Corrective Action Plans

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2024-002 – Annual HQS Inspection Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management implement a centralized tracking system to monitor inspection due dates and follow-up timelines, ensuring all inspections are completed within HUD- mandated...
2024-002 – Annual HQS Inspection Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management implement a centralized tracking system to monitor inspection due dates and follow-up timelines, ensuring all inspections are completed within HUD- mandated timeframes. Additionally, we recommend that PBCHA evaluate current staffing levels and consider hiring additional inspectors or contracting with third-party providers to meet inspection demands. Ongoing training should also be provided to staff on Housing Quality Standards (HQS) protocols and compliance expectations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The PBCHA has seen vast improvement in this area. The PBCHA will continue to monitor its third-party inspection vendor to ensure continued adherence for the provision of inspection reports. The PBCHA will utilize centralized tracking systems within Yardi and other systems to improve oversight of inspection due dates and follow-up timelines, ensuring timely completion of all inspections in accordance with HUD requirements. The PBCHA will assess current staffing levels and evaluate the feasibility of hiring internal inspectors or contracting with additional third-party inspection services to meet demand while being cognizant of current funding uncertainties. Additionally, training will be provided to staff to reinforce Housing Quality Standards (HQS) protocols and compliance expectations. Name(s) of the contact person(s) responsible for corrective action: Yvette Bembry Planned completion date for corrective action plan: August 30, 2026
2024-001 – Eligibility Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management conduct training for program staff on eligibility documentation requirements and program rules. Additionally, we recommend that the Housing Authority implement intern...
2024-001 – Eligibility Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management conduct training for program staff on eligibility documentation requirements and program rules. Additionally, we recommend that the Housing Authority implement internal audits of tenant files to proactively identify and correct documentation issues. A monitoring protocol should also be established to ensure ongoing compliance and to prevent the recurrence of documentation deficiencies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All current PBCHA staff responsible for eligibility determinations have received HCV rent calculation training through Nan McKay as of March 21, 2025. The PBCHA will continue to conduct training for program staff on eligibility documentation requirements and program rules to reinforce compliance standards. Through the implementation of intakes, interims and annual recertifications utilizing Yardi’s online workflows, the PBCHA expects to see increased improvement through automated application and documentation processes. The PBCHA will utilize available dashboards, internal audits and formal monitoring protocols to ensure continued compliance and to minimize the risk of recurring deficiencies. Name(s) of the contact person(s) responsible for corrective action: Yvette Bembry Planned completion date for corrective action plan: December 31, 2025
View Audit 359660 Questioned Costs: $1
Corrective Action Taken or Planned: The Organization will implement a review process to ensure that reports to LSC are filed timely. This review process will consist of the Executive Director and the Director of Finance independently reviewing the Oversight section of Grantease (LSC’s web-based p...
Corrective Action Taken or Planned: The Organization will implement a review process to ensure that reports to LSC are filed timely. This review process will consist of the Executive Director and the Director of Finance independently reviewing the Oversight section of Grantease (LSC’s web-based platform) monthly to ensure compliance. The Organization already has calendared all report deadlines for LSC and has a good track record of meeting those deadlines. The Organization believes the missed deadline identified in the audit was due to changes in job responsibilities following organizational restructuring and will not occur again. Name of Contact Person: Steve Dickinson, Executive Director Phone Number of Contact Person: (804) 200-6049 Projected Completion Date: April 30, 2025
Corrective Action Taken or Planned: The Organization will immediately implement a more formal review process for review of citizenship attestations and asset levels to ensure compliance before cases are reported to LSC. This review process will consist of two checks. The first will be done monthl...
Corrective Action Taken or Planned: The Organization will immediately implement a more formal review process for review of citizenship attestations and asset levels to ensure compliance before cases are reported to LSC. This review process will consist of two checks. The first will be done monthly through reports run in the case management system designed to identify cases where LSC or the Organization’s policies were not met. The second will be a review by the Managing Director of each of the Organization’s practice area groups where the case was closed to ensure compliance with LSC and the Organization’s requirements. In addition, training of new employees as part of their onboarding, and an annual training course for all of the Organization’s staff, will be held on LSC and the Organization’s case acceptance and reporting requirements and the use of tools, such as case management reports and checklists, to ensure compliance. Name of Contact Person: Steve Dickinson, Executive Director Phone Number of Contact Person: (804) 200-6049 Projected Completion Date: April 30, 2025
Corrective Action Taken or Planned: The Organization will immediately implement a more formal review process for review of citizenship attestations and asset levels to ensure compliance before cases are reported to LSC. This review process will consist of two checks. The first will be done monthl...
Corrective Action Taken or Planned: The Organization will immediately implement a more formal review process for review of citizenship attestations and asset levels to ensure compliance before cases are reported to LSC. This review process will consist of two checks. The first will be done monthly through reports run in the case management system designed to identify cases where LSC or the Organization’s policies were not met. The second will be a review by the Managing Director of each of the Organization’s practice area groups where the case was closed to ensure compliance with LSC and the Organization’s requirements. In addition, training of new employees as part of their onboarding, and an annual training course for all of the Organization’s staff, will be held on LSC and the Organization’s case acceptance and reporting requirements and the use of tools, such as case management reports and checklists, to ensure compliance. Name of Contact Person: Steve Dickinson, Executive Director Phone Number of Contact Person: (804) 200-6049 Projected Completion Date: April 30, 2025
Finding 2024-001 – Significant Deficiency in Internal Controls over Reports Submitted to Grantors – Child Care and Development Block Grant – 93.575 Recommendation: YMCA management should strengthen its controls related to the review and approval of information on grant reporting ensuring proper evid...
Finding 2024-001 – Significant Deficiency in Internal Controls over Reports Submitted to Grantors – Child Care and Development Block Grant – 93.575 Recommendation: YMCA management should strengthen its controls related to the review and approval of information on grant reporting ensuring proper evidence is maintained of the control over compliance with financial reporting requirements. Corrective Action: Management will ensure reviews of documents submitted to grantors will be reviewed and documented such that evidence of such reviews will be retained. Person Responsible for Corrective Action: Chief Financial Officer Anticipated Completion Date for Corrective Action: The Corrective Action was implemented effective June 22, 2024. If there are questions regarding this corrective action plan, please call Marcy Towns, Chief Financial Officer, at (615) 259-9622.
Finding 565974 (2024-001)
Significant Deficiency 2024
Finding 2024-001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not revie...
Finding 2024-001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: Taylor County implemented a control process for the last quarter of fiscal year 2024 to have the County Auditor prepare the performance reports, with a mechanical review of the report performed by an individual within the Auditor’s Office. Anticipated Completion Date: Completed
View of responsible officials and corrective action plan: All documents are done in a timely manner with the Board of Directors approval, since dismissing the two past employees. The Board of Directors, MRI, and HUD are fully aware of the situation. The budget questionnaire was turned in in a timel...
View of responsible officials and corrective action plan: All documents are done in a timely manner with the Board of Directors approval, since dismissing the two past employees. The Board of Directors, MRI, and HUD are fully aware of the situation. The budget questionnaire was turned in in a timely manner as it should and all documents that are required are turned in in a timely manner.
To address the finding, ARC will strengthen internal controls related to federal reporting by taking the following actions: 1. Enhance Reporting Oversight: The Finance Manager and Grants and Compliance Officer will assume primary responsibility for monitoring and verifying all federal reporting dead...
To address the finding, ARC will strengthen internal controls related to federal reporting by taking the following actions: 1. Enhance Reporting Oversight: The Finance Manager and Grants and Compliance Officer will assume primary responsibility for monitoring and verifying all federal reporting deadlines and submission requirements. 2. Document Retention Procedure: Additional double checks of record retention will take place in monthly reporting meetings, ensuring that centralized record keeping is complete. 3. Compliance Calendar Audit: A quarterly internal audit of the compliance calendar and reporting checklist will be conducted to verify deadlines are met.
Finding 565818 (2024-002)
Significant Deficiency 2024
For required reporting offirm deadlines (such as those tied to portals or systems), we already have a practice of submitting a bit earlier when deadlines fall on weekends or holidays to avoid timing issues. However, for this specific grant, the reports are submitted via email to a consultant managin...
For required reporting offirm deadlines (such as those tied to portals or systems), we already have a practice of submitting a bit earlier when deadlines fall on weekends or holidays to avoid timing issues. However, for this specific grant, the reports are submitted via email to a consultant managing the ARPA funds on behalf of Riverside County. These deadlines are somewhat flexible, as the consultant collects data from all subrecipients and submits it to the County as a consolidated package. Effective immediately, the Grants Analyst will submit these earlier rather than later. The Finance Director will assess compliance with timely filing requirements to ensure the establishment of internal controls over financial reporting.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2405MN5MAP and 2405MN5ADM, 2024 Pass-Through Agency: Minnesota Department of Human Ser...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2405MN5MAP and 2405MN5ADM, 2024 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2405MN5MAP and 2405MN5ADM Compliance Requirement Affected: Allowable Costs/Allowable Activities Award Period: Year-Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the Agency implement control procedures to ensure Income Maintenance Random Moment Study (IMRMS) and Social Services Time Study (SSTS) listings are accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and implement changes as needed to ensure going forward that the IMRMS and SSTS listings are accurate. Name of the contact person responsible for corrective action plan: Chera Sevcik, Human Services Executive Director Planned completion date for corrective action plan: December 31, 2025
Finding 565797 (2024-002)
Significant Deficiency 2024
Corrective Action Plan: The Director of Finance, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork.
Corrective Action Plan: The Director of Finance, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork.
Finding 565796 (2024-001)
Material Weakness 2024
Corrective Action Plan: The Airport and Director of Finance will implement internal controls to properly record capital assets and lease receivables on a timely basis prior to audit fieldwork.
Corrective Action Plan: The Airport and Director of Finance will implement internal controls to properly record capital assets and lease receivables on a timely basis prior to audit fieldwork.
Management agrees with this finding and understands the importance of timely, complete and accurate reporting to comply with federal regulations and maintain accountability for federal funds. Management will follow the auditors’ recommendation and will cross train individuals to allow for backups a...
Management agrees with this finding and understands the importance of timely, complete and accurate reporting to comply with federal regulations and maintain accountability for federal funds. Management will follow the auditors’ recommendation and will cross train individuals to allow for backups and create an internal control related to reviewing reports for completion and accuracy.
U.S. Department of Health and Human Services Head Start Cluster – Assistance Listing No. 93.600 2024-003 Allowable Costs Recommendation: The Organization should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Addi...
U.S. Department of Health and Human Services Head Start Cluster – Assistance Listing No. 93.600 2024-003 Allowable Costs Recommendation: The Organization should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Additionally, management should ensure all costs charged to the program are allowable under the grant guidelines. Corrective Action Plan: United Way of Acadiana hired a new Finance Director in late 2024 who will develop and ensure internal controls for Federal grant programs. Internal controls have been addressed and implemented in 2025 to provide better operational efficiency.
U.S. Department of Health and Human Services Head Start Cluster – Assistance Listing No. 93.600 2024-001 Allowable Costs Recommendation: The Organization should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Addi...
U.S. Department of Health and Human Services Head Start Cluster – Assistance Listing No. 93.600 2024-001 Allowable Costs Recommendation: The Organization should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Additionally, management should ensure all costs charged to the program are allowable under the grant guidelines. Corrective Action Plan: United Way of Acadiana hired a new Finance Director in late 2024 who will develop and ensure internal controls for Federal grant programs. Internal controls have been addressed and implemented in 2025 to provide better operational efficiency.
View Audit 359451 Questioned Costs: $1
Plan: The District acknowledges the finding and will review the bank reconciliation process and procedures. Anticipated Date of Completion: The District will immediately implement yearly review of the fiscal closing process.
Plan: The District acknowledges the finding and will review the bank reconciliation process and procedures. Anticipated Date of Completion: The District will immediately implement yearly review of the fiscal closing process.
Plan: The District acknowledges the finding and will continue to review the fiscal closing process. Anticipated Date of Completion: The District will immediately implement yearly review of the fiscal closing process.
Plan: The District acknowledges the finding and will continue to review the fiscal closing process. Anticipated Date of Completion: The District will immediately implement yearly review of the fiscal closing process.
Finding 565696 (2024-009)
Significant Deficiency 2024
Auditor recommendation: The County should develop and implement policies and procedures to ensure that all reports are reviewed by someone other than the preparer. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for impleme...
Auditor recommendation: The County should develop and implement policies and procedures to ensure that all reports are reviewed by someone other than the preparer. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for implementation: Ryan Bansbach, Deputy CFO, Housing, 503.846.8811 Response: The Housing Authority of Washington County (HAWC) is addressing these findings by implementing systems and policies that require secondary review of reports and determinations prior to upward reporting, voucher issuance, or tenant move-in. HAWC implemented systems in 2025 where the staff preparing and submitting the HUD 52681-B form will send to the form to the Program Manager or Designee for review and approval stamp before the form is submitted to HUD in the VMS or eVMS system. A checklist has been created and a system updated on routing files after review for eligibility to have a secondary review and final approval prior to issuance of voucher by the program supervisor, program manager, or designee. Additional training and internal quality control checks will be implemented to ensure that metric is met. HAWC has also established checklists and procedures to ensure Rent Reasonableness is reviewed and approved prior to tenant move-in, using a third-party system to conduct the rent reasonableness determinations. This metric will also be added to the internal quality control procedures to monitor compliance.
Finding 565693 (2024-008)
Significant Deficiency 2024
Auditor recommendation: The County should develop and implement policies and procedures to ensure that all HQS inspections are reviewed and retained. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for implementation: Ryan ...
Auditor recommendation: The County should develop and implement policies and procedures to ensure that all HQS inspections are reviewed and retained. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for implementation: Ryan Bansach, Deputy CFO, Housing, 503.846.8811 Response: During the audit period, the Housing Authority of Washington County (HAWC) was actively expanding its inspection team, increasing from two to five inspectors. This significant growth, coupled with an increase in the number of units and the ongoing recovery from COVID-19-related operational challenges, contributed to this isolated instance. HAWC has implemented robust reporting mechanisms to monitor inspection schedules and proactively identify any units approaching or exceeding the 24-month inspection window. We are confident that these enhanced procedures and our expanded inspection team will ensure timely NSPIRE/HQS inspections for all HCV and PBV program units moving forward.
Finding 565690 (2024-007)
Significant Deficiency 2024
Auditor recommendation: The County should develop and implement policies and procedures to ensure that all reports are reviewed by someone other than the preparer. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for impleme...
Auditor recommendation: The County should develop and implement policies and procedures to ensure that all reports are reviewed by someone other than the preparer. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for implementation: Ryan Bansbach, Deputy CFO, Housing, 503.846.8811 Reponse: The Housing Authority of Washington County (HAWC) is addressing these findings by implementing systems and policies that require secondary review of reports and determinations prior to upward reporting, voucher issuance, or tenant move-in. HAWC implemented systems in 2025 where the staff preparing and submitting the HUD 52681-B form will send to the form to the Program Manager or Designee for review and approval stamp before the form is submitted to HUD in the VMS or eVMS system. A checklist has been created and a system updated on routing files after review for eligibility to have a secondary review and final approval prior to issuance of voucher by the program supervisor, program manager, or designee. Additional training and internal quality control checks will be implemented to ensure that metric is met. HAWC has also established checklists and procedures to ensure Rent Reasonableness is reviewed and approved prior to tenant move-in, using a third-party system to conduct the rent reasonableness determinations. This metric will also be added to the internal quality control procedures to monitor compliance.
Finding 565684 (2024-005)
Significant Deficiency 2024
Auditor recommendation: The County should develop and implement policies and procedures to ensure that all reports are reviewed by someone other than the preparer. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for impleme...
Auditor recommendation: The County should develop and implement policies and procedures to ensure that all reports are reviewed by someone other than the preparer. Management response: Agree Target date to complete implementation activities: July 2026 Name of specific point of contact for implementation: Ryan Bansbach, Deputy CFO, Housing, 503.846.8811 Response: The Housing Authority of Washington County (HAWC) is addressing these findings by implementing systems and policies that require secondary review of reports and determinations prior to upward reporting, voucher issuance, or tenant move‐in. HAWC implemented systems in 2025 where the staff preparing and submittng the HUD 52681‐B form will send to the form to the Program Manager or Designee for review and approval stamp before the form is submitted to HUD in the VMS or eVMS system. A checklist has been created and a system updated on routing files after review for eligibility to have a secondary review and final approval prior to issuance of voucher by the program supervisor, program manager or designee. Additional training and internal quality control checks will be implemented to ensure that metric is met. HAWC has also established checklists and procedures to ensure Rent Reasonableness is reviewed and approved prior to tenant move‐in, using a third‐party system to conduct the rent reasonableness determinations. This metric will also be added to the internal quality control procedures to monitor compliance.
Corrective Action Plan Actions Planned – The HRA will create monitoring controls to ensure its policies relating to tenant eligibility are being followed. Official Responsible – Sarah Abe, HRA Administrator Planned Completion Date – December 31, 2025 Disagreement With or Explanation of Finding – The...
Corrective Action Plan Actions Planned – The HRA will create monitoring controls to ensure its policies relating to tenant eligibility are being followed. Official Responsible – Sarah Abe, HRA Administrator Planned Completion Date – December 31, 2025 Disagreement With or Explanation of Finding – The HRA agrees with this finding. Plan to Monitor – Sarah Abe, HRA Administrator, will oversee the process to ensure a tenant checklists for eligibility are completed and a separate program specialist is assigned to review and sign off on the checklists.
Corrective Action Plan Actions Planned – The HRA will continue to strengthen its controls over compliance within the CDBG program, including having the HRA Administrator or HRA Assistant Administrator verify program checklists are completed with proper supporting documentation. Official Responsible ...
Corrective Action Plan Actions Planned – The HRA will continue to strengthen its controls over compliance within the CDBG program, including having the HRA Administrator or HRA Assistant Administrator verify program checklists are completed with proper supporting documentation. Official Responsible – Sarah Abe, HRA Administrator Planned Completion Date – December 31, 2025 Disagreement With or Explanation of Finding – The HRA agrees with this finding. Plan to Monitor – Sarah Abe, HRA Administrator, will oversee the process to ensure environmental reviews are completed with proper supporting documentation.
Corrective Action Plan Actions Planned – The HRA will have a separate individual with appropriate knowledge and experience review and approve the IDIS reports, including a review of reconciliations from these reports to support financial data. Additionally, the HRA staff will work with the Departmen...
Corrective Action Plan Actions Planned – The HRA will have a separate individual with appropriate knowledge and experience review and approve the IDIS reports, including a review of reconciliations from these reports to support financial data. Additionally, the HRA staff will work with the Department of Housing and Urban Development to resolve the system-generated errors in these reports. Official Responsible – Sarah Abe, HRA Administrator Planned Completion Date – December 31, 2025 Disagreement With or Explanation of Finding – The HRA agrees with this finding. Plan to Monitor – Sarah Abe, HRA Administrator, will oversee the process to ensure an individual is assigned to review the reports and that the Department of Housing and Urban Development is contacted to resolve errors in reports.
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