Corrective Action Plans

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Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 th...
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 through August 26, 2029 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR 200.332 (e), (g) and (h) - pass-through entities must monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Condition: AACHC implemented revised subrecipient monitoring procedures in October 2025 as part of its corrective action plan to address the prior-year finding. The revised procedures were applied to all active and new subrecipient agreements beginning October 2025. However, because certain subrecipient agreements had already concluded before the new procedures were implemented, AACHC did not retrospectively apply the monitoring process to those closed agreements. As a result, AACHC did not obtain and review financial statement audit or Single Audit reports for three subrecipients whose agreements ended prior to implementation of the revised procedures. Name of Contact Person: Brenda Hanserd, CFO Phone Number: 602-288-7559 Anticipated Completion Date: March 31, 2027 Views of Responsible Officials and Corrective Action Plan: In October 2025, AACHC implemented revised subrecipient monitoring procedures in response to the prior-year audit finding. The exception identified in the current audit relates solely to three subrecipient agreements that had already concluded before the revised procedures were implemented and therefore could not be incorporated into the new monitoring process. Effective October 1, 2025, AACHC implemented enhanced procedures requiring evaluation of Single Audit applicability, collection and review of applicable audit reports, and follow-up on any findings. In addition, AACHC now requires subrecipients to submit audit documentation covering the entire period of performance under the agreement, ensuring that monitoring activities are completed even when a subrecipient agreement ends prior to the completion of the audit cycle. This corrective action addresses the circumstances that gave rise to the finding and provides assurance that all subrecipient agreements are subject to appropriate audit review and follow-up moving forward.
As explained in Management’s response to Finding 2026-002, Baptist Retirement Village had been approved for MFCS’s reduced (25%) monthly sampling of annual recertifications based on the property’s prior compliance history, its continuous 100% review of move-in and interim certifications, and MFCS’s ...
As explained in Management’s response to Finding 2026-002, Baptist Retirement Village had been approved for MFCS’s reduced (25%) monthly sampling of annual recertifications based on the property’s prior compliance history, its continuous 100% review of move-in and interim certifications, and MFCS’s ongoing availability for certification and compliance support. Because errors were identified during this reduced-sample review, the property is returning to 100% file review for all certifications, which will remain in place until Baptist Retirement Village again meets all criteria for reduced sampling — two consecutive years without MOR resident-file findings, a minimum two-year site manager tenure, and at least one year of error-free annual recertifications. In addition, SPM is updating the standardized tenant file checklist and written internal control procedures covering eligibility determination, income/rent calculation, and required certifications, with a documented compliance sign-off required before a file is considered complete
As with other high-performing SPM-managed properties, Baptist Retirement Village had been approved for a reduced-sampling protocol under which Multifamily Compliance Services (MFCS) reviews 25% of annual recertifications monthly, selected on a rotating basis, while continuing to review 100% of all m...
As with other high-performing SPM-managed properties, Baptist Retirement Village had been approved for a reduced-sampling protocol under which Multifamily Compliance Services (MFCS) reviews 25% of annual recertifications monthly, selected on a rotating basis, while continuing to review 100% of all move-in and interim certification files. Properties are approved for this 25% protocol only when: (1) the resident file audit section of the property’s HUD Management and Occupancy Review scores decline, or on-site management turns over, the property returns to 100% file review for all certifications. Because the errors addressed in this finding were identified during the reduced-sample review, Baptist Retirement Village is returning to 100% file review for all certifications. In addition, SPM is correcting the three affected tenant files, including any retroactive adjustment to Total Tenant Payment and subsidy, and property personnel responsible for completing 50059s are receiving refresher training on income determination requirements under HUD Handbook 4350.3 REV-1.
SPM has developed and issued a new company-wide Extended Absence from the Apartment policy applicable to all HUD-assisted and LIHTC communities, including Section 8, PRAC, Section 202, and LIHTC properties. The policy requires written resident notice of any absence expected to exceed 14 consecutive ...
SPM has developed and issued a new company-wide Extended Absence from the Apartment policy applicable to all HUD-assisted and LIHTC communities, including Section 8, PRAC, Section 202, and LIHTC properties. The policy requires written resident notice of any absence expected to exceed 14 consecutive days; documentation supporting the reason for and expected length of the absence (e.g., a physician’s statement, discharge plan, or nursing facility admission/discharge documentation); a maximum absence of 90 consecutive days, extendable to a total of 180 days only with documentation supporting the need for additional time, with any absence beyond 90 days requiring written approval from the Divisional Vice President; and, when a medical absence triggers an interim certification, a determination of whether program rent requires adjustment based on income or benefit changes. All notices, documentation, approvals, and follow-up contacts must be logged on the new Extended Absence Request and Tracking Form and retained in the resident file. MFCS and property management staff — including the Property Manager, Regional Property Manager and Compliance Specialist — are being trained on this policy, and supervisory review of all extended-absence cases will confirm ongoing compliance going forward. Management is also reviewing the specific resident file identified in the finding and is coordinating with the HUD Account Manager to determine the appropriate disposition of assistance payments, certification corrections, and occupancy status in accordance with HUD requirements.
1. The Project Sponsor acknowledges the requirements of the HUD Regulatory Agreement regarding the safeguarding and segregation of tenant security deposits. With the transition of management in these areas, additional review controls were implemented, including monthly programmatic and financial rev...
1. The Project Sponsor acknowledges the requirements of the HUD Regulatory Agreement regarding the safeguarding and segregation of tenant security deposits. With the transition of management in these areas, additional review controls were implemented, including monthly programmatic and financial reviews of security deposit collections, postings, and account balances to ensure proper classification and maintenance of restricted funds. 2. On September 4, 2026, the $50 security deposit was transferred to the appropriate security deposit account, fully correcting the deficiency. Management will continue to perform monthly monitoring procedures to verify that all tenant security deposits are accurately recorded and maintained in compliance with HUD requirements.
Management will transfer the required deposit to the security deposit cash account
Management will transfer the required deposit to the security deposit cash account
The unauthorized advances have been reimbursed in the subsequent year
The unauthorized advances have been reimbursed in the subsequent year
Management will coordinate with the bank to ensure that there is sufficient collateral on all deposits in the future.
Management will coordinate with the bank to ensure that there is sufficient collateral on all deposits in the future.
The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
Finding 2026-001: Considered a material weakness
Finding 2026-001: Considered a material weakness
Recommendation: It is recommended that the Village implement written policies and procedures over significant internal control areas.
Recommendation: It is recommended that the Village implement written policies and procedures over significant internal control areas.
Action to be taken: We agree with the finding and are in the process of implementing written policies and procedures over significant internal control areas including federal award programs.
Action to be taken: We agree with the finding and are in the process of implementing written policies and procedures over significant internal control areas including federal award programs.
Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.
Contact Person Misty Wanner, CFO Corrective Action Plan Management will obtain and retain all documentation as required by the federal agency. Completion Date The Organization will implement immediately.
SPM has an established process for preparing and reviewing replacement reserve reimbursement requests prior to submission to HUD. In this instance, the duplicate invoices were not identified during that review process and were subsequently included in the October 2025 request. HUD approved the reser...
SPM has an established process for preparing and reviewing replacement reserve reimbursement requests prior to submission to HUD. In this instance, the duplicate invoices were not identified during that review process and were subsequently included in the October 2025 request. HUD approved the reserve release based on the supporting documentation submitted; however, management recognizes its responsibility to ensure the accuracy and completeness of all reimbursement requests. To correct the issue, the property will reimburse the Replacement Reserve account for the duplicate amount of $31,482.32 and maintain documentation supporting the repayment. Management will also review prior replacement reserve reimbursement requests to confirm that no additional duplicate reimbursements exist. To prevent a recurrence, staff responsible for preparing and reviewing replacement reserve requests will be retrained on the review requirements, including verification against previously submitted reserve releases and supporting documentation. Management will also reinforce documentation and review procedures to ensure duplicate expenses are identified and resolved before future submissions are made.
Comments on the Finding and Each Recommendation: During the year ended May 31, 2026, $11,836 was withdrawn from the reserve for replacements without HUD approval. Management should transfer $11,836 from the operating account to the reserve for replacements account. Action(s) taken or planned on the ...
Comments on the Finding and Each Recommendation: During the year ended May 31, 2026, $11,836 was withdrawn from the reserve for replacements without HUD approval. Management should transfer $11,836 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding Agree. Management concurs with the finding and recommendation. On August 11, 2026, management transferred $11,836 from the operating account to the reserve for replacements account.
Finding 2026-001: Statement of condition #2026-001: Management fees of $3,192 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the findin...
Finding 2026-001: Statement of condition #2026-001: Management fees of $3,192 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent reimbursed $3,192 to the Corporation on August 11, 2026.
Finding 2026-004: Utility Allowances Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-007 Criteria: The Authority must maintain an up-to-date utility allowance schedule. The Authority must review utility rate data for each utility cate...
Finding 2026-004: Utility Allowances Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-007 Criteria: The Authority must maintain an up-to-date utility allowance schedule. The Authority must review utility rate data for each utility category each year and must adjust its utility allowance schedule if there has been a rate change of 10 percent or more for a utility category or fuel type since the last time the utility allowance schedule was revised (24 CFR section 982.517). Condition: The Authority had not updated utility rates since the April 1, 2021 effective date schedules. The Authority had obtained new utility rates during the fiscal year but the new schedules were not implemented. Cause: It was a finding in the prior year that the Authority did not update the utility allowances. The Authority contacted a company to perform the analysis but the Authority felt it was too expensive and then failed to calculate the rates itself. The Authority then contacted another company but the process has not yet been completed. Effect or Potential Effect: The Authority did not comply with the requirements of 24 CFR §982.517. Recommendation: The Authority should review the requirements of 24 CFR §982.517 and establish a system of where the utility allowance is reviewed and documented during each fiscal year. View of the Responsible Officials of the Auditee: The auditee's management agrees with the finding.
Finding 2026-003: HQS Quality Control Inspections Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-006 Criteria: 24 CFR §982.405 states the PHA must conduct supervisory qualify control HQS inspections. Condition: The Authority performe...
Finding 2026-003: HQS Quality Control Inspections Housing Choice Voucher, 14.871 Material Weakness/Noncompliance – Special Tests and Provisions Repeat Finding 2025-006 Criteria: 24 CFR §982.405 states the PHA must conduct supervisory qualify control HQS inspections. Condition: The Authority performed quality control inspections during the year; however, the Authority was not maintaining a log of inspections and had to search emails to find them. Further, the quality control inspections were not a random selection but selected by the original inspector. The Authority was not maintaining a log of all inspections for the quality control inspector to select from. Four of the 8 quality control inspections were done more than 90 days after the initial inspection. Cause: The Authority did not have procedures in place to randomly select inspections to perform quality control inspections on. Further, the Authority did not have a log of inspections and quality control inspections completed. Effect or Potential Effect: The Authority did not comply with the requirements of 24 CFR §982.405. Because inspections were not randomly selected, were not always performed within required timeframes, and were not adequately documented, the Authority did not have assurance that HQS inspections were being conducted consistently and in accordance with HUD requirements. Recommendation: The Authority should review the requirements of 24 CFR §982.405 and establish a system of where HQS inspections have a quality control sampling during each fiscal year. View of the Responsible Officials of the Auditee: The auditee's management agrees with the finding.
Finding 2026-002: Compliance, Inadequate Compliance Monitoring, Regulatory Oversight, and Governance Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2025-004 Criteria: Management is responsible for establishing and maintaining...
Finding 2026-002: Compliance, Inadequate Compliance Monitoring, Regulatory Oversight, and Governance Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2025-004 Criteria: Management is responsible for establishing and maintaining effective internal controls over compliance that provide reasonable assurance the Housing Choice Voucher Program is administered in accordance with Federal statutes, regulations, and HUD requirements. Effective controls should include adequate monitoring of compliance requirements, timely implementation of regulatory changes, maintenance of current policies and procedures, and oversight sufficient to compensate for staffing limitations. HUD program requirements and regulatory changes should be reviewed and incorporated into the Authority's Administrative Plan in a timely manner. Similar control expectations are reflected in HCV compliance guidance addressing policy maintenance, Board oversight, monitoring of regulatory changes, and compensating controls where segregation of duties is limited. Condition: The Authority operates only the Housing Choice Voucher Program and employs a single individual responsible for substantially all program administration and compliance responsibilities. Because staffing levels do not permit traditional segregation of duties, the Authority should have established compensating monitoring and oversight controls. However, our audit identified significant weaknesses in the Authority's internal control structure over compliance. Specifically, we noted: • Compliance responsibilities were concentrated in one individual without independent review or documented monitoring procedures. • The Administrative Plan had not been updated to incorporate applicable HOTMA requirements. • Board minutes indicated the Authority was relying upon HUD Notices H-2025-03 and H-2025-07 when evaluating HOTMA implementation. These notices do not apply to the Housing Choice Voucher Program and the Authority was not utilizing the correct guidance in HUD PIH Notices. • The Authority had not established procedures to identify, evaluate, and implement applicable HUD PIH notices and other regulatory updates affecting the Voucher program. • Audit testing identified deficiencies in multiple compliance areas, indicating that compliance monitoring controls were not operating effectively. The existence of compliance deficiencies across multiple program areas demonstrates that the Authority's controls were not reasonably designed or operating effectively to ensure compliance with Federal program requirements. Similar conditions have been identified in other HCV compliance control assessments, including lack of monitoring of regulatory changes, inadequate Board oversight, and insufficient compensating controls where staffing is limited. Cause: The Authority has not established an effective system of internal control over compliance. Management and the Board of Commissioners did not implement sufficient compensating controls to address the risks associated with a single-employee operating structure. In addition, procedures were not established to ensure that changes in HUD regulations, notices, and program requirements were identified, evaluated, and incorporated into Authority policies and operational practices on a timely basis. Effect: The lack of effective compliance oversight increases the likelihood that material noncompliance with Federal program requirements could occur and not be prevented, detected, or corrected timely. Failure to maintain current policies and implement regulatory changes increases the risk of noncompliance in areas including tenant eligibility, rent calculations, utility allowances, inspections, reporting, and other program requirements. The deficiencies identified during the audit demonstrate that the Authority's control environment does not provide reasonable assurance of compliance with Housing Choice Voucher Program requirements. Recommendation: We recommend the Authority: 1. Establish formal procedures for monitoring compliance with Housing Choice Voucher Program requirements. 2. Update the Administrative Plan to incorporate all applicable HOTMA requirements and other current HUD guidance. 3. Develop a process for reviewing HUD PIH notices, regulatory updates, and other program guidance as issued. 4. Implement documented supervisory or independent compliance reviews to compensate for the lack of segregation of duties. 5. Provide periodic compliance reports to the Board of Commissioners and document Board oversight of corrective actions. 6. Establish written procedures to ensure significant regulatory changes are timely evaluated, adopted, and implemented. Views of Responsible Officials The Authority agrees with the finding.
In Finding 2026-001, a condition was noted that a majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary heal...
In Finding 2026-001, a condition was noted that a majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary health care” in order for them to give substantive input into the Organization’s strategic direction and policy. BRCHS Management understands the importance of complying with health center compliance requirements related to board member composition. At the time of the audit, BRCHS had 50% of its board membership within compliance and it is noted that the timeframe for noncompliance was March 2026-June 2026. In response to Finding 2026-001, additional monitoring procedures have been implemented to ensure ongoing compliance with this requirement, and the health center is in compliance as of the date of this corrective action plan.
Comments on the Finding and Recommendations Concur or do not concur with this finding – Concur Agree or disagree with auditor recommendation – Agree Corrective Action Taken or Planned Response to Findings Identified by Auditor Completion date or proposed completion date – September 30, 2026 Actions ...
Comments on the Finding and Recommendations Concur or do not concur with this finding – Concur Agree or disagree with auditor recommendation – Agree Corrective Action Taken or Planned Response to Findings Identified by Auditor Completion date or proposed completion date – September 30, 2026 Actions taken or Planned on the finding – Management will establish a separate Residual Receipts bank account and implement internal controls and procedures to ensure that future surplus cash deposits are made to the Residual Receipts account within the timeframe required by HUD.
Views of Responsible Officials and Planned Corrective Actions – University personnel reviewed the four instances identified for untimely NSLDS reporting and determined that neither case resulted from a failed or rejected submission to the National Student Clearinghouse (NSC) or NSLDS. Rather, the ti...
Views of Responsible Officials and Planned Corrective Actions – University personnel reviewed the four instances identified for untimely NSLDS reporting and determined that neither case resulted from a failed or rejected submission to the National Student Clearinghouse (NSC) or NSLDS. Rather, the timing difference resulted from the enrollment status effective date used for NSC reporting, which did not align with the reporting roster submission cycle. The University reports enrollment information to NSLDS through the National Student Clearinghouse on a regular monthly basis and confirmed through review of NSC acknowledgment and error reports that no transmission errors occurred. To reduce the risk of similar timing differences in the future, the University is working on process improvements in coordination with Banner support, including ensuring backdated drops and withdrawals are processed prior to initial NSC transmissions each term, reviewing the timing of enrollment reporting submissions to improve data capture, strengthening procedures for monitoring post-census backdated status changes, continuing timely review of NSC error reports, reviewing enrollment status calculations for nonstandard coursework, and implementing pre-submission validation procedures to confirm all required status calculation and extract processes have been completed prior to NSC file transmission.
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2026 U.S. Department of Housing and Urban Development Loretto O’Brien Road Housing Development Fund Company, Inc. (O’Brien Road Senior Apartments), HUD Project No. 014-EE262/NY06-S061-007 respectfully submits the following corrective action plan fo...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2026 U.S. Department of Housing and Urban Development Loretto O’Brien Road Housing Development Fund Company, Inc. (O’Brien Road Senior Apartments), HUD Project No. 014-EE262/NY06-S061-007 respectfully submits the following corrective action plan for the year ended March 31, 2026. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 North Franklin Street #60 Syracuse, New York 13204 Audit period: April 1, 2025 – March 31, 2026 The findings from the 2026 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDIT (Continued) Finding 2026-001: Supportive Housing for the Elderly (Section 202), Federal Assistance Listing Number 14.157 Recommendation: Our auditor’s recommended that we ensure sufficient operating cash flow to make all required reserve for replacement deposits in the future. Views of management and planned corrective action: Management concurs. The March payment was made on April 10, 2026. Action Taken: The March payment was made on April 10, 2026. Completion Date: April 10, 2026 Name of Contact Person Responsible for Corrective Action: John Lutz, VPF, (315) 424-1821
Name of Auditee: Newark Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: March 31, 2026 CAP Prepared by: Yolanda Casselman, Executive Director Phone: (315) 331-1574 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2026-001 (a) ...
Name of Auditee: Newark Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: March 31, 2026 CAP Prepared by: Yolanda Casselman, Executive Director Phone: (315) 331-1574 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2026-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendations, please see below for action taken. (b) Action taken - The Authority will implement a training and review process for all documentations and immediately obtain the missing documentation. (c) Planned implementation date of corrective action - Completed by March 31, 2027.
Timely Exit Counseling Notification Finding: The University did not have adequate procedures or review controls to ensure that reports used to identify students requiring exit counseling notifications included all students who withdrew or otherwise ceased to be enrolled at least half-time. As a resu...
Timely Exit Counseling Notification Finding: The University did not have adequate procedures or review controls to ensure that reports used to identify students requiring exit counseling notifications included all students who withdrew or otherwise ceased to be enrolled at least half-time. As a result, four students did not receive timely notifications regarding exit counseling. Corrective Actions Taken or Planned: FNU will update its exit counseling procedures to ensure that all students who withdraw or otherwise cease to be enrolled at least half-time are identified and timely notified of the exit counseling requirement. Additionally, FNU will implement controls to validate the completeness of reports used for this purpose and establish backup procedures and review controls when key personnel are unavailable. Estimated Completion Date: September 30, 2026. Responsible Personnel: Kaleena Burnett, Director of Financial Aid
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