Corrective Action Plans

Finding 503249 (2021-001)

Significant Deficiency 2021

Mt. Zion Land Development Corporation II and Subsidiary

IL

Cash Management HUD Housing Programs

FINDINGS-FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2021-01 Section 207/223(f) - CFDA No. 14.134 Recommendation: Surplus cash should be closely monitored and deposited into residual receipt account in a timely manner to ensure compliance. Action Taken: Deposit was m...

FINDINGS-FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2021-01 Section 207/223(f) - CFDA No. 14.134 Recommendation: Surplus cash should be closely monitored and deposited into residual receipt account in a timely manner to ensure compliance. Action Taken: Deposit was made to the residual receipt account on June 16, 2021 for the surplus cash calculated for the year ended December 31, 2020. Going forward surplus cash will be calculated in a timely manner and any surplus cash will be deposited within 90 days from the fiscal year end.

View Audit 325306

Finding 502346 (2021-001)

Material Weakness 2021

Community Health Aide Services, Inc.

NY

Questioned Costs HUD Housing Programs Material Weakness

CORRECTIVE ACTION PLAN U.S. Department of Health and Human Services Community Health Aide Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Name and address of independent public accounting firm: Bonadio & Co., LLP 100 Corporate Parkway...

CORRECTIVE ACTION PLAN U.S. Department of Health and Human Services Community Health Aide Services, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2021. Name and address of independent public accounting firm: Bonadio & Co., LLP 100 Corporate Parkway Suite 200 Amherst, New York 14226 Audit period: January 1, 2021 December 31, 2021 The material weakness from the December 31, 2021 schedule of findings and questioned costs is discussed below. It is numbered consistently with the numbers assigned in the schedule. Federal Award Finding and Questioned Costs Name of Contact Person: Joel Green, Financial Controller Anticipated Completion Date: December 31, 2024 2021-001 – Material Weakness Corrective Action Plan: Condition: Out of 40 transactions selected for testing, 4 selections were payroll transactions that lacked proper employee and management approval of the effective pay rate and one selection was a rental payment that did not have a supporting lease agreement. Recommendation: Establish policies and procedures to ensure proper retention of transaction documentation and internal control review. Current Status: Policies and procedures are being developed to properly meet the recommendation. If anyone has questions regarding this plan, please call Mr. Joel Green at (716) 285-9681.

View Audit 324388 Questioned Costs: $1

Finding 485143 (2021-002)

Material Weakness 2021

Village of Spring Valley

NY

HUD Housing Programs Material Weakness

Finding number: 2021-002 Special Tests and Provisions - Rolling Forward Equity Balances Program name: Section 8 Housing Choice Vouchers CFDA number: 14.871 Contact Person: Treasurer and Housing Administrator Anticipated Completion Date: May 31, 2025 Planned Corrective Action Category of Finding: Spe...

Finding number: 2021-002 Special Tests and Provisions - Rolling Forward Equity Balances Program name: Section 8 Housing Choice Vouchers CFDA number: 14.871 Contact Person: Treasurer and Housing Administrator Anticipated Completion Date: May 31, 2025 Planned Corrective Action Category of Finding: Special Tests and Provisions Corrective Action Plan: The Treasurer will work with the Housing Administrator to ensure the accurate computation of the HAP equity account and that the correct HAP equity balance is rolled forward on an annual basis. The Village will also establish, and document policies and procedures designed to serve as a system on internal controls required by OM B's Uniform Guidance (2 CFR 200).

View Audit 317957

Finding 485142 (2021-001)

Material Weakness 2021

Village of Spring Valley

NY

HUD Housing Programs Subrecipient Monitoring Material Weakness

Finding Number: 2021-001 Financial Reporting Requirement for Financial Assessment- PHA FASPHA) Program Name: Section 8 Housing Choice Vouchers CFDA Number: 14.871 Contact Person: Treasurer and Housing Administrator Anticipated Completion Date: May 31, 2025. Planned Corrective Action Category of Fin...

Finding Number: 2021-001 Financial Reporting Requirement for Financial Assessment- PHA FASPHA) Program Name: Section 8 Housing Choice Vouchers CFDA Number: 14.871 Contact Person: Treasurer and Housing Administrator Anticipated Completion Date: May 31, 2025. Planned Corrective Action Category of Finding: Reporting Corrective Action Plan: Fina nee staff will be assigned to work with the Housing Administrator in regard to the submission of all financial reporting. Also, procedures will be established to ensure that the financial reporting is revisited on a monthly basis. This will include training of the program personnel to establish policies and procedures for compliance with the terms of the Section 8 reporting requirements. The Village will also establish, and document policies and procedures designed to serve as a system of internal controls required by OM B's Uniform Guidance (2 CFR 200). We will ensure the accurate and timely preparation and submission of the FASS-PH.

View Audit 317957

Finding 485128 (2021-003)

Material Weakness 2021

Cheyenne and Arapaho Tribes Department of Housing

OK

HUD Housing Programs Internal Control / Segregation of Duties

2021-003 Condition: Deficiencies Noted in Maintenance of the Cash Receipts and Deposits and the Tenant Accounts Receivable Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be clea...

2021-003 Condition: Deficiencies Noted in Maintenance of the Cash Receipts and Deposits and the Tenant Accounts Receivable Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Mr. Damon Dunbar, Executive Director Timeframe: As of December 31, 2022

View Audit 317920

Finding 485127 (2021-002)

Material Weakness 2021

Cheyenne and Arapaho Tribes Department of Housing

OK

Procurement, Suspension & Debarment HUD Housing Programs Internal Control / Segregation of Duties

2021-002 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsi...

2021-002 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Mr. Damon Dunbar, Executive Director Timeframe: As of December 31, 2022

View Audit 317920

Finding 485126 (2021-001)

Material Weakness 2021

Cheyenne and Arapaho Tribes Department of Housing

OK

Eligibility HUD Housing Programs

2021-001 Condition: Deficiencies Noted in Maintenance of Tenant Files Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individua...

2021-001 Condition: Deficiencies Noted in Maintenance of Tenant Files Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will implement procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Mr. Damon Dunbar, Executive Director Timeframe: As of December 31, 2022

View Audit 317920

Finding 479185 (2021-001)

Significant Deficiency 2021

Mental Health Association of Columbia-Greene Counties Inc.

NY

HUD Housing Programs Special Tests & Provisions

The Division Director of Residential Services, Susie Cody, will obtain the rent reasonable checklists, a signed lease, and any other required forms when a new client is accepted into the program. Division Director, Susie Cody, will provide the Fiscal Director, Ethan Terrio, with a copy of the follo...

The Division Director of Residential Services, Susie Cody, will obtain the rent reasonable checklists, a signed lease, and any other required forms when a new client is accepted into the program. Division Director, Susie Cody, will provide the Fiscal Director, Ethan Terrio, with a copy of the following items when an apartment is brought online, there is some other change requiring the completion of these forms, or the first week of January each year: Lease, Rent Reasonableness. All forms for new apartments are to be supplied to Director of Finance prior to the issuing of any check forrent or security deposit without Executive Director approval. All forms will be scanned and placed in the resident’s electronic health record (AWARDS). The forms will also be scanned and kept in a shared finance folder.

View Audit 315733

Finding 478312 (2021-006)

Significant Deficiency 2021

City of Compton

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate ...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate calculations in the future. Planned Implementation Date: Implemented as of April 2024 Responsible Person(s): City Controller

View Audit 314981 Questioned Costs: $1

Finding 478311 (2021-008)

Significant Deficiency 2021

City of Compton

CA

Allowable Costs / Cost Principles Subrecipient Monitoring HUD Housing Programs

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy will also be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller

View Audit 314981

Finding 478309 (2021-005)

None 2021

City of Compton

CA

HUD Housing Programs Special Tests & Provisions

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: Policies will be enforced or monitored more closely by Housing Authority management to ensure all inspections and re-inspections are complete and documented. Planned Impl...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: Policies will be enforced or monitored more closely by Housing Authority management to ensure all inspections and re-inspections are complete and documented. Planned Implementation Date: December 31, 2024 Responsible Person(s): Community Development Director

View Audit 314981

Finding 478308 (2021-004)

None 2021

City of Compton

CA

Allowable Costs / Cost Principles HUD Housing Programs

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The payroll policy will be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implem...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The payroll policy will be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller

View Audit 314981

Finding 478307 (2021-003)

Significant Deficiency 2021

City of Compton

CA

HUD Housing Programs Allowable Costs / Cost Principles

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. Planned Implementa...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller

View Audit 314981

Finding 478306 (2021-002)

Material Weakness 2021

City of Compton

CA

HUD Housing Programs Material Weakness Reporting

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in pl...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: December 31, 2024 Responsible Person(s): City Manager, Community Development Director, and City Controller

View Audit 314981

Finding 406447 (2021-006)

Significant Deficiency 2021

City of Jersey City

NJ

Internal Control / Segregation of Duties Cash Management HUD Housing Programs

Corrective Action: The Chief Financial Officer will oversee efforts to close out the old accounts in a timely manner and make sure all systems are reconciled. Internal controls have been set into place to ensure future compliance. The Municipal Comptroller will train and continue to work closely wi...

Corrective Action: The Chief Financial Officer will oversee efforts to close out the old accounts in a timely manner and make sure all systems are reconciled. Internal controls have been set into place to ensure future compliance. The Municipal Comptroller will train and continue to work closely with personnel in charge of reporting and processing IDIS and vouchers drawdowns. The Division of Accounts & Control will continue to maintain a sub-ledger to ensure IDIS and the City’s financial system tie out prior to the processing of any payments, and each payment request will require an IDIS activity reference number in order to be processed. Monthly reconciliation of funds has been implemented and copies are sent to US HUD on a monthly basis. In addition, the City has hired a 3rd party grant consultant to help navigate and strengthen our overall processes. Implementation Date: Ongoing

View Audit 311633

Finding 402371 (2021-011)

Material Weakness 2021

State of California

CA

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guideli...

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. During this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 309913

Finding 402355 (2021-003)

Material Weakness 2021

State of California

CA

Eligibility Allowable Costs / Cost Principles HUD Housing Programs § 200.303

The Women, Infants, and Children Division (WIC) of the California Department of Public Health (Public Health) agrees that the WIC WISE system does not currently store eligibility history that should be included in the “Cert History Report.” Currently, the initial eligibility data is overwritten when...

The Women, Infants, and Children Division (WIC) of the California Department of Public Health (Public Health) agrees that the WIC WISE system does not currently store eligibility history that should be included in the “Cert History Report.” Currently, the initial eligibility data is overwritten when subsequent eligibility information is keyed into WIC WISE. WIC WISE does include preventative internal stops or check points that do not allow ineligible individuals to be certified and issued benefits (e.g., over income, not a CA resident, no nutrition risk factor, etc.). User acceptance testing vetted these items prior to system implementation. The certification history condition will be remediated via a system Defect Correction to WIC WISE. WIC has entered Defect Correction #6972 in Team Foundation Services (TFS), the tracking system used to capture system changes and defects. This correction is included in a release that is currently being tested and is targeted for release into production by May 2023. The defect supports a system change to ensure initial eligibility information is retained when subsequent eligibility information is entered into WIC WISE. Estimated Implementation Date: May 2023 Contact: William Welch, Assistant Division Chief, Operations Women, Infants, and Children Division California Department of Public Health

View Audit 309913

Finding 401298 (2021-002)

Significant Deficiency 2021

The Center in Hollywood

CA

Allowable Costs / Cost Principles HUD Housing Programs

The Center’s payroll practices were found to not be in compliance with federal funding in two areas. a. The Center’s time tracking software does not have the capacity to track employees’ time by funding stream b. The Center has not been auditing and signing off on bi-weekly payroll. This is an addit...

The Center’s payroll practices were found to not be in compliance with federal funding in two areas. a. The Center’s time tracking software does not have the capacity to track employees’ time by funding stream b. The Center has not been auditing and signing off on bi-weekly payroll. This is an additional required step on-top of supervisors reviewing and approving timesheets. The Center has migrated to a new Payroll Processing System, Gusto, as of 5/15/24 and will be fully migrated by the start of the 24-25 FY. Gusto will enable all employees who are billed to multiple funding streams tie their work activities to the appropriate funding streams. The Center is also continuing to develop its Operations Department. Chase Weaver has completed additional audit and compliance trainings and has been promoted to the role of Compliance Manager. His new scope includes the addition of payroll audits among additional internal agency compliance checks.

View Audit 309351

Finding 400966 (2021-004)

Material Weakness 2021

Gloversville Housing Authority

RI

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the F...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 400962 (2021-003)

Material Weakness 2021

Gloversville Housing Authority

RI

HUD Housing Programs Subrecipient Monitoring Eligibility

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Pl...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority provided training to necessary staff and will discuss with the third party management company to ensure compliance with 24 CFP 982.516 in the future. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 400958 (2021-002)

Material Weakness 2021

Gloversville Housing Authority

RI

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.302

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procu...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will maintain proper monitoring, communication and control activities to ensure adherence to the Authority’s key administrative policies including procurement, occupancy and the HCV administrative plan. Additionally, management will have the Board approve all policies and procedures adopted and communicate them with the third party company that manages the Authority’s Housing Choice Voucher and Mainstream Voucher programs. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 395081 (2021-002)

Material Weakness 2021

Houston Housing Authority

TX

HUD Housing Programs Eligibility Material Weakness

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has undertaken a program to review all voucher files for the purpose of getting all delinquent recertifications completed. During this process, if other required documents are identified, steps are taken to complet...

The Houston Housing Authority agrees with this finding. The Houston Housing Authority has undertaken a program to review all voucher files for the purpose of getting all delinquent recertifications completed. During this process, if other required documents are identified, steps are taken to complete the missing documentation and make sure that the files are complete. This review is still ongoing with expected completion in the first half of 2024. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having competent, well-trained staff working in the HCVP as well as other departments within the agency.

View Audit 305009

Finding 395080 (2021-001)

Material Weakness 2021

Houston Housing Authority

TX

Internal Control / Segregation of Duties HUD Housing Programs Material Weakness

The recommendation of the auditor was for the Houston Housing Authority to review its existing internal control procedures to ensure that data is properly recorded in the books and records to prevent misstatements from occurring in the future. l he Houston Housing Authority agrees with this finding ...

The recommendation of the auditor was for the Houston Housing Authority to review its existing internal control procedures to ensure that data is properly recorded in the books and records to prevent misstatements from occurring in the future. l he Houston Housing Authority agrees with this finding and related recommendations. During the audit, as these issues arose, notes were taken, evaluation of what had happened was made so that we could make the necessary adjustments to our procedures to prevent the continuation of these issues. In addition, we hired a firm to come in and undertake a review of the finance department. The purpose of this review was to review our existing staffing levels, workloads, experience, etc., for purposes of proposing a reorganization of the finance department to address any deficiencies. We have reviewed the recommendations from this consultant and are in the process of implementing many of the recommended changes. As we continue to work on getting all past due audits completed we are working very diligently to address the issues within the finance department that gave rise to this finding. We fully expect the finding to be present for the 2022 audit as many of the departmental improvements and changes were not made prior to 2023 so would not have been in practice during 2022. Our audit delinquencies commenced with the 2019 audit being delayed in part due to the COVID pandemic. We also determined in the completion of the 2019 audit that it was in the best interest of HHA to terminate our relationship with the prior auditor and procure a new audit firm. The completion of the 2021 audit will be our second audit wrapped up with the new audit firm. We are confident that the changes we have made and will continue to make will ensure that future prepared by the Houston Housing Authority will be in better condition than those for the 2021 audit. existing internal control procedures to ensure that data is properly recorded in the books and records to prevent misstatements from occurring in the future.

View Audit 305009

Finding 394681 (2021-021)

Significant Deficiency 2021

Housing Authority of the City of Fayetteville

IL

HUD Housing Programs

Views of Responsible Officials and Planned Corrective Actions: At the time of the inquiry, FHA Development, Inc., which is a non-profit partner of the PHA and whose properties were managed by the PHA, changed attorneys. The Executive Director of the PHA did so without the consent of the Board. A re...

Views of Responsible Officials and Planned Corrective Actions: At the time of the inquiry, FHA Development, Inc., which is a non-profit partner of the PHA and whose properties were managed by the PHA, changed attorneys. The Executive Director of the PHA did so without the consent of the Board. A relationship no longer exists between the attorney and the PHA or FHA Development, Inc. The PHA will work to ensure no similar situation arises within its control and that the PHA will take all legal remedies available should the attorney or any future attorney fail to respond to audit inquiries.

View Audit 304565

Finding 394680 (2021-020)

Significant Deficiency 2021

Housing Authority of the City of Fayetteville

IL

HUD Housing Programs

Views of Responsible Officials and Planned Corrective Actions: The disruption caused by the COVID pandemic and staff turnover had an impact on the adherence to proper inspection protocols. Moving forward, the Executive Director and the Director of Programs will implement a strict annual inspection ...

Views of Responsible Officials and Planned Corrective Actions: The disruption caused by the COVID pandemic and staff turnover had an impact on the adherence to proper inspection protocols. Moving forward, the Executive Director and the Director of Programs will implement a strict annual inspection regimen for all units. In addition, internal file audits and quality control inspections will be carried out by either the Executive Director or the Director of Programs to uphold and verify compliance with these standards.

View Audit 304565

Corrective Action Plans

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