Corrective Action Plans

Finding 1214812 (2023-003)

Material Weakness 2023

FL

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

FINDING 2023-003 - Sliding Fee Discount Program MATERIAL WEAKNESS; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93.224/93 .527, Health Center Program Cluster Compliance Requirement: Special Tests & Provisions Criteria: Section ...

FINDING 2023-003 - Sliding Fee Discount Program MATERIAL WEAKNESS; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93.224/93 .527, Health Center Program Cluster Compliance Requirement: Special Tests & Provisions Criteria: Section 330 of the Public Health Service Act and the HRSA Health Center Program Compliance Manual require health centers to maintain and operate a board-approved Sliding Fee Discount Program that adjusts patient charges based on income and family size using the current Federal Pove1ty Guidelines, applies uniformly to all patients and all in-scope services, and is supported by adequate documentation of eligibility determinations. In addition, Uniform Guidance requires nonfederal entities to establish and maintain effective internal controls over federal programs to provide reasonable assurance of compliance with federal statutes, regulations, and award terms. Condition: During testing of the Sliding Fee Discount Program within the Health Center Cluster, the Center could not provide documentation of the appropriate sliding fee discounts for certain patients in accordance with federal requirements. Context: The condition was identified through testing of the Health Center Cluster as pa1i of the single audit, which included testing patient fee assessments and sliding fee discount application as a special test required under the program. Controls were determined to be ineffective in 2 of 40 test items. Noncompliance was noted in 2 of 25 test items. Statistical sampling was not utilized. Cause: The condition was caused by inadequate internal controls over the implementation and monitoring of the Sliding Fee Discount Program, including limited supervisory review to ensure all sliding fee applications are maintained, reviewed, and properly applied. Effect or Potential Effect: The Center's failure to maintain documentation surrounding sliding fee discounts in accordance with federal requirements increases the risk of noncompliance with Health Center Program requirements and may result in patients being charged amounts not aligned with their ability to pay. The condition also increases the risk of adverse findings during HRSA oversight or other federal monitoring activities. Questioned Costs: No questioned costs were identified as a result of this finding. Repeat Finding: This is not a repeat finding. Recommendation: The Center should enhance internal controls over the Sliding Fee Discount Program by ensuring consistent documentation of income and family size, timely reassessment of eligibility in accordance with policy, consistent application of the board-approved sliding fee discount schedule to all applicable in-scope services, and periodic monitoring and supervisory review to ensure ongoingcompliance. Views of Responsible Officials: Neighborhood Medical Center has implemented quarterly SFDP internal audits and training for the intake staff to improve compliance oversight and documentation accuracy. A standardized audit tracking log documenting charts are reviewed, findings identified and corrective actions completed. An annual refresher for the staff has been implemented. A quick-reference eligibility checklist has also been developed for staff use. Person Responsible for Corrective Action: Ronica Mathis and Shenika Mathews Anticipated Completion Date for Corrective Action: This practice has already been implemented.

View Audit 401535

Finding 1211147 (2023-003)

Material Weakness 2023

Carestl Health

MO

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility § 200.302 § 200.303

"Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Pe...

"Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations"

View Audit 400354

Finding 1210578 (2023-006)

Material Weakness 2023

The Salvation Army Golden State Division

CA

Subrecipient Monitoring Eligibility Material Weakness

The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify they meet the grant eligibility requirements. September 2026 Al Agpoon, Golden State Division Controller

View Audit 399931

Finding 1208283 (2023-004)

Material Weakness 2023

Aurora Homes, Inc.

MD

Eligibility HUD Housing Programs Significant Deficiency

Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards,...

Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards, and updated procedures Ongoing Monitoring - Quarterly internal audits; COO and Board Finance Committee review of compliance - ongoing Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to finance committee - ongoing

View Audit 399312

Finding 1208281 (2023-006)

Material Weakness 2023

Ashmore Homes, Inc.

MD

Special Tests & Provisions Eligibility HUD Housing Programs

Fund Account - Deposited back to the replacement reserve account - October 16, 2025 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - M...

Fund Account - Deposited back to the replacement reserve account - October 16, 2025 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - May/June 2026 Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to Finance Committee - Ongoing

View Audit 399311

Finding 1208279 (2023-004)

Material Weakness 2023

Ashmore Homes, Inc.

MD

Eligibility HUD Housing Programs Significant Deficiency

Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards,...

Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards, and updated procedures Ongoing Monitoring - Quarterly internal audits; COO and Board Finance Committee review of compliance - ongoing Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to finance committee - ongoing

View Audit 399311

Finding 1206523 (2023-012)

Material Weakness 2023

MacOmb County

MI

Eligibility Significant Deficiency Internal Control / Segregation of Duties

The County acknowledges deficiencies related to the availability and completeness of supporting documentation for one federal program expenditures and reporting. In some instances, supporting documentation was not readily available at the time of review or required additional follow-up. The County i...

The County acknowledges deficiencies related to the availability and completeness of supporting documentation for one federal program expenditures and reporting. In some instances, supporting documentation was not readily available at the time of review or required additional follow-up. The County is strengthening documentation and record retention practices, improving coordination with program staff, and reinforcing expectations for maintaining complete and timely supporting records. These actions are intended to ensure documentation is available to support reporting and compliance requirements.

View Audit 398574

Finding 1206355 (2023-006)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF MILWAUKEE

WI

HUD Housing Programs Special Tests & Provisions Eligibility

Special Tests and Provisions - Waiting List Public and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of...

Special Tests and Provisions - Waiting List Public and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenants who were admitted i nto the Public Housing Program. Specifically, required records demonstrating waiting list position, selection order, and eligibility determinations were not available for review. As a result, we were unable to verify that applicants were admitted in accordance with HUD waiting list and tenant selection requirements. Auditor Recommendations: We recommend that management perform a reconciliation of the waiting list and reconstruct missing documentation where possible to support applicant selection and admission into the program. Management should update and formalize waiting list procedures in accordance with HUD regulations and the Authority's ACOP, i mplement supervisory review controls to verify completeness of waiting list documentation prior to tenant admission, and ensure records are retained in accordance with HUD and federal record-retention requirements. In addition, management should provide training to staff responsible for waiting list administration to promote consistent compliance with HUD requirements. Action Taken: HACM's Lease and Compliance department has done additional training with their staff since 2023 on Occupancy, Eligibility, Income and Rent Calculation. In addition, the Director has provided additional onboarding training to new employees and has provided YARDI Aspire training in how to perform certain tasks in YARDI software, i ncluding waitlist selection. We believe that the error rate will decrease in future years from 2023. In addition, between March 2026 and June 2026, the Lease and Compliance Director will work with all staff that maintain waitlists or perform waitlist selection to reiterate the proper documentations of how to maintain records that demonstrate waitlist positions, selection order and proper selection. Name of Responsible Person: Marquetta Treadway, Lease and Compliance Director Projected Completion Date: June 30, 2026

View Audit 398376

Finding 1206354 (2023-005)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF MILWAUKEE

WI

HUD Housing Programs Eligibility Material Weakness

Eligibility P ublic and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: Out of an approximate population of 2,150 tenants from the Public and Indian Housing program, we tested 43 tenants and the following deficiencies were noted: • 16 files were m...

Eligibility P ublic and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: Out of an approximate population of 2,150 tenants from the Public and Indian Housing program, we tested 43 tenants and the following deficiencies were noted: • 16 files were missing a flat rent option form, • 14 files were missing 214 forms, • 10 units did not have the required inspection performed, • 9 files had incorrect income or missing income support, • 8 files incorrectly contained prior year information in the current year recertification, • 6 files were missing valid 9886 forms, • 2 files were missing identification for adults in the household, and • 1 file was missing birth certificate or other documentation for minors receiving income credits. A uditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor's sample. Action Taken: HACM's Lease and Compliance department has done additional training with their staff since 2023 on Occupancy, Eligibility, Income and Rent Calculation. In addition, the Director has provided additional onboarding training to new employees and has provided YARDI Aspire training in how to perform certain eligibility tasks in YARDI. We believe that the error rate will decrease in future years from 2023. In add ition,between March 2026 and June 2026, the Lease and Compliance Director will work with all staff that perform initial eligibility or recertifications to reiterate the major topics that HACM has had deficiencies and the proper way to treat those items. Name of Responsible Person: Marquetta Treadway, Lease and Compliance Director Projected Completion Date: June 30, 2026

View Audit 398376

Finding 1206353 (2023-004)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF MILWAUKEE

WI

Special Tests & Provisions Eligibility HUD Housing Programs

2023-004 Special Tests and Provisions - Waiting List Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenan...

2023-004 Special Tests and Provisions - Waiting List Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenants who were issued housing vouchers. Specifically, required records demonstrating waiting list position, selection order, and eligibility determinations were not available for review. In addition, 8 of the 40 new admissions tested lacked support for the auditor to complete testing in this area. A uditor Recommendations: We recommend that management perform a reconciliation of the waiting list and reconstruct missing documentation where possible to support applicant selection and voucher issuance. Management should update and formalize waiting list procedures in accordance with HUD regulations and the Authority's Administrative Plan, i mplement supervisory review controls to verify completeness of waiting list documentation prior to voucher issuance, and ensure records are retained in accordance with HUD and federal record-retention requirements. In addition, management should provide training to staff responsible for waiting list administration to promote consistent compliance with HUD requirements. Action Taken: On the same note and based on a HUD review of operations, HACM entered into a SEMAP Corrective Action Plan with HUD with the goal to improve the SEMAP performance indicator scores. Via a nationwide Request for Proposal, HACM hired the contractor, CVR Associates, Inc. (CVR) to manage and operate the entire Housing Choice Voucher program for HACM, effective January 2, 2025. This contract is currently overseen by the Acting Secretary- Executive Director and will be overseen by the Chief Operations Officer once a new one is hired. CVR was selected as the contractor in part due to their extensive experience in managing similar voucher programs nationwide and on their tools/software that they have developed to manage items, such as quality control testing in the areas such as the items noted above. This included wait list oversight and wait list selection. CVR provided additional training to staff, prepared new standard operating procedures i ncluding those over waiting lists, and perform quality control testing over the course of the entire year. Many of the SEMAP indicators have improved, but some have additional improvement still needed based on the 2025 SEMAP results. When there a re issues, the CVR Quality Control team follows up with the staff person to correct the issue, and to provide guidance or additional training with the goal to reduce the error rate in the future. We believe that HACM will be back to being a standard performer or higher in 2026. In addition, the self-reported 2025 SEMAP testing was showing good scores in the area of Waiting List. Name of Responsible Person: Ken Barbeau, Acting Secretary-Executive Director; Chief Operations Officer (once hired); Projected Completion Date: December 31, 2026

View Audit 398376

Finding 1205816 (2023-002)

Material Weakness 2023

City of Bentonville, Arkansas

AR

Eligibility Reporting Internal Control / Segregation of Duties

Contact Name: Patrick Johndrow Contract Phone Number: 479-271-6781 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2023 Finding #2023-002 – Statement of Condition: The City did not maintain documentation supporting the underlying information included in its quarterly performance report. Sp...

Contact Name: Patrick Johndrow Contract Phone Number: 479-271-6781 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2023 Finding #2023-002 – Statement of Condition: The City did not maintain documentation supporting the underlying information included in its quarterly performance report. Specifically, source records and supporting schedules used to compile reported information were not retained or made available for audit. Response: The Organization concurs with the finding and related adjustments made during the audit. Management will implement additional internal controls related to program reports. The completion date for the above-mentioned corrective action was January 2026.

View Audit 397560

Finding 1181798 (2023-002)

Material Weakness 2023

145 SO. 3RD STREET HOUSING DEVELOPMENT FUND CORPORATION

NY

Eligibility HUD Housing Programs Subrecipient Monitoring

A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and iss...

A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and issue weekly progress reports to the Director of Asset Management. c. Non-compliant files will be flagged for immediate follow-up with tenants. d. PMCS, a third-party group, will assist with recertifications. 2. Enforcing Timely Recertifications: a. Recertifications must be completed no later than 30 days before expiration. b. Staff will receive monthly reminders, and escalation measures will be implemented for delays. 3. Quarterly Internal Audits: a. PMCS and internal staff will conduct random file audits every three months to ensure adherence. b. Deficiencies will be addressed in real-time, and corrective steps will be logged. B. Ensuring EIV System Compliance 1. Standardizing EIV Compliance Procedures: a. A formal checklist will be created for EIV report reviews, ensuring all required reports are generated before lease renewals. b. EIV data will be cross-referenced with tenant files every quarter to ensure completeness. 2. Internal Monthly EIV Reviews: a. The Senior Housing Specialist will generate and review EIV reports on the 1st of each month. b. The Director of Asset Management, Third-Party Compliance Officer (PMCS), and Senior Housing Specialist will verify compliance before reports are finalized. 3. Quarterly Compliance Reports: a. The Compliance Officer will submit a quarterly compliance report documenting completion rates and deficiencies. C. Enhancing Staff Training and Accountability 1. Mandatory Quarterly Training: a. Staff will undergo quarterly compliance training covering HUD Handbook 4350.3, recertifications, and EIV compliance. b. Training sessions will be documented, and staff performance assessed. 2. Clarification of Responsibilities: a. Staff roles will be clearly outlined in a Standard Operating Procedure (SOP) document. b. Staff will be required to acknowledge their roles in compliance processes. 3. PMCS Involvement for Training Support: a. PMCS will offer supplementary training sessions as needed. D. Documentation and Oversight Enhancements 1. Maintaining Complete and Auditable Files: a. All lease and EIV documentation will be stored both physically and digitally. b. A real-time compliance dashboard will track completion rates. 2. Routine Management Reviews: a. The Senior Housing Specialist and Director of Asset Management will conduct monthly spot checks to verify document accuracy and completion. b. Non-compliance will result in formal corrective actions.

View Audit 393088

Finding 1177961 (2023-001)

Material Weakness 2023

Center for Pan Asian Community Services, Inc.

GA

Eligibility

We have reviewed the sliding fee calculations calculated by the system and have implemented internal control procedures to ensure the discount fees are calculated and applied correctly. Implementation date: June 16, 2025

View Audit 391400

Finding 1176890 (2023-002)

Material Weakness 2023

State of Kosrae

FM

Eligibility

We agree with this Finding. Henceforth, we will ask for the employment status of all new and continuing patients. Those who are employed will be required to provide their most recent W-2 form or their paycheck stub as proof of their income and eligibility for the sliding scale discount. This informa...

We agree with this Finding. Henceforth, we will ask for the employment status of all new and continuing patients. Those who are employed will be required to provide their most recent W-2 form or their paycheck stub as proof of their income and eligibility for the sliding scale discount. This information will be kept in each patient’s file and will be updated on a regular basis to ensure the continued compliance of the WCHC to the discount policy. March 31, 2026 Ms. Irene Laabrug Chief, Division of Finance & Treasury (691)350-2142ilaabrug123@gmail.com

View Audit 390739

Finding 1175235 (2023-008)

Material Weakness 2023

Oregon Coast Community Action

AL

Matching / Level of Effort / Earmarking Subrecipient Monitoring Eligibility

Finding 2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Low-Income Home Energy Assistance ALN# 93.568 (Repeat 2022-015) US Department of Health and Human Services Passed through Oregon Housing and Community Services Federal Grant/Contract...

Finding 2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Low-Income Home Energy Assistance ALN# 93.568 (Repeat 2022-015) US Department of Health and Human Services Passed through Oregon Housing and Community Services Federal Grant/Contract Number: 2302ORLIEA, 2202ORLIEA Grant period – 2022 & 2023 ORCCA is aware of lack of documentation and internal control during the audit period due to various reasons, mainly short staffing and staff turnover and has been working hard to prevent such occurrences. The Finance staff (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) have already started communicating with program directors if any such issues are observed. The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants’ requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as finance team (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) working with grants/directors. The estimated date of completion of this process is January 31, 2026. ORCCA’s current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are implementing this internal control at the program level to review the supporting documents and information and proper coding to the correct period.

View Audit 388923

Finding 1174702 (2023-013)

Material Weakness 2023

City of Woonsocket

RI

Procurement, Suspension & Debarment Eligibility HUD Housing Programs

Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The depar...

Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program Compliance Officer after thorough review. Written agreement documentation will be revised to include the requirements from the new compliance manual. The City of Woonsocket plans to procure grant management software which will streamline the application process and allow for improved recordkeeping to ensure compliance with all policies and procedures. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174701 (2023-012)

Material Weakness 2023

City of Woonsocket

RI

Allowable Costs / Cost Principles Reporting Special Tests & Provisions

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued ...

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174135 (2023-001)

Material Weakness 2023

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Subrecipient Monitoring Eligibility HUD Housing Programs

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedure...

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedures to ensure all required actions are taken when a tenant becomes over-income.

View Audit 387791

Finding 1174131 (2023-002)

Material Weakness 2023

Norman County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/train...

Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/trainings for staff Anticipated Completion Date: Quarterly internal audits anticipated start date: April 2026 Anticipated completion date of ongoing program training: July 2026

View Audit 387778

Finding 1172735 (2023-003)

Material Weakness 2023

Town of Guilderland

NY

Procurement, Suspension & Debarment Eligibility Subrecipient Monitoring § 200.213 § 200.318

Finding Reference: 2023-003 Coronavirus State and Local Fiscal Recovery Funds Description: During our discussions with management and testing of the major program, we noted that the Town is not verifying the eligibility of vendors to participate in Federal assistance programs. Recommendation: We rec...

Finding Reference: 2023-003 Coronavirus State and Local Fiscal Recovery Funds Description: During our discussions with management and testing of the major program, we noted that the Town is not verifying the eligibility of vendors to participate in Federal assistance programs. Recommendation: We recommend that the Town review the requirements of 2 CFR Section 200.213 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. Corrective Action: Moving forward, the Town of Guilderland will ensure that vendors are not included on the suspended or debarred list to ensure compliance with the requirements noted above. Person(s) Responsible for Corrective Action: Darci Efaw, Comptroller & Jessica Gulliksen, Fiscal Officer Anticipated Completion Date for Corrective Action: The practice noted above was implemented during September of 2024.

View Audit 386023

Finding 1171299 (2023-084)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Eligibility Special Tests & Provisions § 200.303

DHS continues working with a vendor on the implementation of the Provider Enrollment Application (PEA). Beginning in February 2026, the vendor will assume responsibility for enrolling all USVI providers—both in-territory and out-of-territory. Their enrollment process will address the three bulleted ...

DHS continues working with a vendor on the implementation of the Provider Enrollment Application (PEA). Beginning in February 2026, the vendor will assume responsibility for enrolling all USVI providers—both in-territory and out-of-territory. Their enrollment process will address the three bulleted conditions.

View Audit 384576

Finding 1171293 (2023-078)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibil...

Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibility of reviewing completed case files.

View Audit 384576

Finding 1171275 (2023-073)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Eligibility Special Tests & Provisions Subrecipient Monitoring § 200.303

An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, in...

An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, internal audits will be conducted to ensure alignment with the Federal mandates in addition to ensuring overall compliance.

View Audit 384576

Finding 1171273 (2023-071)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

DHS remains in compliance with this finding from previous audit years, the untimely submission led to the issue in current year. To address this, a shared file will be established to ensure that the necessary information for each year is readily available for audit purposes.

View Audit 384576

Finding 1171270 (2023-068)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking § 200.303

The Department of Human Services (DHS) has introduced a checklist as an additional internal control measure to ensure compliance with Federal requirements for review of provider enrollment applications by the provider relations staff.

View Audit 384576

Corrective Action Plans

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