Corrective Action Plans

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Contact Person – Terry Hanson, Executive Director Corrective Action Plan – The Project will review its policies and procedures over timely reporting submissions. Completion Date – 12/31/26
Contact Person – Terry Hanson, Executive Director Corrective Action Plan – The Project will review its policies and procedures over timely reporting submissions. Completion Date – 12/31/26
"Management concurs that stronger documentation surrounding the collection and monitoring of Continuum of Care program income would have strengthened internal controls and the audit trail. The finding relates to a program that has since been discontinued. Throughout the audit period, all program inc...
"Management concurs that stronger documentation surrounding the collection and monitoring of Continuum of Care program income would have strengthened internal controls and the audit trail. The finding relates to a program that has since been discontinued. Throughout the audit period, all program income that was collected was used for allowable program purposes; however, management acknowledges that documentation supporting assessment, collection, monitoring, and reconciliation procedures should have been more comprehensive. Although this activity is no longer part of the Organization's operations, Ability1st has strengthened its overall documentation standards. Should the Organization administer future programs involving program income, written policies and procedures will be implemented prior to program implementation and will include: • documented fee assessment methodology; • collection and deposit procedures; • reconciliation requirements; • supervisory review; • record retention standards; and • periodic internal monitoring. Management believes these procedures will provide an appropriate level of accountability and compliance with federal requirements should program income be collected in the future. Responsible Official: Executive Director Implementation Date: Completed for discontinued program; procedures will be implemented before any future program income activity."
Management has implemented the following corrective actions to address the deficiencies noted in tenant file maintenance and eligibility determinations: A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monit...
Management has implemented the following corrective actions to address the deficiencies noted in tenant file maintenance and eligibility determinations: A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and issue weekly progress reports to the Director of Asset Management. c. Non-compliant files will be flagged for immediate follow-up with tenants. d. PMCS, a third-party group, will assist with recertifications. 2. Enforcing Timely Recertifications: a. Recertifications must be completed no later than 30 days before expiration. b. Staff will receive monthly reminders, and escalation measures will be implemented for delays. 3. Quarterly Internal Audits: a. PMCS and internal staff will conduct random file audits every three months to ensure adherence. b. Deficiencies will be addressed in real-time, and corrective steps will be logged. B. Ensuring EIV System Compliance 1. Standardizing EIV Compliance Procedures: a. A formal checklist will be created for EIV report reviews, ensuring all required reports are generated before lease renewals. b. EIV data will be cross-referenced with tenant files every quarter to ensure completeness. 2. Internal Monthly EIV Reviews: a. The Senior Housing Specialist will generate and review EIV reports on the 1st of each month. b. The Director of Asset Management, Third-Party Compliance Officer (PMCS), and Senior Housing Specialist will verify compliance before reports are finalized. 3. Quarterly Compliance Reports: a. The Compliance Officer will submit a quarterly compliance report documenting completion rates and deficiencies. C. Enhancing Staff Training and Accountability 1. Mandatory Quarterly Training: a. Staff will undergo quarterly compliance training covering HUD Handbook 4350.3, recertifications, and EIV compliance. b. Training sessions will be documented, and staff performance assessed. 2. Clarification of Responsibilities: a. Staff roles will be clearly outlined in a Standard Operating Procedure (SOP) document. b. Staff will be required to acknowledge their roles in compliance processes. 3. PMCS Involvement for Training Support: a. PMCS will offer supplementary training sessions as needed. D. Documentation and Oversight Enhancements 1. Maintaining Complete and Auditable Files: a. All lease and EIV documentation will be stored both physically and digitally. b. A real-time compliance dashboard will track completion rates. 2. Routine Management Reviews: a. The Senior Housing Specialist and Director of Asset Management will conduct monthly spot checks to verify document accuracy and completion. b. Non-compliance will result in formal corrective actions.
Management will immediately reimburse the property’s operating account for the unauthorized $10,000 distribution. Procedures will be implemented to ensure that all future loan repayments and cash distributions comply with HUD surplus cash requirements and the regulatory agreement. Surplus cash calcu...
Management will immediately reimburse the property’s operating account for the unauthorized $10,000 distribution. Procedures will be implemented to ensure that all future loan repayments and cash distributions comply with HUD surplus cash requirements and the regulatory agreement. Surplus cash calculations will be reviewed and approved prior to authorizing any distributions. Staff responsible for financial oversight will receive additional training on HUD surplus cash rules to prevent recurrence.
The Program Integrity Unit has established SOPPs which identifies the method for identifying fraud cases, investigating cases, and developed procedures in collaborating and cooperating with legal authorities, for referring credible allegations of fraud cases to law enforcement officials.
The Program Integrity Unit has established SOPPs which identifies the method for identifying fraud cases, investigating cases, and developed procedures in collaborating and cooperating with legal authorities, for referring credible allegations of fraud cases to law enforcement officials.
During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To add...
During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To address this finding, the Department recently issued Requests for Qualifications (RFQs) to seven qualified vendors to perform comprehensive security risk assessments of the Medicaid Enterprise Systems (MES), including the VIBES Eligibility and Enrollment System, Provider Enrollment Application (PEA), Pharmacy Benefit Management (PBM) solution, and related supporting systems. Vendor responses are due within three weeks, after which the Department will evaluate submissions and proceed with the procurement process. The selected vendor will conduct the required risk assessments, identify control deficiencies and security vulnerabilities, and provide recommendations to strengthen the Department's security posture and compliance framework. The Department will work collaboratively with its technology partners, system vendors, and oversight entities to implement corrective actions identified through the assessments and enhance monitoring controls to ensure ongoing compliance with applicable federal requirements.
2024-008 – CORONAVIRUS CAPITAL PROJECT FUND – LACK OF SUPPORT FOR PROCUREMENT – ALN 21.029 - MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Williston Basin Public School District No. 7 did not maintain support surrounding the selection process for the construction management at-risk (CMAR) fo...
2024-008 – CORONAVIRUS CAPITAL PROJECT FUND – LACK OF SUPPORT FOR PROCUREMENT – ALN 21.029 - MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Williston Basin Public School District No. 7 did not maintain support surrounding the selection process for the construction management at-risk (CMAR) for the CTE Center. Therefore, we were unable to determine if the CMAR selection was properly completed. In addition, Willison Basin Public School did not have a procurement policy. Management’s Response: We agree. The District will work to ensure that future projects are properly procured within state law and federal guidelines. Anticipated Completion Date: FY 2025
2024-001 Reporting – Late Report Submission to Federal Audit Clearinghouse and HUD Recommendation: Develop internal controls that provide month-end and year-end accounting close milestones that include deadlines that will ensure external reporting deadlines are able to be met. Explanation of disagre...
2024-001 Reporting – Late Report Submission to Federal Audit Clearinghouse and HUD Recommendation: Develop internal controls that provide month-end and year-end accounting close milestones that include deadlines that will ensure external reporting deadlines are able to be met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Authority has reviewed and updated its financial reporting and closing processes and controls for the preparation of the final trial balances and related schedules. As part of this process, the Authority has created a year-end checklist with deadlines and status meetings to monitor the progress. Name(s) of the contact person(s) responsible for corrective action: Lowel Kruger, Executive Director. Planned completion date for corrective action plan: December 31, 2024.
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges gaps in VOCA employee file documentation.  Implement a standardized checklist for VOCA and other grant-funded employees that includes required acknowledgements (nondiscrimination, drug-free workplace, confidentiality, ...
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges gaps in VOCA employee file documentation.  Implement a standardized checklist for VOCA and other grant-funded employees that includes required acknowledgements (nondiscrimination, drug-free workplace, confidentiality, and related forms).  Educate HR staff in auditing best practices, emphasizing complete and accurate employee files and the specific grant documentation required.  Schedule periodic reviews of VOCA-funded employee files (at least quarterly) to verify that all required documents are present and current, with results reported to management.
Planned Corrective Action: Organization of recertification / eligibility files by effective date, 100% completion of all recertifications by 2/28/2025 Contact Name and Title Responsible for Corrective Action Joy Flood, Executive Director
Planned Corrective Action: Organization of recertification / eligibility files by effective date, 100% completion of all recertifications by 2/28/2025 Contact Name and Title Responsible for Corrective Action Joy Flood, Executive Director
Reporting Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Economic Development Initiative, Community Project Funding, and Miscellaneous Grants, Assistance Listing Number 14.251 Award Period: March 9, 2022 through August 31, 2030 Recommendation: The Village should im...
Reporting Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Economic Development Initiative, Community Project Funding, and Miscellaneous Grants, Assistance Listing Number 14.251 Award Period: March 9, 2022 through August 31, 2030 Recommendation: The Village should implement controls to report accurate information in Federal Reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Village continues to work at updating its policy and procedures manuals. The Village will amend policies as necessary. Name(s) of the contact person(s) responsible for corrective action: Teresa Taylor, Village Clerk-Treasurer. Planned completion date for corrective action plan: The Village will adopt reporting policies in accordance with Uniform Guidance by December 31, 2025.
Finding 2024-007: During the year ended June 30, 2024, Housing Choice Voucher Program funds were used by other federal programs, resulting in Housing Choice Voucher Program funds being used to cover expenses for other federal programs and defederalized funds. a. Comments on the Finding We agree with...
Finding 2024-007: During the year ended June 30, 2024, Housing Choice Voucher Program funds were used by other federal programs, resulting in Housing Choice Voucher Program funds being used to cover expenses for other federal programs and defederalized funds. a. Comments on the Finding We agree with finding 2024-007 b. Action(s) Taken or Planned on the Finding The Authority has hired a new CFO who will provide the leadership and technical assistance needed to ensure the Finance department operates effectively within regulations. The Authority has created new policies ensuring monthly reconciliations and implemented the process of reconciling interfund balances to ensure balances are settled monthly, to ensure funds are not intermingled with other federal programs. Columbia Housing is also in the process of implementing a new software system that will provide software solutions to ensure accurate financial processing.
Finding 2024-006: No electronic income verification was done within the required time period for 1 of 40 participant selections. No abatement of housing assistance payments of failed unit inspections after 30 day maintenance windows was completed on 25 participant selections. a. Comments on the Find...
Finding 2024-006: No electronic income verification was done within the required time period for 1 of 40 participant selections. No abatement of housing assistance payments of failed unit inspections after 30 day maintenance windows was completed on 25 participant selections. a. Comments on the Finding We agree with finding 2024-006 b. Action(s) Taken or Planned on the Finding Annual training on program rules has been established for the Housing Choice Voucher Program, to ensure staff are aware of the proper implementation of the program rules. Additionally, a quality control protocol will be established that will require a review of at least 15% of all files. All failed inspection actions will be reviewed to ensure compliance with abatement protocols.
Finding Number: 2024-006 Planned Corrective Action: AMHA will require staff to follow all requirements set forth in 24 CFR 982 regarding income documentation such as obtaining third party verification and documenting the file as to why it was not available, related to annual income, assets, expenses...
Finding Number: 2024-006 Planned Corrective Action: AMHA will require staff to follow all requirements set forth in 24 CFR 982 regarding income documentation such as obtaining third party verification and documenting the file as to why it was not available, related to annual income, assets, expenses, etc. Staff will be instructed to double check calculations before inputting the information into the computer/50058 and to check to make sure calculations are accurate prior to adding the 50058 for submission. AMHA will continue to send staff to the appropriate training courses and AMHA has contracted with Nelrod for online training and will ensure this also includes EIV training courses. AMHA staff will conduct quality control on the files at random. Anticipated Completion Date: 6/11/2026 Responsible Contact Person: Zackary Dye, Executive Director
Finding Number: 2024-005 Planned Corrective Action: The Housing Authority has contracted with the Nelrod Company a national technical consulting firm specializing in Federal Assisted Housing Programs to perform our rent reasonableness determinations. Anticipated Completion Date: 6/11/2026 Responsibl...
Finding Number: 2024-005 Planned Corrective Action: The Housing Authority has contracted with the Nelrod Company a national technical consulting firm specializing in Federal Assisted Housing Programs to perform our rent reasonableness determinations. Anticipated Completion Date: 6/11/2026 Responsible Contact Person: Zackary Dye, Executive Director
Finding Number: 2024-004 Planned Corrective Action: The Housing Authority along with Leggins Casterline & Company LLC accounting will continue working to rectify the accounting issues resulting from the former Executive Director and have all submissions done in a timely manner. Anticipated Completio...
Finding Number: 2024-004 Planned Corrective Action: The Housing Authority along with Leggins Casterline & Company LLC accounting will continue working to rectify the accounting issues resulting from the former Executive Director and have all submissions done in a timely manner. Anticipated Completion Date: 6/11/2026 Responsible Contact Person: Zackary Dye, Executive Director
Finding Number: 2024-003 Planned Corrective Action: Housing Quality Standards are now done internally by the Executive Director and the authority has one dedicated staff member monitoring and they assure a re-inspection is automatically scheduled and notice sent to landlord and tenant. Anticipated C...
Finding Number: 2024-003 Planned Corrective Action: Housing Quality Standards are now done internally by the Executive Director and the authority has one dedicated staff member monitoring and they assure a re-inspection is automatically scheduled and notice sent to landlord and tenant. Anticipated Completion Date: 6/11/2026 Responsible Contact Person: Zackary Dye, Executive Director
Management acknowledges the importance of maintaining appropriate segregation of duties and documented independent review for match calculations and supporting documentation. Corrective actions implemented include the development and implementation of written procedures for preparing, reviewing, and...
Management acknowledges the importance of maintaining appropriate segregation of duties and documented independent review for match calculations and supporting documentation. Corrective actions implemented include the development and implementation of written procedures for preparing, reviewing, and approving match calculations and supporting documentation as well as requiring independent review and documented approval of match calculations by a staff member not involved in the preparation.
Management acknowledges the need to ensure that required documentation is complete and retained in each tenant file, including executed leases, required forms, inspection documentation, and other required program documents. Corrective actions implemented include the creation and use of a standardize...
Management acknowledges the need to ensure that required documentation is complete and retained in each tenant file, including executed leases, required forms, inspection documentation, and other required program documents. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that requires documented supervisory sign-off in each tenant file to ensure all required documentation is complete prior to assistance approval. Staff have completed refresher training on timing requirements, documentation standards, and calculation procedures.
Management acknowledges the importance of completing rent reasonableness determinations timely (i.e., prior to lease execution) and ensuring the accuracy of amounts used in the calculation. Corrective actions implemented include the creation and use of a standardized eligibility determination checkl...
Management acknowledges the importance of completing rent reasonableness determinations timely (i.e., prior to lease execution) and ensuring the accuracy of amounts used in the calculation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that requires documented supervisory sign-off in each tenant file which includes verification of the lease amount and calculation prior to lease execution. Staff have completed refresher training on timing requirements and calculation procedures.
Management acknowledges the need for consistent documentation and secondary review to support income determinations and rent calculations, including ensuring calculations are based on appropriate income measures. Corrective actions implemented include the creation and use of a standardized eligibili...
Management acknowledges the need for consistent documentation and secondary review to support income determinations and rent calculations, including ensuring calculations are based on appropriate income measures. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that requires documented supervisory sign-off in each tenant file confirming the income calculations and rent determinations. Staff have completed refresher training on documentation standards and calculation procedures.
Management recognizes the importance of maintaining clear, documented evidence of supervisory review of eligibility determinations, income calculations, and supporting documentation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist tha...
Management recognizes the importance of maintaining clear, documented evidence of supervisory review of eligibility determinations, income calculations, and supporting documentation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that includes supervisory review steps requiring documented supervisory sign-off in each tenant file prior to finalizing eligibility. A standardized tracker is also being used to ensure completeness of the process.
Finding 1216578 (2024-002)
Material Weakness 2024
Management has implemented the following corrective actions: 1. Established a monthly reserve funding schedule that identifies required deposits and due dates. 2. Included replacement reserve funding requirements in the annual budgeting process and monthly financial review procedures. 3. Assigned re...
Management has implemented the following corrective actions: 1. Established a monthly reserve funding schedule that identifies required deposits and due dates. 2. Included replacement reserve funding requirements in the annual budgeting process and monthly financial review procedures. 3. Assigned responsibility to the Executive Director and Finance Committee to monitor compliance with reserve funding requirements. 4. Developed a plan to fund any reserve shortfall through future operating surpluses and/or approved funding sources.
Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Hous...
Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: Part 1: Immediate corrective actions (to address immediate noncompliance). Submit all overdue Single Audit and REAC reporting packages immediately to resolve the current noncompliance. Task Responsible Party 1.1. Prepare and submit delinquent reports: 1.1.1. Assemble and finalize the overdue Single Audit Reporting Package for FY 2024 and submit it to the Federal Audit Clearinghouse (FAC). Chief Financial Officer (CFO) 1.1.2. Assemble and finalize all overdue REAC Annual Financial Statements (AFS) for FY 2024 and submit them to HUD's Financial Assessment Subsystem (FASS-MF) via the REAC Secure Systems. Property Manager 1.2. Notify HUD: 1.2.1. Immediately notify the local HUD Field Office and the assigned Account Executive of the finding and the plan for submission of all delinquent reports. Property Manager 1.3. Document and address penalties: 1.3.1. Address any penalties or noncompliance flags resulting from the late filings, which may include interaction with HUD's Departmental Enforcement Center (DEC). Property Manager / CFO Part 2: Systemic corrective actions (to prevent future noncompliance) Implement new policies and procedures to ensure all future HUD Single Audit and REAC submissions are filed on time. Task Responsible Party 2.1. Revise and implement internal policies: 2.1.1. Draft a written policy defining the timelines and responsibilities for all HUD financial and audit reporting, including Single Audit and REAC AFS submissions. This policy will be housed in the organization's Operations Manual. CEO / CFO 2.2. Develop a comprehensive compliance checklist: 2.2.1. Create and implement a calendar-based checklist for all HUD reporting requirements, with deadlines for every stage of the process, including financial data collection, auditor engagement, and submission. CFO / Property Manager 2.3. Enhance financial review and control procedures: 2.3.1. Implement a formal review and approval process for all financial statements and audit packages. Require a documented review by the CFO and sign-off by the CEO and Board of Directors before any submission. CFO 2.4. Improve communication and oversight: 2.4.1. Establish a quarterly meeting with all key staff involved in HUD reporting (CFO, Property Manager, accounting staff) to review deadlines and ensure all tasks are on schedule. CEO 2.4.2. Assign a designated staff member as the primary point of contact for external auditors and the HUD REAC Secure Systems. Property Manager 2.5. Provide staff training: 2.5.1. Schedule and conduct training for all relevant staff on the new policies, checklists, and the HUD reporting platforms (FAC and REAC Secure Systems). Third Party Training Professionals, HUD and Property Manager’s compliance officer 2.6. Address external auditor issues (if applicable): 2.6.1. Evaluate the relationship with the current external audit firm. If timeliness was a factor in the audit report delay, establish clear communication protocols and deadlines in the new engagement letter. Consider a different firm for future audits if necessary. CFO Part 3: Monitoring and future enforcement (to sustain compliance) Create a monitoring plan to ensure the corrective actions are working and that late filings do not recur. Task Responsible Party 3.1. Ongoing monitoring: 3.1.1. The CFO will provide a monthly report to the CEO on the status of all HUD reporting deadlines. The report will highlight upcoming deadlines and progress toward completion. CFO 3.2. Annual review: 3.2.1. Conduct an annual review of the HUD Reporting Policy and Compliance Checklist to ensure they are current and effective. CEO / CFO 3.3. Update internal audit program: 3.3.1. Incorporate the timely filing of HUD reports into the organization's internal audit or quality assurance program. CFO Anticipated Completion Date: December 2025
Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing...
Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. The Sponsor shall immediately remedy all past errors by correcting and if applicable, resubmit all vouchers that were inaccurate, incomplete, or submitted late. The Sponsor shall work with the property manager to create a detailed checklist to ensure all required fields and steps are completed for each voucher before submission. From there, we shall provide HUD with a report showing all corrected vouchers and detailing how the current data was reconciled with the original incorrect submissions. 2. Systemic preventative measures: • Develop and implement a training program to create a formal training curriculum for all staff involved in voucher processing. • Update internal policies and procedures to ensure that the Sponsor’s policies and procedures to include a specific, standardized process for all Section 811 voucher submissions. • Establish a monitoring and oversight protocol to ensure regular, ongoing monitoring process to review voucher submissions for accuracy and timeliness. • Leverage HUD resources and technology to ensure that all staff involved in voucher processing are trained on and regularly use the latest guidance from the HUD Exchange and relevant HUD manuals, including the TRACS Manual Voucher Submission application. • The Chief Financial Officer will be responsible for ensuring all corrective actions are implemented and sustained. Anticipated Completion Date: December 2025
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