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Corrective Action Plans

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Finding 1162896 (2024-007)
Material Weakness 2024
City of Peabody
MA
Allowable Costs / Cost Principles Eligibility Material Weakness
Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required documentation is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2026.
Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required documentation is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2026.
View Audit 372554
Finding 1162893 (2024-006)
Material Weakness 2024
City of Peabody
MA
Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the Title I grant for 2026, as well as into future periods.
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the Title I grant for 2026, as well as into future periods.
View Audit 372554 Questioned Costs: $1
Finding 1162890 (2024-005)
Material Weakness 2024
City of Peabody
MA
Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the special education grant for 2026, as well as into future periods.
Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the special education grant for 2026, as well as into future periods.
View Audit 372554 Questioned Costs: $1
Finding 1162755 (2024-004)
Material Weakness 2024
Community Action Agency of Talladega Clay Randolph Calhoun and Cleburn
AL
Internal Control / Segregation of Duties Eligibility Reporting § 200.512
To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.
To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.
View Audit 372376
Finding 1162690 (2024-002)
Material Weakness 2024
City of New Rochelle
NY
Eligibility
Name of Auditee: City of New Rochelle, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Edward Ritter, Commissioner of Finance Phone: (914) 654-2000 (2) Audit Finding 2024-002 - The City did not follow controls for eligibi...
Name of Auditee: City of New Rochelle, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Edward Ritter, Commissioner of Finance Phone: (914) 654-2000 (2) Audit Finding 2024-002 - The City did not follow controls for eligibility certifications of individuals enrolled in the HIPP-RAP. (a) Implementation Plan of Actions - Management has initiated a full review and recertification of all participants in the HIPP-RAP to determine if any additional participants were missing eligibility determinations. (b) Implementation Date - This will be implemented and completed for the year ended December 31, 2025. (c) Persons Responsible for Implementation - The Commissioner of Development and the City Council.
View Audit 372331
Finding 1162410 (2024-002)
Material Weakness 2024
Inova Health System
VA
Subrecipient Monitoring Eligibility Reporting
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
View Audit 372193
Finding 1162368 (2024-006)
Material Weakness 2024
Housing Authority of the City of Newark
NJ
Questioned Costs Eligibility HUD Housing Programs
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Execu...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175 Questioned Costs: $1
Finding 1162309 (2024-003)
Material Weakness 2024
Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center
MO
Special Tests & Provisions Subrecipient Monitoring Eligibility
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.
View Audit 372119
Finding 1162290 (2024-003)
Material Weakness 2024
Waikiki Health
HI
Special Tests & Provisions Subrecipient Monitoring Eligibility
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.
View Audit 372114
Finding 1162272 (2024-002)
Material Weakness 2024
Centerplace Health, Inc.
FL
Special Tests & Provisions Subrecipient Monitoring Eligibility
Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- ...
Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- Patient Service Representative Team Lead. This staff member oversees and trains the Patient Service Representatives in their responsibilities, including the sliding fee discount schedule application and compliance. A focus of this newly created position is training and compliance of the sliding fee schedule throughout all the clinics, which is ongoing from Oct. 15, 2024. The Patient Service Team Lead will be supervised by the Revenue Cycle Manager as part of the Finance Department reporting to the Interim CEO Bob Rodriguez, who will oversee this effort. The new position and implementation of training to correct the finding commenced Oct. 15, 2024.
View Audit 372079
Finding 1162261 (2024-001)
Material Weakness 2024
Astronomical Scoiety of the Pacific
CA
Eligibility Reporting Internal Control / Segregation of Duties § 200.512
Management concurs with the finding and has already implemented a compliance tracking system. A new policy was adopted during FY 2025 to ensure timely submissions moving forward. Contract Person: Brett Metzger, Outside Consultant Completion Date: November 11, 2025
Management concurs with the finding and has already implemented a compliance tracking system. A new policy was adopted during FY 2025 to ensure timely submissions moving forward. Contract Person: Brett Metzger, Outside Consultant Completion Date: November 11, 2025
View Audit 372071
Finding 1162234 (2024-007)
Material Weakness 2024
Fair Haven, Inc.
IN
Reporting Eligibility § 200.512
Views of Responsible Officials and Planned Corrective Actions: Management agrees timeliness is critical. Corrective Action: Maintain an audit compliance calendar with key federal deadlines and internal milestone tracking.
Views of Responsible Officials and Planned Corrective Actions: Management agrees timeliness is critical. Corrective Action: Maintain an audit compliance calendar with key federal deadlines and internal milestone tracking.
View Audit 372043
Finding 1162233 (2024-006)
Material Weakness 2024
Fair Haven, Inc.
IN
Procurement, Suspension & Debarment Eligibility § 200.214
Views of Responsible Officials and Planned Corrective Actions: Management agrees documentation must be retained. Corrective Action: Management has implemented a formal process to document vendor eligibility verficiation. As of FY 2025, all vendors are revewied in SAM. gov prior to payment or contrac...
Views of Responsible Officials and Planned Corrective Actions: Management agrees documentation must be retained. Corrective Action: Management has implemented a formal process to document vendor eligibility verficiation. As of FY 2025, all vendors are revewied in SAM. gov prior to payment or contract execution, and a screenshot or PDF of the verification is saved to the Vendor Verification Log. The Grants & Finance Manager maintains this documentation as part of the procurement file.
View Audit 372043
Finding 1162153 (2024-001)
Material Weakness 2024
Boston Tremont Housing Development Fund Corporation
NY
HUD Housing Programs Eligibility
Management has addressed the issue by recertifying the tenants and does not expect late recertifications to occur again.
Management has addressed the issue by recertifying the tenants and does not expect late recertifications to occur again.
View Audit 371944
Finding 1162014 (2024-008)
Material Weakness 2024
Bill Wilson Center
CA
Questioned Costs Eligibility Material Weakness
For ALN 16.575 Crime Victim Assistance There was a staffing change for the program after FY23-24. Since the new Program Manager joined in December 2023, she worked with her team to put together the following procedures and protocols: For direct program expenses, all copies of rent payment requests, ...
For ALN 16.575 Crime Victim Assistance There was a staffing change for the program after FY23-24. Since the new Program Manager joined in December 2023, she worked with her team to put together the following procedures and protocols: For direct program expenses, all copies of rent payment requests, check stubs and client signed half sheets are retained. Client support purchases have original receipts. For proof of client eligibility, the previous management team kept the files in paper format. The new management team saved all the copies of client IDs, birth certificates or passports in AWARDS to verify age of participants. Client agreements are saved electronically in AWARDS. Paper copies are stored in locked cabinets as well. All time entries are reviewed, approved, submitted, processed and saved in Paycom.
View Audit 371876 Questioned Costs: $1
Finding 1162013 (2024-007)
Material Weakness 2024
Bill Wilson Center
CA
Questioned Costs Allowable Costs / Cost Principles Eligibility
For ALN 21.027 Coronavirus State and Local Fiscal Recovery, There was a staffing change for the program between June to September 2024. The new program team met with the OSH’s fiscal team to review billing requirements and spending guidelines in the beginning of FY24-25. Starting October 2024, the n...
For ALN 21.027 Coronavirus State and Local Fiscal Recovery, There was a staffing change for the program between June to September 2024. The new program team met with the OSH’s fiscal team to review billing requirements and spending guidelines in the beginning of FY24-25. Starting October 2024, the new program team followed the guideline to restrict allowable expenses for clients only to the following: ● Tenant rent portion only on an emergency or as needed basis ● Move in deposit ● Housing application fees In FY24-25, clients came from referrals from OSH as agreed upon. Client eligibility is verified by data in HMIS by the program team. Client files are stored in locked cabinets in the program team’s office. All time entries are reviewed, approved, submitted, processed and saved in Paycom.
View Audit 371876 Questioned Costs: $1
Finding 1161952 (2024-007)
Material Weakness 2024
Washoe County
NV
Reporting Subrecipient Monitoring Allowable Costs / Cost Principles
Internal controls will be created to ensure that the Quarterly Compliance Reports agree to internal supporting documents and that reports will be submitted timely.
Internal controls will be created to ensure that the Quarterly Compliance Reports agree to internal supporting documents and that reports will be submitted timely.
View Audit 371844
Finding 1161951 (2024-006)
Material Weakness 2024
Washoe County
NV
Eligibility Reporting Significant Deficiency
Internal controls will be created for reviewing the determination of eligibility for participation in the Emergency Rental Assistance Program.
Internal controls will be created for reviewing the determination of eligibility for participation in the Emergency Rental Assistance Program.
View Audit 371844
Finding 1161857 (2024-006)
Material Weakness 2024
Open Cities Health Center, Inc. and Affiliate
MN
Special Tests & Provisions Subrecipient Monitoring Eligibility
Finding 2024-006 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Significant Deficiency Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testi...
Finding 2024-006 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Significant Deficiency Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testing the Federal Poverty Guideline (FPG) was inaccurately applied for two patients. Action Planned in Response to the Finding: In the past year, the collection and retention of sliding fee discount qualifying documents have been integrated and the calculation performed by the clinic’s electronic medical record system. An employee was added, in part, to provide oversite of the sliding discount process. Official Responsible for Ensuring the CAP: Darian Davis Planned Completion Date: December 2025
View Audit 371776
Finding 1161794 (2024-001)
Material Weakness 2024
Mha Housing of the Piedmont, Inc.
NC
Eligibility HUD Housing Programs Reporting
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prior...
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
View Audit 371720
Finding 1161792 (2024-002)
Material Weakness 2024
Mha Housing of Eastern North Carolina, Inc.
NC
Eligibility HUD Housing Programs Reporting
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prior...
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
View Audit 371719
Finding 1161791 (2024-001)
Material Weakness 2024
Mha Housing of Eastern North Carolina, Inc.
NC
Eligibility HUD Housing Programs Significant Deficiency
To address the noted deficiencies in tenant file documentation, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed ...
To address the noted deficiencies in tenant file documentation, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
View Audit 371719
Finding 1161703 (2024-001)
Material Weakness 2024
Meadow Lane Housing Development Fund Company, Inc.
NY
Eligibility HUD Housing Programs
An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail.
An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail.
View Audit 371649
Finding 1161542 (2024-001)
Material Weakness 2024
Pueblo County Colorado
CO
Eligibility Internal Control / Segregation of Duties Special Tests & Provisions
Food Distribution Cluster– Assistance Listing No. 10.565, 10.568, and 10.569 Recommendation: We recommend the County review controls and procedures surrounding the programs including review and record retention requirements. Explanation of disagreement with audit finding: There is no disagreement wi...
Food Distribution Cluster– Assistance Listing No. 10.565, 10.568, and 10.569 Recommendation: We recommend the County review controls and procedures surrounding the programs including review and record retention requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will develop and implement new policy and procedures to appropriate review and record retention. Names of the contact persons responsible for corrective action: Tanya Gurule Planned completion date for corrective action plan: December 31st, 2025
View Audit 371432
Finding 1161538 (2024-002)
Material Weakness 2024
K & L Housing Development Fund Company,inc
NY
HUD Housing Programs Eligibility
Finding 2024-2 a. Statement of Condition In connection with our review of 1 lease file for move-ins we noted the following deficiency: 1 file did not have timely income verification through Enterprise Income Verification System (EIV). b. Action(s) Taken or Planned on the Finding Management plans to ...
Finding 2024-2 a. Statement of Condition In connection with our review of 1 lease file for move-ins we noted the following deficiency: 1 file did not have timely income verification through Enterprise Income Verification System (EIV). b. Action(s) Taken or Planned on the Finding Management plans to implement a system to track EIV verification to ensure compliance with tenant eligibility requirements within the 90-day deadline.We will provide ongoing training and support to staff to ensure that the updated rules and regulations on tenant eligibility are followed.
View Audit 371431
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