procedural changes, or performance follow-up. Because the department experienced staff turnover during the audit period, training and quality control will remain ongoing. New employees will receive focused instruction on MAXIS documentation and data-entry requirements, while established staff will continue to receive refresher training and case-specific coaching. Supervisory and lead-worker review will be used to reinforce consistent expectations across the team. Clay County has also begun using Al-assisted policy guidance to help staff more quickly locate and reference relevant state and federal eligibility requirements, This resource supports policy research and staff learning but does not make eligibility determinations or replace required verification, supervisory consultation, human judgment, or employee accountability. In addition, Clay County is partnering with the State of Minnesota to pilot the Mn Benefits-to-MAXIS application process. The pilot is intended to streamline the transfer of application information into MAXIS and reduce duplicate manual data entry. Reducing unnecessary keystrokes should decrease opportunities for human data-entry errors and allow eligibility workers to focus more attention on verifying information and accurately applying program requirements. Clay County will evaluate the pilot's impact and incorporate effective practices into its internal workflow as the state rollout progresses. Anticipated Completion Date: The enhanced training, case-review, and policy-support procedures will be fully implemented by December 31, 2026. Case reviews, staff training, monitoring, coaching, and participation in the state's MnBenefits-to-MAXIS are already underway and will continue to be utilized.
Finding 1238772 (2025-002)
Material Weakness 2025
Finding Number: 2025-002 Finding Title: Eligibility - METS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mika la Wodarek, Social Services Supervisor Corrective Action Planned: Clay County Social Services...
Finding Number: 2025-002 Finding Title: Eligibility - METS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mika la Wodarek, Social Services Supervisor Corrective Action Planned: Clay County Social Services will continue utilizing internal case reviews to monitor the accuracy and completeness of METS eligibility documentation. Reviews will be completed for eligibility workers and discussed directly with each worker. Identified errors will be corrected, and individualized coaching or additional training will be provided as appropriate. Review results will also be monitored for recurring patterns that may require broader team guidance or training. The department will provide continued instruction focused on the areas identified in the 2025 audit, including Social Security number documentation, citizenship verification, and accurate income documentation. Clay County has also begun using an internal Al-assisted policy research tool to help eligibility staff more quickly locate and reference applicable state and federal policy provisions when questions arise. This tool is intended to support efficient policy research only. It does not make eligibility determinations or replace staff judgment, required verification, supervisory consultation, or employee responsibility for accurately applying program policy. These measures will strengthen the existing review process while recognizing the size and complexity of Clay County's METS workload. During 2025, Clay County administered 16,604 active METS recipients. The audit identified four exceptions in its sample of 40 recipient files. Clay County takes each exception seriously and will continue refining its training, policy-reference, case-review, and coaching practices to reduce future errors. Anticipated Completion Date: Al-assisted research tool has been implemented immediately and is currently in use now. All healthcare eligibility staff will have cases randomly reviewed prior to December 31, 2026, with all policy support, monitoring, and corrective coaching continuing after each staff's review but also occurring before December 31, 2026.
Statement of Condition and Criteria The Authority did not consistently perform required participant recertifications and certification updates within the Housing Choice Voucher (HGV) and Moving to Work (MTW) programs. During testing, we identified instances where participant files and Forms HUD-5005...
Statement of Condition and Criteria The Authority did not consistently perform required participant recertifications and certification updates within the Housing Choice Voucher (HGV) and Moving to Work (MTW) programs. During testing, we identified instances where participant files and Forms HUD-50058 were not updated to reflect current household information when certification actions were required. Recommendation We recommend the Authority strengthen monitoring controls over recertification and eligibility processing within both the HGV and MTW programs to ensure participant information is updated timely and eligibility determinations are supported by current household information. Corrective Action - Quality Control & Monitoring Enhancements To strengthen internal controls and ensure consistent file compliance within the Housing Choice Voucher (HCV) and Moving to Work (MTW) programs, The Greenville Housing Authority (TGHA) is executing a structural reorganization of department staff. • Dedicated Compliance Personnel: Final restructuring of the current HGV department will be completed by October 31, 2026. This includes the onboarding of a dedicated Compliance Specialist by January 2027. This role will strictly focus on quality control, preventing overlooked regulatory procedures, verifying income calculations, and ensuring complete file documentation. • Real-Time Quality Control Reviews: The Compliance Specialist will implement a proactive file-checking system, auditing annual and interim recertifications, and any other occurrences, e.g., moves, that a new certification is required in real time prior to final Form HUD-50058 transmission. This allows immediate correction of deficiencies and prevents recurring systemic errors. • Management Oversight & Target Training: Compliance reporting will be reviewed at least monthly by the Director of HCV and the HCV Lead Specialists. These monthly reviews will track error rates, identify chronic deficiencies, and directly inform the department's ongoing staff training needs. TGHA anticipates fully executing these new compliance review processes and workflows by April 30, 2027.
Finding Number: 2025-006 Finding Title: Eligibility – METS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Berit Spors, Health and Human Services Director Corrective Action Planned: McLeod County recognizes the importance of proper information ...
Finding Number: 2025-006 Finding Title: Eligibility – METS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Berit Spors, Health and Human Services Director Corrective Action Planned: McLeod County recognizes the importance of proper information to be maintained in the METS system to ensure eligibility to qualified individuals for Medicaid. The two cases that were addressed were errors in the METS system caused by periodic date match. It would be helpful if DHS would issue discrepancy reports for the METS system similar to the MAXIS report to catch these errors. County Social Services staff will audit cases periodically to catch these errors in the systems. Anticipated Completion Date: These cases have been resolved as of September 2026.
Management acknowledges the need for appropriate segregation of duties and documented independent review of match calculations and supporting documentation. Management plans to establish written procedures that assign preparation, review, and approval responsibilities and require the completed match...
Management acknowledges the need for appropriate segregation of duties and documented independent review of match calculations and supporting documentation. Management plans to establish written procedures that assign preparation, review, and approval responsibilities and require the completed match calculation and supporting records to be independently reviewed and approved by an individual who was not involved in their preparation before the match report is submitted.
Management acknowledges the need to maintain complete documentation supporting participant income determinations, reassessments, and related rent calculations and to complete required procedures in the prescribed order. Management plans to implement a standardized checklist identifying required docu...
Management acknowledges the need to maintain complete documentation supporting participant income determinations, reassessments, and related rent calculations and to complete required procedures in the prescribed order. Management plans to implement a standardized checklist identifying required documents and sequencing, require supervisory review and sign-off before each reassessment and rent determination is finalized, and provide refresher training on documentation and procedural requirements.
Auditee’s Response and Planned Corrective Action Peabody Housing Authority hired two new employees to manage and operate the HCV Program in late 2025. These two employees replaced the prior employees who completed the recertifications noted with findings. While the new employees came with strong pri...
Auditee’s Response and Planned Corrective Action Peabody Housing Authority hired two new employees to manage and operate the HCV Program in late 2025. These two employees replaced the prior employees who completed the recertifications noted with findings. While the new employees came with strong prior experience, they have participated in many trainings and classes since they have been hired. Together with continued education, better oversight, and clear requirements, these issues should not be repeated. Quality control measures, such as secondary reviews and engagement with participants, will result in fewer recertification missteps and errors. Planned Implementation Date of Corrective Action: June 30, 2026 Person Responsible for Corrective Action: Eric Cronin, Executive Director
OCDC has implemented the following corrective actions: 1. Implement a secondary review control Eligibility determinations will include documented evidence of review, such as reviewer name/initials and date, to demonstrate that eligibility has been verified prior to or as part of the applicable claim...
OCDC has implemented the following corrective actions: 1. Implement a secondary review control Eligibility determinations will include documented evidence of review, such as reviewer name/initials and date, to demonstrate that eligibility has been verified prior to or as part of the applicable claiming process. 2. Reinforce Staff Training and Procedures Staff responsible for determining, reviewing, or maintaining CACFP eligibility will receive a refresher training on the procedures, documentation requirements, review responsibilities, and record retention expectations. 3. Conduct periodic monitoring Program leadership will periodically review a sample of eligibility files to confirm that required documentation is present, eligibility determinations are supported, and evidence of review is documented. Identified exceptions will be corrected promptly and recurring issues addressed through additional training or process improvements. Name(s) of the contact people responsible for correction action: Melissa Buxton, Chief Financial Officer and CACFP Program Leadership Plan completion date for corrective action plan: Corrective actions began in spring 2026 after OCDC self-identified the weakness. Initial corrective measures have been implemented, with periodic monitoring continuing as an ongoing internal control with training reinforcement completed by October 31, 2026.
Housing Voucher Cluster - Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend the Authority review their internal controls over the eligibility requirements to ensure all recertifications are performed timely. Explanation of disagreement with audit finding: There is no disagree...
Housing Voucher Cluster - Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend the Authority review their internal controls over the eligibility requirements to ensure all recertifications are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAKC has reviewed and strengthened its internal controls and procedures for completing annual reexaminations in a timely manner. HAKC implemented enhanced monitoring of annual reexamination activity through regularly scheduled reports and supervisory review. As part of the corrective action, HAKC established a centralized tracking process to identify upcoming and delinquent annual reexaminations. Staff are required to monitor reexamination due dates and take appropriate action to obtain required documentation and complete the reexamination process timely. HAKC also implemented the following additional controls: • Weekly monitoring of annual reexamination completion and processing status; • Use of delinquent reexamination reports to identify households requiring immediate action; • Supervisory review of outstanding and delinquent reexaminations; • Monitoring of EIV-related failed or outstanding reexamination dates; • Scheduled mass annual reexamination appointments to address outstanding workload; • Additional staff training regarding annual reexamination requirements, income verification, allowances, deductions, and applicable HUD regulations. HAKC will continue to monitor annual reexamination performance through management-level review and will take corrective action when deficiencies or delays are identified. Name(s) of the contact person(s) responsible for corrective action: Director of HCVand Assistant Directors of HCV
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 is in the process of hiring a new Executive Director who will implement the required safeguards and ensur...
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 is in the process of hiring 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 Public and Indian Housing Program to remedy the aforementioned deficiencies. Dexter Brady, Interim Executive Director, is the responsible official and this will be completed by December 31, 2026.
The Authority has recognized the deficiencies in the Housing Voucher Cluster Programs and will train staff on HQS enforcement and implement internal control procedures that will ensure compliance with federal regulations. Dexter Brady, Interim Executive Director, is the responsible official and this...
The Authority has recognized the deficiencies in the Housing Voucher Cluster Programs and will train staff on HQS enforcement and implement internal control procedures that will ensure compliance with federal regulations. Dexter Brady, Interim Executive Director, is the responsible official and this will be completed by December 31, 2026.
The Authority has recognized the deficiencies in the Housing Voucher Cluster Programs and will train staff on rent reasonableness and implement internal control procedures that will ensure compliance with federal regulations. Dexter Brady, Interim Executive Director, is the responsible official and ...
The Authority has recognized the deficiencies in the Housing Voucher Cluster Programs and will train staff on rent reasonableness and implement internal control procedures that will ensure compliance with federal regulations. Dexter Brady, Interim Executive Director, is the responsible official and this will be completed by December 31, 2026.
The Authority acknowledges the deficiencies identified in its historical waiting list administration. The Authority completed a comprehensive waiting list purge on July 31, 2026, and is now reconciling and reorganizing the remaining applicant entries. Quality control procedures are being incorporate...
The Authority acknowledges the deficiencies identified in its historical waiting list administration. The Authority completed a comprehensive waiting list purge on July 31, 2026, and is now reconciling and reorganizing the remaining applicant entries. Quality control procedures are being incorporated to establish appropriate checks and balances over applicant selection and processing. Consistent with the Authority's corrective action plan, each applicant selected from the waiting list will be subject to documented supervisory review and approval, with supporting documentation maintained in the applicant's file. Because the Authority no longer has operational access to Yardi, current management may be unable to independently reconstruct every historical waiting list selection or action recorded in the former system. Dexter Brady, Interim Executive Director, is the responsible official and this will be completed by December 31, 2026.
The Authority acknowledges the inspection and enforcement deficiencies identified in this finding. The inspection department and Housing Choice Voucher management are coordinating to ensure that units requiring abatement after a failed inspection and the applicable correction period are properly ide...
The Authority acknowledges the inspection and enforcement deficiencies identified in this finding. The inspection department and Housing Choice Voucher management are coordinating to ensure that units requiring abatement after a failed inspection and the applicable correction period are properly identified, documented, and processed. The Authority is also working with the HUD Receiver to develop a scope of work to address outstanding historical files and to determine which remediation activities will be performed internally and which may require third-party assistance. Dexter Brady, Interim Executive Director, is the responsible official and this will be completed by December 31, 2026.
The Authority acknowledges that certain documentation identified by the auditors could not be located in the participant files currently available to staff. During the year, the Authority converted its housing management software from Yardi to MRI Lindsey and no longer has operational access to the ...
The Authority acknowledges that certain documentation identified by the auditors could not be located in the participant files currently available to staff. During the year, the Authority converted its housing management software from Yardi to MRI Lindsey and no longer has operational access to the former Yardi system. As a result, management cannot currently determine whether some of the missing electronic documentation was maintained in Yardi prior to the conversion. To prevent recurrence, the Authority is consolidating its paper records into a permanent digital participant file, so that all required eligibility documentation is complete, retained, and available for review. Dexter Brady, Interim Executive Director, is the responsible official and this will be completed by December 31, 2026.
The organization implemented a digital data management platform called ClientTrack and begin to maintain client records for program years 2025 and thereafter to ensure the proper retention of all required client eligibility and service documentation. In addition, management will perform periodic sel...
The organization implemented a digital data management platform called ClientTrack and begin to maintain client records for program years 2025 and thereafter to ensure the proper retention of all required client eligibility and service documentation. In addition, management will perform periodic self-assessments to monitor compliance with eligibility documentation and record retention requirements. Certain participant files pertaining to enrollments prior to 2025 were lost due to flood damage at an o􀀁-site storage facility and were not recoverable.
ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sa...
ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least one casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2026
Finding 2025-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 & 14.879 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency...
Finding 2025-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 & 14.879 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family 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 6,490 units. Of a sample size of fifty-six (56) tenant files, the following was noted: • HUD form 9886 was unable to be provided in 9 files • Citizen Declaration Section 214 form was unable to be provided in 7 files • Verification of income was unable to be provided in 1 file • Lead based paint form was unable to be provided in 1 file Known Questioned Costs: $15,432* * Represents HAP attributable to one (1) tenant file for which the Authority could not demonstrate compliance with eligibility requirements. The questioned costs do not represent amounts determined to be ineligible but rather costs associated with the tenant that remained in noncompliance beyond the required recertification date. Cause: There is a significant deficiency in internal controls over the eligibility type of compliance related to the maintenance of tenant files in the Housing Voucher Cluster. The Authority has not maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Authority is in non-compliance with the eligibility requirements of the Housing Voucher Cluster programs. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers Program to ensure that established internal control policies are being followed on a timely basis. Nicole Alexander, HCV Program Director, is responsible for implementing this corrective action by December 31, 2026.
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