Corrective Action Plans

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Corrective Action: deferred Capital Fund Program (CFP) revenue balance of $15,076 resulted from IHA inadvertently drawing funds from the incorrect CFP grant to pay an eligible expense. When the error was discovered, IHA drew the funds from the correct CFP grant and applied an eligible expense to the...
Corrective Action: deferred Capital Fund Program (CFP) revenue balance of $15,076 resulted from IHA inadvertently drawing funds from the incorrect CFP grant to pay an eligible expense. When the error was discovered, IHA drew the funds from the correct CFP grant and applied an eligible expense to the CFP grant that had previously been drawn down, net zeroing the error. To ensure CFP funds are drawn only to cover valid expenses and no more than three (3) days in advance of disbursement, as required by the HUD Capital Fund Guidebook (2016) and 2 CFR 200.305(b), IHA has implemented the following internal control procedures over CFP cash management: 1. Draw Timing. CFP funds will be drawn in eLOCCS only after an invoice has been received, approved, and scheduled for payment, or after payment has been issued. No draw will be requested more than three (3) days before the related disbursement, and the amount drawn will not exceed the approved invoice amount. 2. Grant Verification Before Each Draw. Each eLOCCS draw will be supported by a CFP Draw Request worksheet identifying the vendor, invoice number, amount, CFP grant number, and Budget Line Item (BLI). Before submission, the grant number and BLI will be verified against the approved Annual Statement/Performance and Evaluation Report (form HUD-50075.1) and the invoice to confirm the expense is charged to the correct grant year. 3. Segregation of Duties. The staff member who prepares the draw request will not be the same individual who approves the draw in eLOCCS. The CEO will review and approve each draw request and its supporting documentation before the draw is submitted. 4. Monthly Reconciliation. Each month, eLOCCS draws will be reconciled by grant number to CFP deferred CFP revenue account will be reviewed monthly, and any CFP funds that remain undisbursed more than three (3) days after a draw will be investigated and resolved. 5. Year-End Review. Before fiscal year-end close, the CEO and fee accountant will review the deferred CFP revenue account to confirm that all CFP funds drawn have been expended on eligible costs for the correct grant. 26 6. Correction of Future Draw Errors. Going forward, if a draw from the incorrect grant or a draw in excess of an eligible expense is discovered, IHA will not offset the error between grants. IHA will return the funds to HUD and then draw the correct amount from the correct grant, following HU Repayments greater than $2,000 will be remitted by wire transfer to the U.S. Treasury (FRB New York) for the U.S. Department of HUD (Ft. Worth, TX), with the complete grant number (PPN) entered in the third-party memorandum field. Department of HUD and mailed to US Bank, HUD-FAD Collections Ft. Worth, with the required cover letter. On the day of the wire transfer, IHA will email the HUD Office of the Chief Financial Officer (FWAC-AccountsReceivableDocuments@hud.gov), the PIH Field Office, and the PIH Office of Capital Improvements (PIHOCI@hud.gov), copying the designated OCFO contacts, using Backup documentation will include a copy of the wire transfer or check and a cover letter that identifies the reason for repayment, the source year of the federal appropriation, and the grant number (PPN). Once HUD has credited the returned funds, IHA will draw the eligible expense from the correct CFP grant, and the repayment and redraw documentation will be retained in the grant file. 7. Written Procedures and Training. cash management procedures, and all staff involved in CFP draws will be trained on them. Compliance will be monitored through the monthly reconciliation described above. Responsible Person: Tina Bartlett, CEO Implementation Date: Effective immediately If you have any further questions, please let me know. Contact Person: Tina Bartlett, CEO 4215 S. Hocker Dr., Bldg. 5 Independence, MO 64055 816-994-0204 4215
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have an adequate internal control policy for subrecipient monitoring to ensure the procedures necess...
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have an adequate internal control policy for subrecipient monitoring to ensure the procedures necessary to comply with Uniform Guidance requirements are followed. Corrective Action Plan: We have implemented a formal subrecipient monitoring policy that complies with Uniform Guidance that includes procedures for conducting risk assessments, performing monitoring activities, obtaining and reviewing required subrecipient reports, maintaining subaward documentation, and following up on identified compliance issues. Responsible Individuals: David Whipps, CFO, and Kurt Waldbillig, CEO Anticipated Completion Date: 12/31/2026
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have adequate internal controls to ensure that the FFATA reporting requirements were completed in ac...
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have adequate internal controls to ensure that the FFATA reporting requirements were completed in accordance with the grant agreement, and within the timeframe required. Corrective Action Plan: We will implement internal controls over FFATA reporting to ensure that all reportable first-tier subawards are appropriately identified, evaluated for reporting requirements, and submitted in SAM.gov accurately and within the required reporting timeframe. Responsible Individuals: David Whipps, CFO, and Kurt Waldbillig, CEO Anticipated Completion Date: 12/31/2026
Management concurs with the finding and acknowledges that additional controls are necessary to ensure full compliance with Federal procurement requirements. During fiscal year 2026, the Organization revised procurement procedures and conducted training sessions for finance personnel and departmental...
Management concurs with the finding and acknowledges that additional controls are necessary to ensure full compliance with Federal procurement requirements. During fiscal year 2026, the Organization revised procurement procedures and conducted training sessions for finance personnel and departmental stakeholders responsible for purchasing activities. Management plans to continue quarterly compliance reviews of procurement transactions and enhance monitoring procedures related to bid documentation and suspension and debarment verification. Oversight responsibility has been assigned to the Vice President of Finance and Director of Finance.
Unearned Funds – Public Housing Capital Fund: HACM Management will process checks to be paid from Capital Fund on the same day that funds are drawn down in LOCCS but dated as of the date funds are expected to be deposited. Receipt of Capital Funds will be confirmed via online banking and then checks...
Unearned Funds – Public Housing Capital Fund: HACM Management will process checks to be paid from Capital Fund on the same day that funds are drawn down in LOCCS but dated as of the date funds are expected to be deposited. Receipt of Capital Funds will be confirmed via online banking and then checks sent out. Re: Federal Awards Findings: Unearned Funds - Sec􀆟on 8 Housing Choice Vouchers HACM Management will work closely with so􀅌ware vendor to ensure HAP amounts agree to the HAP contracts.
2026-002 Suspension and Debarment Corrective action planned: CSV verifies each vendor’s exclusion status in SAM.gov before entering into any contract, purchase order, or agreement of $25,000 or more paid with federal funds. Each verification is documented, and active vendors are re-verified annually...
2026-002 Suspension and Debarment Corrective action planned: CSV verifies each vendor’s exclusion status in SAM.gov before entering into any contract, purchase order, or agreement of $25,000 or more paid with federal funds. Each verification is documented, and active vendors are re-verified annually. Initial verification records for new vendors are retained in the Vendor Record within CSV’s general ledger system. Annual vendor verification records are documented and maintained in CSV’s electronic files. These procedures apply to all federal awards received by the organization Anticipated completion date: Completed in June 2026 Contact person responsible for corrective action: Harjeet Sidhu, Chief Financial Officer
YWCA will develop a written procurement policy that conforms with the Uniform Guidance. In addition, we will implement procedures and control processes to retain documentation supporting compliance with major federal compliance requirements regarding suspension and debarment.
YWCA will develop a written procurement policy that conforms with the Uniform Guidance. In addition, we will implement procedures and control processes to retain documentation supporting compliance with major federal compliance requirements regarding suspension and debarment.
Finding #2026-002 – Allowable Costs – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Agriculture, Assistance Listing #10.932, Regional Conservation Partnership Program, Contract period: 06/12/24 – 12/31/26 Contract number: Supplemental-2983-A-1608, Co...
Finding #2026-002 – Allowable Costs – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Agriculture, Assistance Listing #10.932, Regional Conservation Partnership Program, Contract period: 06/12/24 – 12/31/26 Contract number: Supplemental-2983-A-1608, Contract period: 10/31/23 – 07/31/27 Contract number: Supplemental-2757-A-1212, Contract period: 08/29/23 – 03/31/26 Contract number: 917442230013, Passed through Sul Ross State University: Contract period: 04/01/25 – 03/31/26 Contract number: N/A. Condition and context: Of the $1,838,681 expended during the year ended March 31, 2026, approximately $1,729,640 related solely to the purchase of a conservation easement. The remaining expenditures of $109,041 consisted of payroll and related charges. In a sample of three payroll transactions tested, we noted in each case that reimbursement requests were based on hourly rates that exceeded the actual rates of pay of the employees performing the work, resulting in an overstatement of payroll charged to the grantors of $14,668. Recommendation: Develop policies and procedures to ensure that all costs charged to federal awards are based on actual costs incurred in accordance with federal award requirements. Planned corrective action: Management will establish procedures to ensure personnel costs charged to federal awards are based on actual allowable employee compensation and supported by appropriate time records. Federal reimbursement requests will be reviewed by the Director of Operations and the Director of Finance prior to submission to ensure that billed costs comply with federal award requirements. Management will also review the questioned costs identified in the audit and coordinate with the applicable grantor regarding any required repayment or adjustment. Responsible officer: Dina McIlhenny, Director of Finance and Brenna Gaik, Director of Operations. Estimated completion date: October 31, 2026.
Oversight Agency for Audit, Senior Citizens Housing Development Fund Corporation of Steuben County Two respectfully submits the following corrective action plan for the year ended March 31, 2026. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Driv...
Oversight Agency for Audit, Senior Citizens Housing Development Fund Corporation of Steuben County Two respectfully submits the following corrective action plan for the year ended March 31, 2026. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201 Coral Springs, Florida 33067 Audit period: April 1, 2025, through March 31, 2026 The findings from the March 31, 2026 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2026-001 Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should return the excess withdrawal of $14,757 to the replacement reserve account. Action Taken: Staff training has been provided to ensure proper procedures are followed. Staff will monitor quote vs invoice withdrawals to ensure there are no duplications.
Federal Awards Findings: Finding 2026.001 - Procurement, Suspension and Debarment – Material Weakness Recommendation The Organization should develop a written procedure to review all employees in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be...
Federal Awards Findings: Finding 2026.001 - Procurement, Suspension and Debarment – Material Weakness Recommendation The Organization should develop a written procedure to review all employees in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Repeat Finding No Action Taken United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health acknowledges the audit finding regarding the lack of documented suspension and debarment reviews for clinical providers, as required under Uniform Guidance. Gensis Family Health has developed and implemented a formal written procedure requiring verification of providers against applicable federal exclusion databases, including the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) and other applicable federal suspension and debarment resources, prior to hire and on an ongoing basis. Genesis Family Health already conducts exclusion and debarment screenings for all newly hired employees and contracted providers prior to the commencement of services. Effective immediately, GFH will: 1. Perform and document an annual review of all licensed providers each January to verify that no individual is suspended, debarred, or otherwise excluded from participation in federal healthcare programs. 2. Maintain documentation of all screening results within personnel and credentialing files. 3. Assign responsibility for annual screening and documentation to the Credentialing and Compliance functions, with oversight by executive management. 4. Include annual monitoring of compliance with this policy within the organization's internal compliance review process. Corrective Action Taken Subsequent to identification of this finding, Genesis Family Health completed OIG exclusion inquiries for all applicable clinical providers in September 2026 and retained supporting documentation demonstrating completion of the reviews. No providers were identified as excluded, suspended, or debarred from participation in federal healthcare programs. Responsible Official Amanda Vaughan, Chief Financial Officer and Tracy Lillibridge, Revenue Cycle Director in coordination with the Credentialing and Compliance staff. Anticipated Completion Date Implemented September 2026; ongoing annual reviews will be conducted each January thereafter. Management Explanation Management notes that this finding resulted from a transition in credentialing personnel and responsibilities during the audit period. While provider credentialing activities continued, documentation evidencing the required exclusion and debarment screening process was not consistently maintained. Following identification of the issue, all required OIG exclusion inquiries for affected clinical providers were completed in September 2026, and formal procedures have been established to ensure annual review and documentation each January going forward. If there are any question regarding this plan, please e-mail Amanda Vaughan at amanda.vaughan@Genesisfh.org.
Management agrees with the finding and has provided staff training to ensure compliance with HUD guidelines.
Management agrees with the finding and has provided staff training to ensure compliance with HUD guidelines.
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village's engineer has searched the state procurement office webpage to check if any vendor for a federal project i...
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village's engineer has searched the state procurement office webpage to check if any vendor for a federal project is on the debarment list, which they are not. In the future, the Village will have controls in place to ensure that vendors are not debarred or suspended from federal funding awards. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2027 fiscal year. The plan for adherence is the Council will review and implement controls to ensure that vendors are not suspended, debarred, or otherwise excluded.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2026 fiscal year. The plan for adherence is that the Board will review all proposed policies and adopt them, the Board will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
2026-004 Procurement Corrective action planned: OMC will follow its current procurement policy and will seek bids for contracts with autorenewals, utilities, and professional services. However, OMC will also review its current procurement policy to see if changes are necessary to reflect the current...
2026-004 Procurement Corrective action planned: OMC will follow its current procurement policy and will seek bids for contracts with autorenewals, utilities, and professional services. However, OMC will also review its current procurement policy to see if changes are necessary to reflect the current environment to exclude items such as certain utilities and services from the bid process if such utilities and services are unique and limited to the service area of the health center and if only one option exists or the current vendor is performing sufficiently so that undue burden would be placed on the Organization to switch vendors, then a sole source justification will be documented, in both paper format and electronically so that records are readily available for review. Anticipated completion date: 08/31/2026 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification for suspension and debarment prior to entering into a transaction/contract. With annual review of suspension and debarment throughout the program lifecycle. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Significant Deficiency - Suspended or Debarred Covered Transactions Corrective Action Plan: The Village administration team will collaborate with the engineering team and funding source to establish required written and documented procedures to ensure that contractors and sub-contractors working on ...
Significant Deficiency - Suspended or Debarred Covered Transactions Corrective Action Plan: The Village administration team will collaborate with the engineering team and funding source to establish required written and documented procedures to ensure that contractors and sub-contractors working on projects within the Village are not suspended or debarred. Responsible Party: Thomas J. Ostrander, Village Manager Proposed Completion Date: February 28, 2027
Management is in the process of drafting an updated procurement policy to comply with the new requirements of the Uniform Guidance.
Management is in the process of drafting an updated procurement policy to comply with the new requirements of the Uniform Guidance.
2026-001 Suspension and Debarment Corrective action planned: To ensure full compliance with federal documentation standards moving forward: 1. Formalized Onboarding Control: In May 2026, the Organization updated its standard New Vendor Form to include a mandatory verification checkbox and documented...
2026-001 Suspension and Debarment Corrective action planned: To ensure full compliance with federal documentation standards moving forward: 1. Formalized Onboarding Control: In May 2026, the Organization updated its standard New Vendor Form to include a mandatory verification checkbox and documented sign-off confirming SAM.gov exclusion checks are completed prior to vendor setup or contract execution. 2. Existing Vendor Audit: Management is currently conducting a comprehensive review to document and retain SAM.gov exclusion verifications for all active vendors. Anticipated completion date: May 2026 Contact person responsible for corrective action: Scott Matlock
Audit Finding 2026-001: During our testing of tenant security deposits, it was discovered that the balance in the bank account maintained for tenant security deposits was insufficient to cover the liability for tenant security deposits payable. -Response: There was a temporary depletion of funds in ...
Audit Finding 2026-001: During our testing of tenant security deposits, it was discovered that the balance in the bank account maintained for tenant security deposits was insufficient to cover the liability for tenant security deposits payable. -Response: There was a temporary depletion of funds in the operating account, since they paid the amount of their insurance deductible to a vendor for urgent water damage remediation after an apartment fire on the property. This resulted in the operating account not having sufficient funds to cover the next payroll. Hence a temporary transfer of funds was made from the tenant security deposits account. Management is aware that the Regulatory Agreement stipulates maintaining sufficient funds in a separate tenant security deposit account to cover the liability for tenant security deposits payable and have since replenished the balance in the tenant security deposit account. The $1,900 was deposited back into the Security Deposit account on 08/17/2026. - Responsible Party: Linda G. Holder - Executive Director - Houston Housing Management Corporation - 1418 Preston St. - Houston, TX 77002
2026-001 Public Housing Capital Fund Recommendation: The Commission should implement policies and procedures to ensure all federal compliances are followed pertaining to Procurement, Suspension and Debarment. Action Taken: Management will implement policies and procedures to ensure the Commission is...
2026-001 Public Housing Capital Fund Recommendation: The Commission should implement policies and procedures to ensure all federal compliances are followed pertaining to Procurement, Suspension and Debarment. Action Taken: Management will implement policies and procedures to ensure the Commission is in compliance with all grant requirements pertaining to the Public Housing Capital Grant. Anticipated Completion Date of Action: October 31, 2026
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer has searched the state procurement office webpage to check if any vendor for a federal project i...
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer has searched the state procurement office webpage to check if any vendor for a federal project is on the debarment list, which they are not. In the future, the Village will have controls in place to ensure that vendors are not debarred or suspended from federal funding awards. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2027 fiscal year. The plan for adherence is the Council will review implement controls to ensure that vendors are not suspended, debarred, or otherwise excluded.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2027 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 & Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization update its procurement policy to be in lin...
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 & Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization update its procurement policy to be in line with the federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will update the Procurement and Purchasing Policy and Procedure to include a Small and Micro-Purchase Threshold and the BABA requirements. The Organization will have this policy and procedure update completed by July 13, 2026.
Statement of Condition 2026-001 (Assistance Listing 14.155): The Corporation did not make all of the HUD required reserve for replacement deposits for the year ended January 31, 2026. Recommendation: Management should notify the lender of the new reserve for replacement deposit amount and make an ad...
Statement of Condition 2026-001 (Assistance Listing 14.155): The Corporation did not make all of the HUD required reserve for replacement deposits for the year ended January 31, 2026. Recommendation: Management should notify the lender of the new reserve for replacement deposit amount and make an additional $565 deposit to the reserve for replacements fund on the next billing. Management Response: Agree. Management has notified the lender of the new required deposit and will make an additional $565 deposit to the reserve for replacements fund on the next billing.
The City of Atlanta’s Department of Grants and Community Development (DGCD) will establish and implement internal controls to ensure all relevant first-tier subawards are reported timely and accurately in accordance with FFATA requirements. Effective immediately, FFATA applicability will be evaluate...
The City of Atlanta’s Department of Grants and Community Development (DGCD) will establish and implement internal controls to ensure all relevant first-tier subawards are reported timely and accurately in accordance with FFATA requirements. Effective immediately, FFATA applicability will be evaluated during DGCD’s subrecipient contracting process. After the final action legislation but prior to contract execution, DGCD Program and Fiscal Operations staff will review all subawards to determine if FFATA reporting thresholds are applicable and document applicability in subaward files. DGCD staff will complete required FFATA submissions through SAM.gov by the end of the month following the month in which the subaward contract is executed. Additionally, DGCD Program and Fiscal Operations managers will conduct quarterly reviews of all active subrecipient agreements to verify compliance with FFATA requirements. Supporting documentation will be properly maintained in subrecipient files. DGCD will document reporting status, due dates, and completion dates in a standardized FFATA tracking log and checklist. DGCD’s Compliance Division will perform periodic oversight reviews to verify adherence to FFATA requirements and ensure corrective action is taken promptly if reporting deficiencies are identified. Additionally, the Controller’s Office will establish a periodic review process to ensure all City Departments are adhering to FFATA requirements.
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