Corrective Action Plans

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Finding 2025-006 I. Procurement, Suspension and Debarment Procurement Approval and Executed Agreement Compliance Management agrees with the finding and has outlined the following corrective actions: • Obtain Board approval for a new intergovernmental agreement for Chicago Police Department at the Se...
Finding 2025-006 I. Procurement, Suspension and Debarment Procurement Approval and Executed Agreement Compliance Management agrees with the finding and has outlined the following corrective actions: • Obtain Board approval for a new intergovernmental agreement for Chicago Police Department at the September 2026 board meeting. • Complete a full review of 2025 and 2026 procurement files by the end of Q1-2027 to ensure all required Board approvals and executed agreements are retained. • Strengthen internal workflows to prevent procurement actions from proceeding without verified approvals and executed agreements through inclusion of a new checklist which will be reflected in an updated standard operating procedures (SOP). • Provide refresher training to procurement staff on 2 CFR 200 documentation retention requirements by December 2026. Suspension and Debarment Compliance Management concurs with the findings and will implement: • Semiannual targeted training to reinforce staff responsibilities for verifying vendor eligibility and documenting compliance to begin December 2026. • Enhanced managerial monitoring through a standardized checklist to ensure required suspension/debarment checks are completed and retained before issuing purchase orders. Implemented January 2027. Responsible for Corrective Action: Tamika Carson, Director of Procurement; Sheila Johnson, Deputy Chief Procurement Anticipated Completion Date: Q1-2027
Finding 2025-004 N. Special Tests and Provisions: H6. Housing Assistance Payment HCV: CHA acknowledges the auditors’ interpretation regarding the HUD‑52641A Tenancy Addendum but maintains that participant signatures are not required under HUD regulations or standard program practice. The auditors’ p...
Finding 2025-004 N. Special Tests and Provisions: H6. Housing Assistance Payment HCV: CHA acknowledges the auditors’ interpretation regarding the HUD‑52641A Tenancy Addendum but maintains that participant signatures are not required under HUD regulations or standard program practice. The auditors’ position that the Tenancy Addendum must be signed by the participant in order to be executed is based on the 2025 Compliance Supplement, not on HUD regulation or normal program operations. HCV has provided sufficient evidence that all HAP contracts have been fully executed in accordance with HUD regulations. All HAP issued during the audit period was accurate based on income calculations provided by the family at program admission or during the most recent regular or interim recertification. HCV will continue to seek updated guidance from HUD regarding the execution of the HAP contract which includes the Tenancy Addendum. No further actions are warranted. Low Rent & RAD: CHA Management centralized the RAD rent‑increase process under a single Asset Manager in Q4-2025, with full control procedures implemented in Q2-2026 to ensure consistent tracking, timely processing, and stronger accountability. The Asset Manager now manages owner outreach, request review and submission, Yardi updates, management‑firm coordination, and quality‑control verification, while maintaining complete documentation of approvals and system updates. A standard operating procedure (SOP) formalizing this process will be completed by Q3-2026. The centralized process applies through 2026, with responsibilities planned to return to individual asset managers in 2027. Responsible for Corrective Action: Solonge Robinson, Director of Asset Management Anticipated Completion Date: 3Q-2026
Finding 2025-003 N. Special Tests and Provisions: N4. NSPIRE/Housing Quality Standards Inspections HCV generally agrees with the recommendation to follow its established internal controls over HQS/NSPIRE inspections as outlined in its HCV Administrative Plan. HCV Inspections Compliance team will rev...
Finding 2025-003 N. Special Tests and Provisions: N4. NSPIRE/Housing Quality Standards Inspections HCV generally agrees with the recommendation to follow its established internal controls over HQS/NSPIRE inspections as outlined in its HCV Administrative Plan. HCV Inspections Compliance team will review inspection scheduling procedures of contracted HCV inspections team to ensure HQS/NSPIRE inspections are scheduled and conducted biennially in accordance with the Inspections Guidebook and HCV Administrative Plan. Yardi and Power BI reporting will be generated and employed to aid tracking of inspections scheduling practices. Also, HCV will update guidance in its Administrative Plan to mirror HUD regulations in relation to timelines of inspections conducted. Responsible for Corrective Action: Roberto Galvez, HCV Inspections Compliance Manager Anticipated Completion Date: Q4-2026
Finding 2025-002 N. Special Tests and Provisions: N16. Environmental Contaminants Testing and Remediation Low-Rent and RAD (UPCS): Management has designed a control to further strengthen work order compliance. The control includes: • As CHAs third party vendor completes its NSPIRE inspections, the P...
Finding 2025-002 N. Special Tests and Provisions: N16. Environmental Contaminants Testing and Remediation Low-Rent and RAD (UPCS): Management has designed a control to further strengthen work order compliance. The control includes: • As CHAs third party vendor completes its NSPIRE inspections, the Property and Office Management team will run a report day of inspection and/or day after to capture/identify work orders requiring 24hr completion. • CHA monitors 24-hour work orders daily and generates weekly remediation reports covering all required timeframes (24-hour, 30-day, 60-day). • Weekly reports are generated by CHA and provided to the PPMs for review and work order closure. • Work orders which remain open past due dates trigger warning letters to the respective property managers. Additionally, comments are added to the weekly reports to document reasons for outstanding compliance. Weekly reports are stored on SharePoint and accessible by management. • Property Managers are provided with warning letters for untimely closed work orders. 3 warning letters triggers a default by the PPM as enacted by the Department of Procurement and Contracts. • The above process has been enacted as of Aug 2026 and will be captured in a standard operating procedure (SOP) by Q3-2026. Responsible for Corrective Action: Anthony Myers, Director, Property Operations; Takina Clark, Property Operations; Pamela Fairley, Director RAD Anticipated Completion Date of: 3Q-2026 Low-Rent and RAD (Environmental): The Green and Healthy Homes Program, in coordination with Property Operations and Private Property Management (PPM), is implementing process improvements to strengthen environmental contaminant testing, moisture assessment, and mold remediation practices across CHA properties. Key actions include finalizing internal, partner, and vendor guidelines and SOPs—covering product specifications, guidance, and decision mapping—targeted for distribution in Q4-2026. CHA established a dedicated environmental vendor pool as of September 1, 2026, enabling standardized training and compliance monitoring for moisture assessments and remediation work. PPM staff will receive ongoing quarterly training on identifying and triaging suspected mold, implementing prevention strategies, and applying best practice remediation responses. Resident education will focus on prevention and safe housekeeping practices. Pending the release of new Illinois Department of Public Health mold and moisture regulations, CHA will conduct targeted training and certification outreach to ensure compliance once rulemaking is complete. Two PPM training sessions were completed in Q2 & Q3 2026. Completion and ongoing compliance will be validated through (a) workflow process improvement efforts, (b) distribution of updated guidelines/SOPs, (c) implementation of quality assurance audits of remediation work (sampling one out of every four relevant projects), and (d) enhanced data capture within Yardi to support screening during inspections. Relevant projects include work orders that are flagged as either mold/moisture or lead-based paint hazard. Audits will include a desktop review to determine whether property is a target property (per building year data and 24 CFR Part 35) and whether property management took appropriate moisture/mold remediation steps or lead-safe work practices. Responsible for Corrective Action: Elizabeth Poole, Director Healthy Homes Anticipated Completion Date: Q4-2026
Finding 2025-001 E. Eligibility, L. Reporting (Form HUD-50058 MTW), and N. Special Tests and Provisions – N1. Waiting List, N2. Reasonable Rent, N3. Utility Allowance Schedule, N6. Housing Assistance Payment HCV: HCV generally agrees with the recommendation to strengthen policies, procedures, and in...
Finding 2025-001 E. Eligibility, L. Reporting (Form HUD-50058 MTW), and N. Special Tests and Provisions – N1. Waiting List, N2. Reasonable Rent, N3. Utility Allowance Schedule, N6. Housing Assistance Payment HCV: HCV generally agrees with the recommendation to strengthen policies, procedures, and internal controls surrounding the timeliness of ensuring program eligibility. HCV notes that no ineligible households were identified during the audit period. HCV Program Compliance team will review quality control procedures of HCV program administrators to ensure processes are sound and efficient, proper controls are in place and regular recertifications are conducted and submitted to the U.S. Department of Housing and Urban Development (HUD) completely and timely. HCV will work closely with the CHA Internal Audit team to create an audit plan to ensure established strengthened procedures and internal controls are effective. Responsible for Corrective Action: Isaelena Albarran, HCV Program Compliance Manager Anticipated Completion Date: Q2-2027 Low-Rent and RAD: CHA is strengthening internal controls and oversight for Public Housing and RAD tenant file compliance through 2027. CHA has issued a request-for-proposal for a comprehensive 100% tenant file audit to address deficiencies in eligibility, reexaminations, documentation, income/rent calculations, and HUD 50058 reporting. As part of this effort, CHA Compliance will also assess enhancements to electronic document management systems to improve document completeness and support streamlined, accountable workflows. CHA will reinforce Perfect File standards, update written procedures and controls, and provide standardized training to Private Property Management firms (PPMs) and staff on core compliance requirements and common deficiencies. PPMs will remain responsible for maintaining compliant files. CHA will improve tracking of findings and corrective actions, including accountability, due dates, escalation for overdue or repeat issues, and enforcement when appropriate. CHA Compliance will monitor the 100% audit, report on progress and trends, and use results to assess control effectiveness and determine needed training, guidance, and management actions. Responsible for Corrective Action: Iwona Kowalska, Director of Compliance Anticipated Completion Date: 4Q-2027
Finding 2025-005 N. Special Tests and Provisions: N4. Vacant Units HCV agrees with the auditor’s recommendation to reassess its internal control over vacant units to ensure claims are reduced or reduced in a timely manner. Project Based Voucher (PBV) Program Compliance staff will review and update w...
Finding 2025-005 N. Special Tests and Provisions: N4. Vacant Units HCV agrees with the auditor’s recommendation to reassess its internal control over vacant units to ensure claims are reduced or reduced in a timely manner. Project Based Voucher (PBV) Program Compliance staff will review and update written quality control procedures of PBV program administrators to ensure vacancy payment processes are efficient, properly controlled, and compliant with HUD requirements. PBV Program Compliance will provide updated procedures and training to all impacted teams. In addition, the HCV Program Compliance Manager will strengthen existing compliance monitoring activities to identify and address any exceptions related to vacancy payment processing. Responsible for Corrective Action: Isaelena Albarran, HCV Program Compliance Manager Anticipated Completion Date: Q4-2026
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: The Authority should implement a process and control to ensure that all proper documentation is being maintained for HQS inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit...
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: The Authority should implement a process and control to ensure that all proper documentation is being maintained for HQS inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Keene Housing has implemented a process to ensure that all proper documentation is being maintained for HQS inspections. Name(s) of the contact person(s) responsible for corrective action: Ellen Wishart, Director of Voucher Program Planned completion date for corrective action plan: immediately, August 1, 2026
Finding 2025-002: Housing Voucher Cluster- Section 8 Housing Choice Vouchers Criteria: The Uniform Guidance requires that local entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations, and program compliance requiremen...
Finding 2025-002: Housing Voucher Cluster- Section 8 Housing Choice Vouchers Criteria: The Uniform Guidance requires that local entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations, and program compliance requirements. The Uniform Guidance further requires auditors to obtain an understanding of the local entity's internal control over federal programs. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the review and approval of participant eligibility. Condition/Context: After completing an internal investigation and an extensive analysis of payments under the program, the City determined there was $16,424 in housing assistance payments paid to ineligible participants in 2025. In a sample of 60 benefit payments, excluding the aforementioned payments, no additional instances of payments to ineligible participants were found during the audit. Our sample was not statistically valid. Cause: Payments to ineligible participants were due to City employees' falsification of records, undisclosed conflict of interest, and collusion. Questioned Costs: All known questioned costs related to 2025 were identified by the City and are included in the condition/context section above. There were no questioned costs identified that exceed the required reporting threshold. Effect: Payments were made to ineligible participants. Recommendation: We recommend the City implement internal controls in order to prevent ineligible beneficiary payments. Corrective Action Planned: The City of Janesville has internal controls that ensure that Section 8 Housing Choice Vouchers clients are eligible to be served by the program. Employees receive training on program eligibility guidelines. Employees are subject to background checks prior to employment. Employees also are provided with, and acknowledge the City's conflict of interest policy. Conflicts of interest are to be reported to the supervisor so conflicts can be avoided by providing the subject participant to another case manager. Additionally, all conflict of interest applications are reviewed by a supervisor. Applicants are required to complete an application and provide documentation proving income and other eligibility requirements for the program are met. The case manager reviews this documentation and makes an initial determination as to eligibility. Annually, the City performs quality control checks on client files to review eligibility, income calculations, and inspection requirements. The quality control checks are done by a supervisor. Each payment batch also goes through a review process before being paid. In this instance, the two employees that initiated the files for eligibility, respectively, colluded to circumvent the system of controls in place. The two employees falsified eligibility documents, failed to disclose the conflict of interest, and deemed related parties (families and friends) to be eligible for benefits, The employees then approved the payments for each other's clients to avoid detection of the ineligible payments. This collusion allowed for the employees to provide benefits to ineligible related parties. When another employee was asked to initiate an inspection, she recognized that the inspection was with a related party and reported it to a supervisor. This led to the supervisor doing a review, and at that time, it was discovered that the employees appeared to be approving benefits to ineligible, related parties, in violation of both City and Housing and Urban Develop (HUD) policies. Once discovered, the City immediately did a thorough and complete investigation and referred the matter to the Police Department for investigation into possible criminal charges. Both employees were placed on Administrative Leave of Absence and subsequently resigned their positions. Formal felony criminal charges were referred to, and filed by, the District Attorney. Those cases are pending. The internal controls in place do not contemplate the ability to prevent collusion from circumventing the controls. To implement such controls would be financially prohibitive. The City's detection controls identified fraud prior to the fraud exceeding the required reporting threshold. However, the City self-reported the fraud to both our independent auditors and HUD. Given the unique nature of two employees colluding to circumvent the City's internal controls, the fact that detection controls stopped the fraud before it materially impacted the program, and the City's response to seek criminal charges, the City believes this matter is a unique event and will not occur again in the future. Furthermore, the City believes that it would be cost-prohibitive to hire the additional staff necessary to prevent internal controls being circumvented by collusion. Planned Completion Date for the Corrective Action Plan: Completed. Contact Persons Responsible for the Corrective Action Plan: The following Finance Office staff members are responsible for items outlined above in the Corrective Action Plan: • David Godek, Finance Director • Jennifer Petruzzello, Neighborhood and Community Services Director • Kelly Bedessem. Housing and Emergency Management Director
Interfund Receivable / Payable (same as financial statement finding #2025-003). HCV admin fees were paid from the PH Operations account and re-imbursed by the HCV program on a yearly basis. A check will be written from the HCV account to the PH account to cover a majority of the difference. Moving f...
Interfund Receivable / Payable (same as financial statement finding #2025-003). HCV admin fees were paid from the PH Operations account and re-imbursed by the HCV program on a yearly basis. A check will be written from the HCV account to the PH account to cover a majority of the difference. Moving forward, reconciliation will occur quarterly, and payment on the balance will be made. Contact person: Ryandal Gilmore, Executive Director. Anticipated completion date: Implemented and ongoing
Finding 2025.002 - 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 2025.002 - 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 and again in 2024. 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, including clarification of documentation requirements, 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 Representative (PSR) staff to consistently assess and apply sliding fee discounts. The SOP includes 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, provide corrective follow-up, and provide any needed training for PSR personnel on the updated policy and procedures. 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. Waikiki Health is also considering engaging an outside firm to assist with streamlining the sliding fee scale process and strengthening related internal controls.
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 130...
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Significant Deficiencies 2025-002 Compliance Requirement: Special Tests and Provisions – Excess of Residual Receipts Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Project, Assistance Listing 14.155 Project-Based Rental Assistance, Assistance Listing 14.195 Recommendation: It is recommended that efforts be made to ensure compliance with the residual receipts excess fund requirements going forward. Planned Corrective Actions: Every effort will be made to ensure compliance with the residual receipts excess funds requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100.
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 130...
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Significant Deficiencies 2025-001 Compliance Requirement: Special Tests and Provisions – Surplus Cash Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Project, Assistance Listing 14.155 Project-Based Rental Assistance, Assistance Listing 14.195 Recommendation: It is recommended that efforts be made to ensure compliance with the surplus cash remittance requirements going forward. Planned Corrective Actions: Every effort will be made to ensure that deposits are made within the 90-day allotted period. Planned Corrective Actions: Every effort will be made to ensure compliance with the residual receipts excess funds requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100.
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300,...
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Significant Deficiencies 2025-002 Compliance Requirement: Special Tests and Provisions – Excess of Residual Receipts Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Project, Assistance Listing 14.155 Project-Based Rental Assistance, Assistance Listing 14.195 Recommendation: It is recommended that efforts be made to ensure compliance with the residual receipts excess fund requirements going forward. Planned Corrective Actions: Every effort will be made to ensure compliance with the residual receipts excess funds requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100.
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300,...
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Significant Deficiencies 2025-001 Compliance Requirement: Special Tests and Provisions – Surplus Cash Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Project, Assistance Listing 14.155 Project-Based Rental Assistance, Assistance Listing 14.195 Recommendation: It is recommended that efforts be made to ensure compliance with the surplus cash remittance requirements going forward. Planned Corrective Actions: Every effort will be made to ensure that deposits are made within the 90-day allotted period. Planned Corrective Actions: Every effort will be made to ensure compliance with the residual receipts excess funds requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100.
Forty (40) tenant files sampled by the auditors, seven (9) files did not have utility allowance calculation that agreed to the HUD form 50058; four (4) files did not have tied to the HAP register for the period as management was unable to locate documentation. Additionally, five (4) tenants were not...
Forty (40) tenant files sampled by the auditors, seven (9) files did not have utility allowance calculation that agreed to the HUD form 50058; four (4) files did not have tied to the HAP register for the period as management was unable to locate documentation. Additionally, five (4) tenants were not reexamined and re-certified annually. Based upon staffing issues and staff s inability to learn the HUD regulations with Annual Reexaminations and Administrative Plan requirements between 2023 - 2025, Annual Reexaminations were getting further and further behind. RHA had hired independent contractors back in 2025 to assist RHA catch up but that did not work out. After the conversion of the software in June 2024 to Scott Accounting and Computer Software (SACS) from YARDI, most of the HAP errors came from old PIC files that were pulled over from PIC because the current staff were not double data entering the AR s and IR s into both programs for the few months prior to submission. This caused the HAP issues. All files have been reviewed the past 1.5 years and all HAP has been corrected to landlords based off those errors. Prior staff did not put a checkmark in the box to print reports, which forced the software to put the reports into a Document Management storage system for each tenant. The CEO worked with the software vendor to force the pushing of all reports associated with the AR, IR, MI, PMI, Transfers, MO and PMO to go into Document Management system and store. All FY2024 and FY2025 files are being completed in FY2026 and will be done by December 2026. The CEO and COO are reviewing all files by HCV staff and ensuring that a Compliance Checklist is completed on each file and once the file is certified for its AR, the file automatically goes into Document Management. The 50058 form is reviewed to ensure that the Utility Allowance on the form is also what is pulled onto the 52667 Utility Allowance Schedule form. All AR supporting documents are also monitored and ensured that they scanned into the Document Management system under the tenant folder for that Transaction Type. Beginning January 2027, RHA will be searching for a Compliance Officer staff person to go through files each month (10% of each Program Specialist s case load for prior months Annual Reexams or other types of transactions that occurred that prior month)
It has been identified that the FASSPHA Unaudited Submissions were not submitted by the February 28, 2025, deadline. RHA Administration has achieved in getting all outstanding Independent Audits completed and submitted for 2020-2024. The Unaudited FY2025 was submitted late by the contracted Fee Acco...
It has been identified that the FASSPHA Unaudited Submissions were not submitted by the February 28, 2025, deadline. RHA Administration has achieved in getting all outstanding Independent Audits completed and submitted for 2020-2024. The Unaudited FY2025 was submitted late by the contracted Fee Accountant for the 2nd year. RHA CEO will monitor the timeline of the contracted Fee Accountant going forward for FY2026 Unaudited Submission deadline of February 28, 2027. RHA CEO will monitor the progress of the Fee Accountant throughout the month of January 2027 with weekly reports/phone meeting. On or by February 10th, if the Fee Accountant does not feel they can have the Unaudited FASSPHA submitted by February 28th, an extension has to be requested by February 12th to get an additional 30-day extension approved by HUD by showing a verifiable extenuating circumstance preventing the on-time submission. Under 24 CFR § 902.60, a grace period of 15-days is provided to a PHA for the FASSPHA unaudited submission, which would give RHA until March 15, 2027 but if the extension was never requested on February 12, 2027, then the submission would have to occur prior to the end of the grace period of the 15- days. RHA Administration feels that prior years being completed and software conversion completed in 2024 and all corrections have been made on the GL, there should not be a future reason for the FASSPHA Unaudited Submission to not be on time by February 28th of each year.
RHA agrees with the finding. that the RHA inspection department was utilizing a 72-hour correction and reinspection timeframe for Life- Threatening (LT) deficiencies that required correction within 24 hours. This was due to inspection staff not reviewing the Administrative Plan or understanding Fede...
RHA agrees with the finding. that the RHA inspection department was utilizing a 72-hour correction and reinspection timeframe for Life- Threatening (LT) deficiencies that required correction within 24 hours. This was due to inspection staff not reviewing the Administrative Plan or understanding Federal Regulation requirements on LT or Life- Threatening deficiencies. RHA Administration is performing monthly reviews of trackable, updated Excel Spreadsheet for Failed Inspections and abatements. Along with the monthly review of its Failed Inspections and Abatements, RHA Administration is also performing quarterly training of the inspection department on inspection protocols and timelines, especially if the Administrative Plan is updated or federal inspection protocols change. Effective May 19, 2026, RHA revised its procedures to align with the requirements outlined in the RHA Administrative Plan. RHA now requires that all 24-hour Life-Threatening deficiencies be reinspected and verified within the required 24-hour timeframe after the landlord and/or tenant receives notification of the deficiency via email. RHA Administration recognizes the importance of ensuring that all LT deficiencies are addressed within the required timeframe and that units are placed into abatement when deficiencies are not corrected within the applicable timeframe. Corrective Action 3x3 Quality Control Process To ensure compliance with the required correction and reinspection timeframes and to prevent units from being incorrectly delayed from abatement, RHA will implement a 3x3 monthly quality-control process. 1. HCV Inspection Coordinator Monthly Inspection Report The HCV Inspection Coordinator will generate a monthly inspection report covering the previous month's inspection activity. The report will include, at a minimum: Total number of inspections completed which should be reconciled with RHA's Excel inspection tracker. Total number of inspections passed. Total number of inspections failed. 43 Identification of units currently on their second inspection attempt and within the applicable 30-day correction timeframe, with particular attention given to units approaching the abatement deadline. Total number of units placed into abatement, if applicable, for the reporting month. The Inspection Coordinator will compare the monthly report against the Excel inspection tracker to identify any discrepancies or missing inspection activity. 2. Inspector Secondary Review Following completion of the monthly report, the Inspector will conduct a secondary review of the inspection activity. The Inspector will verify that: Inspection results are accurate. Required were completed within the applicable timeframe. LT deficiencies were reinspected and verified within the required 24-hour timeframe. Units approaching or exceeding the applicable correction timeframe have been appropriately identified. Any unit requiring abatement has been appropriately processed. No inspection or deficiency has been inadvertently missed. Any discrepancies identified during the review will be corrected and documented. 3. HQS Supervisor and CEO Quality Control and Tracking The completed monthly inspection report will then be submitted to the HQS Supervisor and CEO for final quality-control review and tracking purposes. The HQS Supervisor / CEO will review the report to ensure that: Inspection activity is accurately reported. Correction and reinspection timeframes are being followed. LT deficiencies are being handled within the required 24-hour timeframe. Units requiring abatement are being identified and processed in a timely manner. Any discrepancies identified during the first two levels of review have been resolved. Ongoing Monitoring and Compliance RHA will conduct a monthly audit of all HQS inspections throughout FY 2026 to ensure compliance with the applicable inspection requirements and to prevent Indicator 12 from being missed. The 3x3 process will provide three levels of review: 1. HCV Inspection Coordinator 2. Inspector 3. HQS Supervisor / CEO This process is intended to provide an additional layer of accountability, identify discrepancies promptly, ensure accurate tracking of inspections and verify that required abatements are initiated within the applicable timeframe. RHA will maintain documentation of the monthly reviews and any corrective actions identified through the quality-control process. Any discrepancies discovered during the monthly audit will be
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Economic Development Audit Finding Number: 2025-016 – DED FFATA Reporting Name of the contact person responsible for corrective action: Christopher McCormick Anticipated completion date for cor...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Economic Development Audit Finding Number: 2025-016 – DED FFATA Reporting Name of the contact person responsible for corrective action: Christopher McCormick Anticipated completion date for corrective action: June 30, 2026 The Department partially agrees with the auditor's findings. The Departments Corrective Action Plan below includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. The Department agrees that we need to strengthen internal controls to ensure information is timely and accurately reported for the CDBG program and complete FFATA reporting in accordance with the applicable requirements. The one (1) award that was not reported as required was a clerical error and was not repeated. The Department disagrees with the findings that exceed the scope of the current audit period (July 1, 2024 – June 30, 2025). The correct audit population comprises new subawards, and amendments executed during the audit period, rather than all active subawards. The reported items were submitted before June 30, 2024, and correspond to prior award periods that are now closed. Furthermore, the Department's internal control mechanisms identified the FFATA reporting discrepancy in September 2024. The Department subsequently conducted a retrospective review and reported all outstanding amendments. Because the Department discovered and corrected the breakdown through its own internal controls, we believe the finding is inconsistent with the regulatory intent regarding systemic non-compliance. The Department maintains that FFATA does not require the reporting of deobligations or a reconciliation with USASpending.gov. Per 2 CFR §170 Appendix A, the regulatory requirement is as follows: “…the recipient must report each subaward that equals or exceeds $30,000 in Federal funds... The recipient must also report a subaward if a modification increases the Federal funding to an amount that equals or exceeds $30,000. All reported subawards should reflect the total amount of the subaward.” The Department adheres to the literal language of this regulation. The requirement specifies reporting the total amount of the subaward, rather than a "net" amount or a "remaining balance." In accounting and auditing standards, "Total," "Balance," and "Net" are distinct terms with specific applications; had the regulation intended for deobligations to be factored into the reported figure, it would have specified a "net", “balance”, or "liquidated" balance. The Department disagrees with the finding that subawards were reported in the incorrect year. For annual federal funds, the Department operates on a First-In, First-Out (FIFO) basis. In the standard course of business, subaward invoices are typically paid from the specific pool of funds from which they were awarded. However, as older funding streams approach expiration, an invoice for a subaward originally awarded and properly reported to FFATA in FY2022 may be relieved using FY2019 funds. Since the subawards were reported accurately at the time of the award action, they remain in compliance with FFATA regulations. Corrective Plan of Action: The CDBG program will implement the following measures to ensure ongoing compliance and strengthen oversight: • Training and Regulatory Review: The Department will conduct comprehensive FFATA training for the reporting team, specifically focusing on the requirements set forth in 2 CFR Part 170. This review will ensure that all staff are aligned with federal reporting standards and the literal requirements of the regulation. • Internal Control Enhancement: A thorough evaluation of existing internal controls related to FFATA reporting is underway. The Department will identify and implement any necessary improvements to provide reasonable assurance that all reporting remains accurate and compliant. • Best Practice Research and Benchmarking: The Department will engage with peer agencies in other states to determine if a reconciliation process with USAspending.gov is utilized as a best practice. • Process Implementation: If an effective reconciliation model is identified through this benchmarking, the Department will evaluate its feasibility and integrate a similar reconciliation process into the State of Missouri’s standard operating procedures to further bolster reporting integrity.
93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend management continue to strengthen review cont...
93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend management continue to strengthen review controls over the setup, maintenance, and application of sliding fee discount schedules, including periodic monitoring procedures to identify and promptly correct exceptions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has established a system of review and documentation of an internal audit that is conducted monthly to ensure slides are being applied properly. Name(s) of the contact person(s) responsible for corrective action: Jolene Joseph Planned completion date for corrective action plan: December 31, 2025
FINDING 2025-002: Waiting List Selections Condition The Housing Authority did not maintain documentation showing how preference criteria determined the participant's place on the waiting list. Corrective Action Plan The Housing Authority has purged the waiting list to obtain updated information from...
FINDING 2025-002: Waiting List Selections Condition The Housing Authority did not maintain documentation showing how preference criteria determined the participant's place on the waiting list. Corrective Action Plan The Housing Authority has purged the waiting list to obtain updated information from applicants. The Housing Authority is now utilizing its’ wait list management software to apply preference points (if applicable) to each applicant on the waiting list per the tenant selection policy. Name(s) of Contact Person(s) Responsible for Corrective Action: Jessica Oleson-Bue Anticipated Completion Date: Ongoing
Recommendation: We recommend, the Authority develop a process that all recertifications are reviewed by a different individual from the individual preparing the recertification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in r...
Recommendation: We recommend, the Authority develop a process that all recertifications are reviewed by a different individual from the individual preparing the recertification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will review processes in place to comply with HUD requirements. Name of the contact person responsible for corrective action: Georgia Crownhart Planned completion date for corrective action plan: December 31, 2026
Recommendation: We recommend, the Authority develop a process to ensure that rent quality control reinspection's are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will trai...
Recommendation: We recommend, the Authority develop a process to ensure that rent quality control reinspection's are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will train individuals doing the quality control re- inspections to ensure they are completed timely and enforce processes to verify them has been done timely. Name of the contact person responsible for corrective action: Georgia Crownhart Planned completion date for corrective action plan: December 31, 2026
Catholic Charities of Spokane will strengthen internal controls over compliance to ensure that all required eligibility, intake, exit, and program‑specific documentation is completed and reviewed prior to providing assistance and charging costs to federal awards. Corrective actions include the follo...
Catholic Charities of Spokane will strengthen internal controls over compliance to ensure that all required eligibility, intake, exit, and program‑specific documentation is completed and reviewed prior to providing assistance and charging costs to federal awards. Corrective actions include the following: • Management has reassigned responsibilities to ensure that case management and supervisory staff are clearly accountable for completing and reviewing required documentation before assistance is released. • The organization has implemented enhanced supervisory review procedures, including documented review of participant files to confirm required documentation is complete prior to billing HUD funding. • Standardized documentation checklists have been implemented for Continuum of Care participant files to promote consistency and completeness of required records. • Targeted training has been provided to staff involved in program administration to reinforce HUD Continuum of Care documentation and eligibility requirements. • Management will perform periodic monitoring of participant files to verify ongoing compliance and to identify and remediate documentation issues on a timely basis.
Finding: 2025-002 - Significant Deficiency in Internal Control over Preparation of the SEFA Contact Person: Leon Karnovsky, Chief Financial Officer leonk@jfsannarbor.org Explanation and Specific Reasons for Disagreement with the Audit Finding or that Corrective Action is not Required: No disagreemen...
Finding: 2025-002 - Significant Deficiency in Internal Control over Preparation of the SEFA Contact Person: Leon Karnovsky, Chief Financial Officer leonk@jfsannarbor.org Explanation and Specific Reasons for Disagreement with the Audit Finding or that Corrective Action is not Required: No disagreement Corrective Action Taken/Planned: Management acknowledges the importance of accurate and complete SEFA reporting. The Organization has already taken corrective action to address the identified deficiency and has integrated steps to enhance its internal review procedures. Anticipated Completion Date: Corrective action was completed in July 2026.
Management continues to resolve this prior year issue. While 25% failure rate is unacceptable, please note 2024 audit reporteda 55% rate and 2023 it was a 100% failure rate. Management will continue to address this issue.
Management continues to resolve this prior year issue. While 25% failure rate is unacceptable, please note 2024 audit reporteda 55% rate and 2023 it was a 100% failure rate. Management will continue to address this issue.
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