Corrective Action Plans

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Contact Person: Steven Dolak, Business Administrator. Recommendation: The District should revise procedures to ensure the data entered into the claim for reimbursement is reviewed for accuracy prior to the report being submitted. Evidence of the approval of submission should be documented in writi...
Contact Person: Steven Dolak, Business Administrator. Recommendation: The District should revise procedures to ensure the data entered into the claim for reimbursement is reviewed for accuracy prior to the report being submitted. Evidence of the approval of submission should be documented in writing, such as with an initial, to demonstrate the review of the information has been performed. Action: The Business Administrator will prepare the reports for submission. Prior to submitting the report through the reimbursement system, a second individual will review the information entered. Upon satisfactory completion of the review, the second individual will acknowledge review by initialing and dating the document(s). Date of Completion: This procedure will be implemented at the beginnign of the 2025-26 school year.
Program: Summer Food Service Program CFDA: 10.559 Finding Type: Noncompliance / Significant Deficiency Issue: Two closed enrolled sites lacked documentation to support eligibility based on child enrollment. Management's Response: Response: Management recognizes the critical role of eligibility docum...
Program: Summer Food Service Program CFDA: 10.559 Finding Type: Noncompliance / Significant Deficiency Issue: Two closed enrolled sites lacked documentation to support eligibility based on child enrollment. Management's Response: Response: Management recognizes the critical role of eligibility documentation in maintaining compliance with SFSP regulations and ensuring program integrity. Corrective Action Taken: • The YMCA has implemented a formal monitoring protocol for all SFSP operating sites, including a pre-operational review checklist to verify eligibility documentation. • Site agreements now explicitly require submission of enrollment records and eligibility documentation prior to participation. Ongoing site monitoring includes periodic reviews to ensure continued compliance with eligibility requirements. Staff have been trained on 7 CER 225.6(c) and 2 CFR 200.303 to reinforce sponsor responsibilities. Responsible Individuals: Jeff Reynolds and Rachel Dumas Completion Date: Plan has been implemented as of the date of audit submission.
Finding Number: 2024-001 Compliance Requirement: Reporting Programs: United States Department of the Treasury • ALN Number: 21.027 • ALN Name: Coronavirus State and Local Fiscal Recovery Funds • Contract Periods: June 16, 2023 – December 31, 2025 (City of New Orleans, Louisiana); April 1, 2022 - Dec...
Finding Number: 2024-001 Compliance Requirement: Reporting Programs: United States Department of the Treasury • ALN Number: 21.027 • ALN Name: Coronavirus State and Local Fiscal Recovery Funds • Contract Periods: June 16, 2023 – December 31, 2025 (City of New Orleans, Louisiana); April 1, 2022 - December 31, 2026 (City of Toledo, Ohio); August 1, 2024 - September 30, 2026 (County of Orange, Florida) Management’s Corrective Action Plan: The Organization recognizes the importance of timely reporting to its government partners, and has developed a plan to improve the timeliness of progress reporting, which includes: • Establishing a Government Initiatives department to oversee all government projects, as well as enhance operational efficiency and planning to meet the increased reporting demands from the growing number of grants. • Further expanding internal capacity by hiring additional team members - Vice President of Government Affairs (January 2025), Grant Accountant (June 2025), and Grant Initiatives Program Manager (September 2025), as well as other departments that are integral for programmatic delivery - most importantly, debt acquisition and analysis (Associate Vice President of Analytics) to accelerate and optimize the preparation of data for reporting. • Standardizing the various reporting pertaining to government funders. • Preparing, monitoring, and updating the reporting schedule for government funders. • Utilizing new software to facilitate and track fiscal and progress reporting. • Extending standardized timeframe for progress reporting from 45 days to 60 days on government contracts where available. Person(s) Responsible: Chief Operating Officer (performance reporting) and Vice President, Finance & Administration (fiscal reporting) Expected Completion Date: September 30, 2025
Finding 574145 (2024-002)
Significant Deficiency 2024
Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in ...
Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in paper files in the finance department for easy access during the course of the audit. Person(s) Responsible: Mary Bell, Finance Manager Anticipated Completion Date: September 1, 2025
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
Finding 574140 (2024-002)
Significant Deficiency 2024
The Town acknowledges the finding related to the delayed submission of the 4th Quarter 2024 ARPA report and concurs with the auditor’s recommendation. While the Town ultimately recognizes its responsibility to meet the filing deadlines for all federal reporting, the Town has instituted efforts to mi...
The Town acknowledges the finding related to the delayed submission of the 4th Quarter 2024 ARPA report and concurs with the auditor’s recommendation. While the Town ultimately recognizes its responsibility to meet the filing deadlines for all federal reporting, the Town has instituted efforts to mitigate the reporting lapse since the oversight. To prevent recurrence, the Town has implemented the following corrective actions: 1. Formal Reporting Calendar: A centralized ARPA reporting calendar has been created. This calendar will include internal deadlines at least 14 days in advance of federally mandated submission dates. 2. Assigned Reporting Officer: A designated ARPA Reporting Officer has been appointed, responsible for coordinating all necessary documentation and submissions related to ARPA funding. 3. Pre-Submission Review Process: A new protocol has been established requiring internal review and sign-off from both the Comptroller and the Town Supervisor’s designee no less than one week prior to each deadline. 4. Ongoing Training and Coordination: The Town will continue to work closely with its auditors and legal counsel to remain current on federal guidance, ensure continued compliance with Uniform Guidance standards, and maintain internal staff awareness of applicable obligations under ARPA. We believe these measures will ensure timely and accurate reporting for all future quarters and strengthen our internal compliance infrastructure.
Finding 574139 (2024-001)
Significant Deficiency 2024
The grant administrator shall include notifications within their Outlook calendar two weeks prior to the due date for each progress report deadline. This will ensure progress reportes are completed and submitted on time.
The grant administrator shall include notifications within their Outlook calendar two weeks prior to the due date for each progress report deadline. This will ensure progress reportes are completed and submitted on time.
Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025
Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025
Action taken in response to finding: •LMC will increase the frequency and sample size of its review of patient encounters. •LMC will be providing additional training for front desk staff regarding the collection and verification of patient information. Name(s) of the contact person(s) responsible fo...
Action taken in response to finding: •LMC will increase the frequency and sample size of its review of patient encounters. •LMC will be providing additional training for front desk staff regarding the collection and verification of patient information. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 08/15/2025
The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff ...
The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff primarily responsible for this function have left their positions in the last two years and have been replaced by staff new to the position. The Authority did increase quality control reviews due to the transition period. The finding does not identify a systemic issue rather it found various instances of noncompliance. Prior to the Audit the Authority scheduled a three-day onsite rent calculation training for all staff with Nan McKay inc that occurred the week of May 20, 2025. Finding 2024-001- Moving To Work Demonstration Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Authority will continue and enhance its training regimen for staff responsible for rent determination. Furthermore, the Authority has engaged the services of Edgemere Consulting. As part of this engagement Edgemere will conduct an independent quality control review of public housing and rental assistance files. From the information gathered from the file review Edgemere Consulting will develop specific training initiatives for the staff including enhanced quality control measures. Person Responsible: Bruna Campbell, Compliance officer Anticipated Completion Date: December 31, 2025 - Ongoing
View Audit 364699 Questioned Costs: $1
We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took so...
We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took some time before we got the access to all the projects on PMS. We are already tracking both financial and narrative reports from the signing stage of projects, and most of the reports are prepared on time. Going forward, we will further strengthen our backup plans for submission of reports, both online and through email. We will develop a backup plan and strengthen delegation plans for each region during the times when the primary contact is not available
See Corrective Action Plan table/chart.
See Corrective Action Plan table/chart.
View Audit 364669 Questioned Costs: $1
Finding 2024-003 See response to finding 2024-001.
Finding 2024-003 See response to finding 2024-001.
Finding 574080 (2024-002)
Significant Deficiency 2024
Finding Number: 2024-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Michelle Trulock, Financial Assistance Supervisor Corrective Action Planned: Cases where there was an income discrepancy have been reviewed and upd...
Finding Number: 2024-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Michelle Trulock, Financial Assistance Supervisor Corrective Action Planned: Cases where there was an income discrepancy have been reviewed and updated. Peacetime instructions used during COVID are no longer in place. MAXIS cases have reverted to pre-pandemic processing and will be reviewed and updated. Specific income calculations were reviewed with staff. Supervisor will promote annotation on documents for clarification, as well as clear and concise case noting. Desk reviews are completed periodically for review of income, assets and citizenship and all transfer in cases are reviewed for the like. Supervisor will request that each worker review citizenship (STAT/ MEMB/MEMI and imaging) at healthcare renewal month to ensure accuracy. Policy and procedure review for staff on reviewing forms for asset information. This also relates to the self-attestation of cash on the review forms. Anticipated Completion Date: On 06/03/2025, Supervisor met with staff to discuss the results of the audit and train and review policy and procedure on best practices for processing and maintenance of healthcare cases. This will be an ongoing agenda item at monthly unit meetings.
• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review firs...
• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review first three months of FY26 by 12/31/25
Finding 574051 (2024-001)
Significant Deficiency 2024
The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Direct...
The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Director and approved by the Finance Director prior to submission to the auditing firm. In addition to federal grants adopted as part of the City's annual operating budget, after adoption of the annual operating budget any federal grant approved by City Council for acceptance and expenditure will be maintained in the City's electronic archival system. The SEFA will be compard to the list of budgeted grants and the grants accepted after adoption of the annual operating budget to ensure grants are appropriately reported on SEFA.
2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rent...
2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rented to eligible low-income households. Complete and accurate income documentation is essential to demonstrate compliance with program eligibility requirements and long-term affordability commitments. Condition: During our review of 34 tenant files for HOME-funded rental units, we noted the following: • 6 files did not contain any income verification documentation • 1 file include income documentation, but it was incomplete and missing required supporting documentation Cause: These issues primarily occurred during a transition in property management. The change in personnel and processes led to a lapse in documentation and inconsistent application of income verification procedures. Effect: Without proper income verification, there is a risk that units may be rented to households that do not meet eligibility requirements. Additionally, the absence of documentation may hinder the Organization’s ability to demonstrate compliance during monitoring or audit reviews. Questioned Costs: Not applicable. Auditor’s Recommendation: We recommend that management strengthen internal controls over the income verification process by: • Implementing a standardized checklist for required documentation • Providing staff training on income verification procedures • Conducting supervisory reviews of all files prior to tenant approval, especially during periods of staff transition Auditee’s Response: Management agrees with the finding and has taken steps to address the issue. Four of the seven identified files have been updated with complete income documentation for 2025, and the remaining three are in process. Contact Person: Brad Hinkfuss Anticipated Completion: 9.30.2025
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management shoul...
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should immediately reimburse the amount due to the property and establish procedures to ensure payments of this nature are not made in the future. Action Taken: REACH has policies in place to ensure that costs are allocated to the appropriate property. In 2024, costs from an adjacent property, Community Housing I, were accidentally paid by Community Housing II. These funds were repaid to the Community Housing II in 2025. Completion Date: June 30, 2025
View Audit 364592 Questioned Costs: $1
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management shoul...
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that move out inspections are performed timely, security deposits are returned timely and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Program. Action Taken: REACH has policies in place to ensure security deposits are returned in a timely manner. Staffing shortages at the property had an impact on the timely return of security deposits. As new staff are brought onboard training is provided and management will continue to coordinate and provide assistance to on-site staff to ensure that the security deposits are being returned or an itemized list of charges is provided and properties are in compliance. Completion Date: June 30, 2025.
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management shoul...
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that EIVs are performed timely, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2024. As new staff are brought onboard training is provided and annual HUD training is completed by all staff. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance. Completion Date: June 30, 2025.
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Home Investment Partnership Program Federal Assistance Listing: Number 14.239 Recommendation: Management should establish procedures and monitor c...
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Home Investment Partnership Program Federal Assistance Listing: Number 14.239 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to ensure that HQS inspections are done in a timely manner. Staffing shortages at the property had an impact on the completion of HQS inspections in 2024. As new staff are brought onboard training is provided and management will continue to coordinate and provide assistance to on-site staff to ensure that the inspections are being completed and properties are in compliance.
Federal Award Findings and Questioned Costs Item 2024-005 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish pro...
Federal Award Findings and Questioned Costs Item 2024-005 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Action Taken: REACH has policies in place to ensure that move out inspections are done in a timely manner. Staffing shortages at the property had an impact on the timeliness of the move out. As new staff are brought onboard training is provided and training is provided to on-site staff to ensure that the inspections are being completed and properties are in compliance. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance.
Federal Award Findings and Questioned Costs Item 2024-004 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish pro...
Federal Award Findings and Questioned Costs Item 2024-004 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures to ensure the correct amount is being transferred into the replacement reserve account monthly. Action Taken: During 2024 when a rental increase was approved it came to management’s attention that the correct amount was not being deposited into the replacement reserve. Management had not received any previous notification from HUD that the deposits were insufficient and began payment of the agreed upon amount in September, 2024. The entity does not have the funds to adjust for payments prior to September, 2024.
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should change its po...
Federal Award Findings and Questioned Costs Item 2024-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should change its policies and procedures related to refunding of tenant security deposits to comply with the thirty-day timeline required by HUD regulations. Action Taken: REACH has policies in place to ensure that the return of tenant security deposits are done in a timely manner. Staffing shortages at the property had an impact on the timeliness of the return of security deposits. As new staff are brought onboard training is provided and training is provided to on-site staff to ensure that the return of security deposits are being completed and properties are in compliance. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance.
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish pro...
Federal Award Findings and Questioned Costs Item 2024-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2024. As new staff are brought onboard training is provided and annual HUD training is completed by all staff. Management will continue to coordinate and provide assistance to on-site staff to ensure that the properties are in compliance.
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