Corrective Action Plans

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Recommendation: We recommend that the City review and update internal controls to ensure that the Financial Data Schedule (FDS) is completed and submitted in a timely manner Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to f...
Recommendation: We recommend that the City review and update internal controls to ensure that the Financial Data Schedule (FDS) is completed and submitted in a timely manner Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City has contracted a financial consultant to prepare and submit financials monthly and annually. Internally, RBHA staff has established timelines for data preparation in advance of FDS deadlines to ensure the consultant is prepared to submit the financial reports in a timely manner. Staff has set ongoing calendar reminders to monitor and coordinate with all the parties involved the FDS submissions. Name of the contact person responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: January 2026
Recommendation: We recommend that the City review and update internal controls to ensure that supporting documentation for re-inspections and failed inspections is complete and properly reviewed and maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit f...
Recommendation: We recommend that the City review and update internal controls to ensure that supporting documentation for re-inspections and failed inspections is complete and properly reviewed and maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA is updating the administrative policy which includes a timeline for inspection follow-up within 30 days and scheduling re-inspections within five business days from the date requested. The revised policies include a description of the types of inspections to be conducted by the Housing Authority, the steps that will be taken when units fail, and identifies conditions which are considered to be life-threatening. The current RBHA staff will review and implement the revised policies to ensure inspections are completed in a timely manner and proper follow up is administered. The Housing Manager is already implementing protocols for the review and approval of inspections conducted by staff to ensure compliance. In addition, quality control inspections are regularly conducted by a Team Lead, a process that is also required for the annual Section Eight Management Assessment Program (SEMAP) submitted to HUD. The updated administrative policies include a chapter for the National Standards for the Physical Inspection of Real Estate (NSPIRE) that will sunset and replace the Housing Quality Standards (HQS) inspection process scheduled for February 1, 2027. Name of the contact person responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: January 2026
Name of Contact Person: Stephanie Hanvey, Director, Regional Housing, Western Piedmont Council of Government Corrective Action: With the merger of the City of Hickory public Housing Authority into the Western Piedmont Council of Governments affected July 1, 2025, staff have impacted new processes to...
Name of Contact Person: Stephanie Hanvey, Director, Regional Housing, Western Piedmont Council of Government Corrective Action: With the merger of the City of Hickory public Housing Authority into the Western Piedmont Council of Governments affected July 1, 2025, staff have impacted new processes to make sure that all the HPHA files and past processes are brought into compliance. Reviewing PIC inspection delinquency reports and scheduling overdue inspections, beginning with the most delinquent cases, while also coordinating current annual inspections with annual reexaminations to maintain compliance. Staff is reviewing the PIC delinquent annual reexamination report and completing overdue examinations in order of priority, and an annual reexamination checklist has been added to ensure all required documentation is collected. An audit process has been implemented for every examination to strengthen oversight, and quarterly quality control inspections are being conducted to monitor the inspection process. In addition, staff review EIV reports monthly to verify the integrity of the client information-including multiple subsidy, SSN screening, and income reporting-and monitor SACS software reports each month to ensure recertification are completed within required timelines. Proposed Completion Date: Immediately
Reconciliations of accounting records will be completed before the beginning of the audit to avoid future delays
Reconciliations of accounting records will be completed before the beginning of the audit to avoid future delays
Finding 2024-002 Federal Agency U.S. Department of Housing and Urban Development Federal Program Community Project Funding Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedure...
Finding 2024-002 Federal Agency U.S. Department of Housing and Urban Development Federal Program Community Project Funding Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow procedures to ensure program eligibility and we will review the accuracy / completion of the documentation being processed in our participant files on a periodic basis. Anticipated Completion Date November 30, 2025
Management accepts the recommendation of the auditor and has contacted the insurance carrier to increase the amount of the fidelity bond to cover two months gross rent. This action should be completed by April 30, 2025. Karen Raugh, Chief Executive Officer, is responsible for implementing this corre...
Management accepts the recommendation of the auditor and has contacted the insurance carrier to increase the amount of the fidelity bond to cover two months gross rent. This action should be completed by April 30, 2025. Karen Raugh, Chief Executive Officer, is responsible for implementing this corrective action.
Management agrees to maintain separate trial balances for the allocation of cash, property and equipment, interest rate swap asset and loans payable between Palmyra Area Interfaith Housing Council and Palmyra Interfaith Manor HUD Project No. 034-EH015. Management notes that this represents a differe...
Management agrees to maintain separate trial balances for the allocation of cash, property and equipment, interest rate swap asset and loans payable between Palmyra Area Interfaith Housing Council and Palmyra Interfaith Manor HUD Project No. 034-EH015. Management notes that this represents a difference of opinion from the prior auditors, who found the financial records of the two entities to be properly reconciled through the use of schedules to separate the council and project’s allocation of cash, property and equipment, interest rate swap asset and loans payable between the Council and the Project for 19 years with no consequence.
Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF retrained staff on FFATA reporting deadlines and documentation expectations so that if new sub...
Views of Responsible Officials: CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. CIF retrained staff on FFATA reporting deadlines and documentation expectations so that if new subawards are entered into in FY 26, this requirement will be met in a timely fashion. Details relating to FFATA reporting requirements are documented in the CIF Subaward Management & Subrecipient Monitoring Policy and Procedures.
The Corporation should file the December 31, 2024 financial statements as soon as possible and should ensure the annual financial report is filed within 90 days in future periods or within nine months of fiscal year end if an owner certified submission was furnished to HUD.
The Corporation should file the December 31, 2024 financial statements as soon as possible and should ensure the annual financial report is filed within 90 days in future periods or within nine months of fiscal year end if an owner certified submission was furnished to HUD.
Finding 1168472 (2024-003)
Material Weakness 2024
Mana Maoli has implemented a practical review and reconciliation step as part of payroll processing. This step compares approved timesheets to payroll register hours to help ensure that payroll allocations to federal programs are based on accurate records. This reconciliation is integrated into the ...
Mana Maoli has implemented a practical review and reconciliation step as part of payroll processing. This step compares approved timesheets to payroll register hours to help ensure that payroll allocations to federal programs are based on accurate records. This reconciliation is integrated into the existing payroll workflow to avoid added administrative burden. Management will conduct periodic reviews of payroll records and refine the process as needed to maintain reasonable assurance of accuracy, recognizing that the goal is continuous improvement. Anticipated completion date: December 31, 2026
AHC has revised its patient intake procedures to ensure that all required documentation is collected and verified at the point of service. An electronic eligibility checklist has been integrated into the EHR, and staff have been trained to collect alternative income documentation where appropriate. ...
AHC has revised its patient intake procedures to ensure that all required documentation is collected and verified at the point of service. An electronic eligibility checklist has been integrated into the EHR, and staff have been trained to collect alternative income documentation where appropriate. Monthly audits of ten patient files per site are conducted, and exceptions are logged and resolved within ten business days. Policies and procedures have been updated to reflect documentation and compliance standards. Ongoing monitoring and periodic staff retraining continue to support program integrity and compliance with federal requirements. Moving forward, responsibility for managing the sliding fee discount process will transition from front-desk personnel to the Revenue Cycle department to ensure stronger oversight and accountability.
Statement of Condition #2024-003: The Partnership did not furnish HUD with a complete annual financial report within ninety (90) days following the end of the fiscal year ending March 31, 2024. Recommendation: The annual financial statements should be issued in a timely manner pursuant to the time f...
Statement of Condition #2024-003: The Partnership did not furnish HUD with a complete annual financial report within ninety (90) days following the end of the fiscal year ending March 31, 2024. Recommendation: The annual financial statements should be issued in a timely manner pursuant to the time frame set forth by HUD. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. The audited financial statements have been submitted to HUD. No further action is required.
Statement of Condition #2024-001: The Form SF-SAC Single Audit Data Collection Form for the year ended March 31, 2024 was not submitted to the federal audit clearinghouse in the required timeframe. Recommendation: The Corporation should submit the Form SF-SAC Single Audit Data Collection Form for th...
Statement of Condition #2024-001: The Form SF-SAC Single Audit Data Collection Form for the year ended March 31, 2024 was not submitted to the federal audit clearinghouse in the required timeframe. Recommendation: The Corporation should submit the Form SF-SAC Single Audit Data Collection Form for the year ended March 31, 2024 as soon as practical. Action(s) taken or planned on the finding: Agreed. The Agent concurs with the finding and recommendation.
Statement of Condition #2024-002: During the year ended March 31, 2024, the Corporation did not make the required deposit to the residual receipts account within 90 days after the end of the fiscal year, resulting in the account being underfunded at year end. Recommendation: The Agent should transfe...
Statement of Condition #2024-002: During the year ended March 31, 2024, the Corporation did not make the required deposit to the residual receipts account within 90 days after the end of the fiscal year, resulting in the account being underfunded at year end. Recommendation: The Agent should transfer $16,431 from the REDI IV operating account to the residual receipts account. The Agent should make all required deposits to the residual receipts account within 90 days after the end of the fiscal year. Action(s) taken or planned on the finding: Agreed. The Agent concurs with the finding and the auditor's recommendation. The Corporation will ensure future deposits to the residual receipt account are made within 90 days after the end of the fiscal year.
To date, The Director of Housing Choice Vouchers (Section 8) have tested all our reports to ensure they are properly filtered to include all tenant with approaching recertifications will be performed timely.
To date, The Director of Housing Choice Vouchers (Section 8) have tested all our reports to ensure they are properly filtered to include all tenant with approaching recertifications will be performed timely.
2024-005 - In October 2023, NYSHCR implemented a new software system, requiring all Local Administrators to transition to the Emphasys Elite system. In 2025, NYSHCR determined that the Waiting List Reports for prior periods could not be regenerated due to system limitations. This issue was related t...
2024-005 - In October 2023, NYSHCR implemented a new software system, requiring all Local Administrators to transition to the Emphasys Elite system. In 2025, NYSHCR determined that the Waiting List Reports for prior periods could not be regenerated due to system limitations. This issue was related to the software system itself and was not the result of any error or omission by RUPCO. The NYS HCR Procedure Manual, released on July 14, 2025 (page 47), instructs Local Administrators to retain copies of all sort/draw reports when selecting applicants from the Waiting List. Moving forward, The Director of Housing Choice Voucher (Section 8) will maintain records of all sort/draw reports in accordance with NYSHCR guidance to ensure full compliance and ease of verification.
Finding Number: 2024-006 Planned Corrective Action: The Special Projects Manager will ensure the County establishes policies/procedures related to Section 3 and includes Section 3 accomplishments in semi-annual performance reports submitted in Disaster Recovery Grant Reporting System. Anticipated Co...
Finding Number: 2024-006 Planned Corrective Action: The Special Projects Manager will ensure the County establishes policies/procedures related to Section 3 and includes Section 3 accomplishments in semi-annual performance reports submitted in Disaster Recovery Grant Reporting System. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: P Philip Schaffer, Special Projects Manager
Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delays in processing invoices were due to heightened fiscal oversight implemented after it was determined that the...
Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delays in processing invoices were due to heightened fiscal oversight implemented after it was determined that the Office had exceeded its budget allocation. As a result, all invoices for OHS-contracted services were subject to additional layers of review beyond the standard OHS and Finance approval process. These invoices were routed to the Managing Director’s Office before payment authorization, which extended the normal processing timelines. To prevent recurrence, the Office of Homeless Services will strengthen its invoice-processing policies and procedures to ensure timely review and payment of all subrecipient invoices, consistent with applicable federal requirements. Now that the enhanced review protocols are no longer in effect, OHS will reestablish standard review timelines and reinforce internal expectations for prompt processing. OHS will also provide guidance to fiscal staff on escalation procedures should future budgetary reviews impact invoice timeliness. These corrective actions will support improved compliance and reduce the likelihood of processing delays. Contact Person: Jerome Hill, Director of Compliance, OHS, 215-686-0371
FDecember 19, 2025 United States Department of Housing & Urban Development Northside Properties, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Barton, Gonzalez & Myers, P.A., 13137 66th Str...
FDecember 19, 2025 United States Department of Housing & Urban Development Northside Properties, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Barton, Gonzalez & Myers, P.A., 13137 66th Street, Largo, FL 33773. Audit period: January 1, 2024 – December 31, 2024 The findings from December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section I of the schedule, Summary of Auditor’s Results, does not include findings and is not addressed. Federal Award Findings: Finding 2024-002 Reporting – Late REAC Submission and Late OMB Data Collection Form Submission 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects 14.195 Section 8 Housing Assistance Payments Program Material Weakness in Internal Control – Material Noncompliance Condition: The Organization’s annual financial statement data was not submitted within the timeframes specified by HUD. The financial statement data was due by March 31, 2025, but the financials were not issued until December 19, 2025. The Organization was also required to submit the OMB Data Collection Form to the Federal Audit Clearinghouse (“FAC”) by September 30, 2025, but was not filed timely as the audit was completed on December 19, 2025. Auditor’s Recommendation: We recommend that the Organization make every effort to submit its annual financial statement data within the timeframe specified by HUD. Action Taken: The Organization has maintained contact with HUD and prioritized submitting the annual financial statement data after they were informed it was late. Effective Date: December 19, 2025 Contact Information: Susan Wright, Director of Operations Northside Mental Health Center, Inc. Management Agent 12512 Bruce B Downs Blvd Tampa, FL 33612 (813) 977-8700
Finding 2024-002—Activities Allowed or Unallowed Repeat Finding—See Finding 2023-003, 2022-004 Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements, which should include a periodic analysis comparing actual time spent on th...
Finding 2024-002—Activities Allowed or Unallowed Repeat Finding—See Finding 2023-003, 2022-004 Recommendation: We recommend the City implement internal control procedures to ensure compliance with allowable cost requirements, which should include a periodic analysis comparing actual time spent on the CDBG program versus the budgeted allocations and evaluating need for adjustments. Action Taken: Effective June 30, 2025, the City adopted additional procedures for the review of payroll-related reimbursements by the Grants Accountant and Grants Manager prior to funds being drawn. Time spent on the CDBG program will be evaluated at least annually by the Grants Manager and Grants Accountant as part of the budget process.
Finding 2024-239: The Division does not have documented control procedures in place to ensure compliance with period of performance requirements for the Rehabilitation Services-Vocational Rehabilitation Grants to States. Related to Prior Finding: N/A Agency’s view: Agree 3.1 Corrective Action Plan: ...
Finding 2024-239: The Division does not have documented control procedures in place to ensure compliance with period of performance requirements for the Rehabilitation Services-Vocational Rehabilitation Grants to States. Related to Prior Finding: N/A Agency’s view: Agree 3.1 Corrective Action Plan: Document Control Procedures: Develop and implement formal, written procedures (Grants Management Manual Chapter) for verifying that expenditures are assigned to the correct period of performance in both Aware and Luma. 3.2 Training: Train IDVR team members on policies and procedures tied to Period of Performance. Anticipated Corrective Action Date: 04/01/2026 Responsible for Corrective Action: Eric Bjork, Fiscal Officer
Finding 2024-220: The expenditures reported on the Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program form (CMS-64) were understated by $16,348,275 for the Medicaid program. Agency’s View: Agree Corrective Action: As noted in the finding, the late submission and understa...
Finding 2024-220: The expenditures reported on the Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program form (CMS-64) were understated by $16,348,275 for the Medicaid program. Agency’s View: Agree Corrective Action: As noted in the finding, the late submission and understated expenditures were primarily the result of the Luma system implementation and the unavailability of required data for CMS reporting. During the development phase, concerns were raised regarding the system’s ability to meet federal reporting requirements—specifically the CMS-64 and CMS-21 reports for Medicaid. The Budget Team requested sample output reports to proactively update workpapers and ensure accurate and timely reporting; however, these requests were not fulfilled. During the delay in timely reporting, DHW maintained ongoing communication with our federal partners. The Budget Team developed the necessary reports and revised internal processes to bring reporting current. The Budget Team also worked closely with our federal auditors to ensure no reporting elements were inadvertently omitted. During this review, we identified that our initial submission excluded indirect expenditures associated with the federally approved Cost Allocation Plan. This allocation process cannot be completed within Luma and requires coordination among the State Controller’s Office, two external vendors, and the Cost Allocation Budget Analyst. These dependencies created significant delays. As a result, indirect cost allocation charges were substantially delayed, and the first successful import for July 2023 did not occur until November 2023. Upon receiving the complete data, the Reporting Team corrected the process, documented the updates, and submitted a prior period adjustment to capture previously under-reported expenditures. As we entered SFY 2025, we had a more comprehensive understanding of the new processes and required timelines. This resulted in improved timeliness: the December 2024 submission was five days late submitted 2/4/25, the March 2025 submission was two days late submitted 4/30/25 and resubmitted 7/31/25, and the June 2025 submission was only one day late submitted 7/31/25. We are pleased to report that the September 2025 submission was certified on time and submitted 10/30/25. While some reporting adjustments were needed, CMS and the Budget Team collaborated effectively to update and recertify the report to ensure accuracy. We have updated all relevant process documentation and continue to automate steps where feasible to further improve efficiency and reduce turnaround times. Anticipated Corrective Action Date: Completed 10/30/2025 Responsible for Corrective Action: Magnum Forkner, Financial Manager magnum.forkner@dhw.idaho.gov 208-332-7241
Finding 2024-214: The Department does not have documented internal controls for cash draws and requested reimbursement for the same $175,500 grant expenditure twice. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: DEQ has had significant turnover in the fiscal office, whic...
Finding 2024-214: The Department does not have documented internal controls for cash draws and requested reimbursement for the same $175,500 grant expenditure twice. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: DEQ has had significant turnover in the fiscal office, which has resulted in gaps of knowledge of policies and practices. In summer 2025, DEQ leadership reorganized the fiscal department to improve efficiency, enhance oversight of grants and contracts, and strengthen financial controls. The fiscal office is currently in a rebuilding phase and is dedicated to training and developing staff, implementing best practices, and documenting processes and procedures, including those for federal grant compliance. The duplicate payment in question was issued but not redeemed. The issuance was to a similar, but incorrect, vendor name and was caught by staff before it was sent to the vendor. The transaction was cancelled in Luma but was not properly recorded in the following draw request. Fiscal staff now perform a thorough review of transactions before a loan draw is finalized in Luma, reconciling the transactions from the Loans and Grants Tracking System (LGTS) to the information generated in the Luma draw invoice. The reconciling and supporting documentation from LGTS is attached to the Luma draw invoice. Anticipated Corrective Action Date: January 31, 2026 Responsible for Corrective Action: Linda Brown, Financial Executive Officer, at 208-373-0292 or linda.brown@deq.idaho.gov
Finding 2024-212: The Department’s Indirect Cost Rate Proposal (ICRP) contained multiple errors. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: DEQ has had significant turnover in the fiscal office, which has resulted in gaps of knowledge of policies and practices. In sum...
Finding 2024-212: The Department’s Indirect Cost Rate Proposal (ICRP) contained multiple errors. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: DEQ has had significant turnover in the fiscal office, which has resulted in gaps of knowledge of policies and practices. In summer 2025, DEQ leadership reorganized the fiscal department to improve efficiency, enhance oversight of grants and contracts, and strengthen financial controls. The fiscal office is currently in a rebuilding phase and is dedicated to training and developing staff, implementing best practices, and documenting processes and procedures, including those for federal grant compliance. The agency has new staff that will be preparing and submitting the indirect cost rate proposal this year and will take the auditor’s recommendations very seriously in our development and preparation. We have reached out to our federal oversight agency for assistance and direction Page 2 of 3 and are committed to maintaining a file with all supporting documentation used to compile and prepare the proposal, as required by 2 CFR 200. Anticipated Corrective Action Date: January 31, 2026 Responsible for Corrective Action: Linda Brown, Financial Executive Officer, at 208-373-0292 or linda.brown@deq.idaho.gov
2024-003 - SPECIAL TESTS AND PROVISIONS Auditee’s Response and Planned Corrective Action Post the 2023 audit it was determined that we would fund an internal reserve at the property level. The internal reserve was to be funded, and accounts were opened to reflect that however since the implementatio...
2024-003 - SPECIAL TESTS AND PROVISIONS Auditee’s Response and Planned Corrective Action Post the 2023 audit it was determined that we would fund an internal reserve at the property level. The internal reserve was to be funded, and accounts were opened to reflect that however since the implementation of the software conversion did not complete in a timely fashion it was not reflected in the 2024 transaction. Planned Implementation Date of Corrective Action: In progress Person Responsible for Corrective Action: Marianne Correia, General Manager
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