Corrective Action Plans

Finding 1179663 (2023-003)

Material Weakness 2023

MN

Questioned Costs Reporting Significant Deficiency § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Assistance Listing Number: 93.498 Finding Summary: The Organization’s special reports submitted to the Department of Health and Human Services (H...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Assistance Listing Number: 93.498 Finding Summary: The Organization’s special reports submitted to the Department of Health and Human Services (HHS) for Period 5 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Stephanie Schmidt Corrective Action Plan: Before future reports are submitted to the federal agency, documented approval of this submission will be acquired. Anticipated Completion Date: January 2025

View Audit 392080

Finding 1179344 (2023-003)

Material Weakness 2023

East Alabama Regional Planning and Development Commission

FL

Questioned Costs Allowable Costs / Cost Principles Reporting

We plan to start the next fiscal year's audit right after issuance of September 30, 2023 financial statements to catch up on the filing of the reporting package.

View Audit 391711

Finding 1176970 (2023-004)

Material Weakness 2023

Papa Ola Lokahi

HI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.512 § 200.514

Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2022-004) and current year renumbered recommendation (2023-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a del...

Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2022-004) and current year renumbered recommendation (2023-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a delay in securing a new independent auditor (April 2023) and related Organization and new auditor scheduling and staffing challenges, persists. The Organization notes the status and progress of the following single audits: • June 30, 2022, filed in the Federal Audit Clearinghouse in February 2025; • June 30, 2023, field work began March 2025, report draft issued February 2026 and scheduled for Board action; • June 30, 2024, field work began January 2026 and in progress; and • June 30, 2025, pending receipt of auditor engagement letter. The Organization notes the corrective actions that have been implemented, regarding internal controls to ensure compliance with the Uniform Guidance with respect to the submission deadline of single audit reports and the Data Collection Form: A. Internal Controls in Practice Since Inception of New Auditor Engagement – April 2023 As noted in the prior year corrective action response, the Organization established internal compliance controls related to the timely submission of single audit reports. Such process and review controls are implemented by the director of administrative operations, chief of staff (since December 2024), and chief executive officer; and subsequently communicated to the Board finance sub-committee and full Board, including the documented Board action(s) taken (e.g., Board agenda, minutes). B. Financial Policies and Procedures – May 2025. By May 2025, the Organization completed financial policies related to: implementation of significant accounting policies, internal control environment, cash and banking, cash disbursements and check issuance, payroll processes, procure to pay and revenue recognition policies, processes and procedures. Note the internal control policy of the Organization documents process and review controls, which were already in practice, applying to the timely filing of single audit reports. The current practices of the Organization, to the present period of the report dated March 2, 2026, is consistent with established process and review controls for timely submission of single audit reports.

View Audit 390799

Finding 1174703 (2023-014)

Material Weakness 2023

City of Woonsocket

RI

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current ...

Reference Number: 2023-014 Finding: Housing Quality Standards Inspections for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The division of housing and community development is now fully staffed, which will ensure that proper monitoring is completed annually. Current staff has completed HUD training modules on monitoring to ensure that monitoring that takes place will follow all guidelines. With the updated catalogue of all HOME loans, the division of housing and community development can have an accurate list of properties that are in the period of affordability and subject to monitoring. Staff will refer to monitoring files from previous years to create documents and letters to be sent to homeowners. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174686 (2023-005)

Material Weakness 2023

City of Woonsocket

RI

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Reference Number: 2023-005 Finding: Update Documented Policies amt Procedures Over Federal Awards Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement comprehensive policies and procedures specifically addressing the management and oversight of fe...

Reference Number: 2023-005 Finding: Update Documented Policies amt Procedures Over Federal Awards Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement comprehensive policies and procedures specifically addressing the management and oversight of federal awards to ensure compliance with the Uniform Guidance. Designated staff will be tasked with drafting these documents, which will be reviewed and approved by senior management. Training sessions will be conducted for all relevant personnel to ensure consistent application of the new policies and procedures. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174673 (2023-004)

Material Weakness 2023

City of Woonsocket

RI

Reporting Matching / Level of Effort / Earmarking Significant Deficiency

Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is ...

Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is both complete and accurate. This will include establishing a formal process for reconciling all reported federal expenditures with supporting documentation such as the general ledger and grant reports. Additionally, the SEFA will undergo a documented review by a qualified individual who was not involved in its preparation prior to finalization and submission. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174135 (2023-001)

Material Weakness 2023

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Subrecipient Monitoring Eligibility HUD Housing Programs

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedure...

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedures to ensure all required actions are taken when a tenant becomes over-income.

View Audit 387791

Finding 1174132 (2023-003)

Material Weakness 2023

Norman County

MN

Questioned Costs Cash Management Reporting § 200.303

Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification sinc...

Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification since 2024 and has been reporting since receiving notification. Anticipated Completion Date: 1/1/2024

View Audit 387778

Finding 1174131 (2023-002)

Material Weakness 2023

Norman County

MN

Questioned Costs Eligibility Significant Deficiency § 200.303

Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/train...

Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/trainings for staff Anticipated Completion Date: Quarterly internal audits anticipated start date: April 2026 Anticipated completion date of ongoing program training: July 2026

View Audit 387778

Finding 1173029 (2023-008)

Material Weakness 2023

Yankton Sioux Tribe

SD

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.313

2023 – 008: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008, 2021-007 and 2022-009) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Constru...

2023 – 008: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008, 2021-007 and 2022-009) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Construction ALN 93.575 Child Care and Development Block Grant Condition: During compliance requirement testing for Activities Allowed and Unallowed, Allowable Costs and Period of Performance for the above noted major programs, the auditors selected 120 transactions for testing from each major program. The following number of transactions were not provided for review during the audit: ALN 93.441 – Indian Self Determination – 18 transactions ALN 20.205 – Highway Planning and Construction – 16 transactions ALN 93.575 – Child Care and Development Block Grant – 7 transactions Corrective Action Plan: The Finance Department will become familiar with the requirements of 2 CFR, Part §200.313(a) and establish appropriate internal control policies and procedures to ensure compliance with the requirements of Uniform Guidance and each major program. In addition, all staff will be trained on those policies and procedures, so they are familiar with the requirements. The Finance Department will not process payment for disbursements that does not contain sufficient, appropriate supporting documentation and necessary approvals. The Finance Department will implement and execute an internal audit, by pulling random vouchers packets to test for compliance mid-year. An internal audit process is being developed and personnel assigned. Forms will be developed to assist with the internal audit process to ensure a timely and consistent process will be followed.

View Audit 386455

Finding 1173018 (2023-006)

Material Weakness 2023

Yankton Sioux Tribe

SD

Questioned Costs Reporting Significant Deficiency

2023 - 006: Reporting (Compliance; Internal Controls Over Compliance) (Repeat 2014-004, 2015-008, 2016-005, 2017-006, 2018-005 2019-006,2020-006, 2021-005 and 2022-007) Significant Deficiency ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds (ARPA) Condition: During the testing of the rep...

2023 - 006: Reporting (Compliance; Internal Controls Over Compliance) (Repeat 2014-004, 2015-008, 2016-005, 2017-006, 2018-005 2019-006,2020-006, 2021-005 and 2022-007) Significant Deficiency ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds (ARPA) Condition: During the testing of the reporting compliance requirement for ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds, we noted that the necessary reports were filed timely; however, no general ledger backup was provided to verify the accuracy of the reported numbers. Corrective Action Plan: The Governmental Department will work to establish procedures to ensure that all reports submitted to funding agencies are accurate, complete, and supported by reconciled documentation. These procedures will include reconciling Federal Financial Reports (SF-425) to the general ledger on a quarterly basis, as required by ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds, and verifying the accuracy of the Project and Expenditure Report and the Recovery Plan Performance Report as required for ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds. Additionally, The Governmental Department will review and incorporate program-specific reporting requirements into a formal policy to maintain compliance with federal guidelines. An internal audit process is being developed and personnel assigned. Forms will be developed to assist with the internal audit process to ensure a timely and consistent process will be followed.

View Audit 386455

Finding 1172859 (2023-003)

Material Weakness 2023

Creating Housing Coalition

OR

Questioned Costs Procurement, Suspension & Debarment Significant Deficiency § 200.318 § 200.320 § 200.326

Corrective Actions Planned To address the deﬁciency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive ...

Corrective Actions Planned To address the deﬁciency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive adequate training on the procurement policy and the required methods of procurement to be made when making procurements with federal awards. Responsible Person(s): CHC President, Rob Dibble as Primary; CHC Vice President Betsy Gordon as Backup Corrective Action Plan Dates: Schedule implementation starts: February 1, 2026; Staff training starts: March 1, 2026; Review process in effect starts: April 1, 2026

View Audit 386255

Finding 1172858 (2023-002)

Material Weakness 2023

Creating Housing Coalition

OR

Subrecipient Monitoring Reporting Significant Deficiency

Corrective Actions Planned To address the deﬁciency in internal controls over compliance with respect to reporting, CHC will implement the following corrective actions: CHC will implement a workﬂow process for federal grants that address speciﬁc steps and areas of responsibilities to meet grant repo...

Corrective Actions Planned To address the deﬁciency in internal controls over compliance with respect to reporting, CHC will implement the following corrective actions: CHC will implement a workﬂow process for federal grants that address speciﬁc steps and areas of responsibilities to meet grant reporting requirements; CHC will develop a grant procedure that outlines speciﬁc requirements of each grant that include supervisory review and reconciliation of data prior to submission.; Each Grant has a speciﬁc schedule for timely submission of reports. CHC plans to build a primary grant schedule that outlines each grant task, responsible member, milestones (if needed) and due date for each grant reporting cycle.; CHC will develop sta􀀁 training requirements that address federal and non-federal reporting responsibilities. Training will focus on the grant project manager, support sta􀀁, and other CHC board members to ensure comprehensive understanding of full disclosure. Responsible Person(s): CHC President, Rob Dibble as Primary; CHC Vice President Betsy Gordon as Backup Corrective Action Plan Dates: Schedule implementation starts: February 1, 2026; Staff training starts: March 1, 2026; Review process in effect starts: April 1, 2026

View Audit 386255

Finding 1171005 (2023-003)

Material Weakness 2023

Nation's Finest and Subsidiaries

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did...

FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did not agree to the underlying profit and loss detail from the Organization’s General Ledger(s) for the related grants. In addition, the certified authorized official was not an employee of the Organization and there was a lack of documentation for how the certifying official was deemed appropriate. In the sample quarterly reports, the Organization had contradicting responses related to whether reimbursement requests reflect actual spending of designated Supportive Services for Veteran Families (SSVF) funding. Corrective Action Plan: • Internal Controls are being evaluated and addressed with the Board of Directors on clarity of Financial Policy and Procedures • Implement a formal reconciliation process to ensure all grant financial reports agree to the underlying general ledger and profit and loss statements. • Establish a documented policy identifying employees authorized to certify grant reports, ensuring these individuals are employees of the Organization and appropriately trained. • Conduct regular training and internal reviews to confirm consistent understanding of grant-specific reporting requirements, particularly those related to reimbursement-based funding such as SSVF. • Develop a standard operating procedure (SOP) for reviewing and approving financial reports before submission to funders. Prior to sending to funder/portal. Must have reconciliation to numbers prior to next period reporting. • Site Review of reporting will have oversight of Financial Dept and reconciliation communication. Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: We cannot alleviate within 12 months

View Audit 384402

Finding 1170987 (2023-001)

Material Weakness 2023

Fusion Parterships, Inc.

MD

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system...

We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system. The creation and implementation of a google submission for disbursements has added the necessary review and approval of all expenses. Additional Partner Engagement Coordinator review of requests and backup documentation has been implemented for weekly approval of disbursements.

View Audit 384386

Finding 1170910 (2023-001)

Material Weakness 2023

Grand Island Regional Medical Center

NE

Questioned Costs HUD Housing Programs Reporting

Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 2...

Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 27, 2025. The Medical Center has implemented a tracking procedure for all grants that includes due dates for required reporting. The Controller maintains a list of compliance requirements for each grant which is reviewed by the Chief Financial Officer. Additionally, the primary contact information for grants is updated upon any changes in personnel to ensure communications are routed to the appropriate individual for follow-up.

View Audit 384219

Finding 1170544 (2023-005)

Material Weakness 2023

County of Delaware

PA

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time fra...

This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/ petitions to case files and file documentation beginning in November 2023.

View Audit 383805

Finding 1170506 (2023-006)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Internal Control / Segregation of Duties Questioned Costs Reporting § 200.303

SAOP will establish a rocedure to track reporting due dates and implement a process for verifying the accuracy and completeness of required reports before submission.

View Audit 383712

Finding 1170504 (2023-004)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Allowable Costs / Cost Principles Questioned Costs Significant Deficiency § 200.303

SAOP will enhance the internal controls over the payroll allocation process by conducting regular reviews and reconiliations to ensure the accuracy of payroll allocations.

View Audit 383712

Finding 1170503 (2023-003)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303

SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.

View Audit 383712

Finding 1170502 (2023-002)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

SAOP shall implement a policy to secure approvals for charges related to the federal program.

View Audit 383712

Finding 1170351 (2023-001)

Material Weakness 2023

New Directions, Inc.

CA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.

View Audit 383444

Finding 1169792 (2023-007)

Material Weakness 2023

Temenos Community Development Corporation

TX

Procurement, Suspension & Debarment Significant Deficiency § 200.303

2023-007 Internal Controls over Systems for Award Management (SAM Debarment) (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to suspe...

2023-007 Internal Controls over Systems for Award Management (SAM Debarment) (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to suspension and debarment are consistently implemented. Corrective Action: 1. SAM Debarment Registration: Under new leadership, we became compliant with SAM Debarment Registration in March 2025. 2. Compliance Tracking: We have implemented systems to ensure that registration will be completed annually and on time, supported by a robust compliance tracking system. 3. Vendor Vetting: 1. All new vendors will be vetted through the SAM (System for Award Management) Department prior to the initiation of services. 2. Continuous service providers will undergo an annual vetting process to ensure ongoing compliance and quality. Responsible Parties: Sandra Robicheaux – ED Madelyn Wages – Director of Operation Date to be Corrected: March 2025

View Audit 382882

Finding 1169787 (2023-006)

Material Weakness 2023

Temenos Community Development Corporation

TX

Questioned Costs Special Tests & Provisions HUD Housing Programs § 200.303

2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that ...

2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to special tests and provisions – reasonable rental rates are consistently implemented including maintaining documentation of the verification of rental reasonableness in the program participant's file. Corrective Action: In response to the findings from the 2023 audit regarding the annual requirement for rent reasonableness, we developed the following action plan to ensure compliance with HUD regulations: 1. Annual Schedule: We established that annual rent reasonableness assessments for Temenos TCDC would be conducted each January, as required by HUD. This included comprehensive assessments for all scatter site properties. 2. Staff Reminders: A systematic reminder protocol was implemented for all staff involved in the rent reasonableness process. This included: 1. Calendar alerts 2. Email notifications 3. Regular team meetings to discuss timelines and responsibilities 3. Monitoring and Compliance: The Executive Director (ED) and Director of Operations closely monitored the compliance process to ensure assessments were completed accurately and on time. By implementing this action plan, Temenos TCDC aimed to address the 2023 audit findings effectively and ensure compliance with HUD's annual rent reasonableness requirements, including assessments for all TCDC site properties. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Implemented in January of 2025

View Audit 382882

Finding 1169782 (2023-005)

Material Weakness 2023

Temenos Community Development Corporation

TX

Questioned Costs Subrecipient Monitoring Significant Deficiency § 200.303

2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are c...

2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are consistently implemented. In addition, documentation should be included in each participant's files to support income calculations and the participant's share of rent payable to the program. Corrective Action: We would like to clarify our approach to income documentation within client files: 1. Income Documentation: While not all clients have income, we will ensure that clients without income provide a zero-income affidavit (also known as a non-income affidavit) to document their status. 2. Stabilized Case Management: Our current case managers have been with Temenos CDC (TCDC) for over a year, providing stability and experience in verifying client income. 3. Policy and Procedure Updates: Recent updates to our policies and procedures have introduced standardized forms that clearly differentiate between households with income and those without. 1. Households with income will include the mandatory TCDC income calculation sheet. 2. Households without income will be required to submit the zero-income affidavit. 4. File Checklists: We have created file checklists to ensure uniformity across all client files, enhancing our documentation process. 5. Annual Audits: All client files will be audited by a supervisor at least once a year to ensure compliance with our policies. 6. HMIS Training: Case managers are required to complete mandatory HMIS training, which supports effective compliance in file management and income verification. These measures are designed to strengthen our documentation practices and ensure compliance with audit requirements. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Mandatory Training Implemented 01/2025 Updated Document Requirements 11/2025

View Audit 382882

Corrective Action Plans

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