Corrective Action Plans

Finding 500265 (2023-005)

Significant Deficiency 2023

Legal Services Nyc and Constituent Corporations

NY

Eligibility

The attorney responsible for this error has been instructed on the LSC rules for eligible income overrides and specific corrections in this case, including that the financial eligibility override reason of "client seeking to maintain government benefits for low-income is only applicable if those ben...

The attorney responsible for this error has been instructed on the LSC rules for eligible income overrides and specific corrections in this case, including that the financial eligibility override reason of "client seeking to maintain government benefits for low-income is only applicable if those benefits are the subject of our legal representation in a case, and families" that a client must be marked "no" for "Income Eligible (LSC guidelines)" even if they are financially eligible for our representation under a non-LSC funding contract. She was also instructed to review the LSC Financial Eligibility Training video. Ongoing compliance trainings and financial eligibility trainings have been modified to emphasize how to use the income override categories, and that a be marked as "no" for "Income Eligible (LSC guidelines)" and "LSC Eligible" even if the case must client's income makes them eligible to be served under non-LSC funding contracts.

View Audit 323047

Finding 500264 (2023-004)

Significant Deficiency 2023

Legal Services Nyc and Constituent Corporations

NY

Eligibility

LSNYC's Compliance Officer spoke at length with the attorney who mistakenly failed to exclude the value of the client's primary residence from the asset total and an erroneous asset override. She now understands that the "exclude" radio button should entered have been selected for this asset, which ...

LSNYC's Compliance Officer spoke at length with the attorney who mistakenly failed to exclude the value of the client's primary residence from the asset total and an erroneous asset override. She now understands that the "exclude" radio button should entered have been selected for this asset, which would have put the client's assets under the asset ceiling. now understands that an asset override must be approved in writing by her supervisor and She also that the asset override must be uploaded into the case file. Ongoing compliance trainings and financial eligibility trainings have been modified to emphasize the importance of selecting the "exclude" button for assets that do not count toward the total under LSC regulations, and that asset waivers must be approved in writing by a supervisor.

View Audit 323047

Finding 500263 (2023-003)

Significant Deficiency 2023

Legal Services Nyc and Constituent Corporations

NY

Eligibility

The attorney responsible for failing to obtain a retainer in this case was advised that retainers must always be obtained for full representation cases, and required to review a compliance training video. Ongoing compliance trainings have been modified to emphasize the importance of completing retai...

The attorney responsible for failing to obtain a retainer in this case was advised that retainers must always be obtained for full representation cases, and required to review a compliance training video. Ongoing compliance trainings have been modified to emphasize the importance of completing retainers with clients, for LSC compliance purposes, professional liability protection purposes, and to ensure that clients are made aware of the scope of services that LSNYC has agreed to provide and their own responsibilities in their representation.

View Audit 323047

Finding 500260 (2023-001)

Significant Deficiency 2023

Housing Authority of the County of Chester

PA

HUD Housing Programs Eligibility Reporting

Finding 2023-001 –– During our current year audit, it was noted that one HCVP was not inspected during the year. In this instance, the Authority did not abate payments for this unit. It was also noted one instance of a unit failing inspection, and not passing within the 30 day window. However, the...

Finding 2023-001 –– During our current year audit, it was noted that one HCVP was not inspected during the year. In this instance, the Authority did not abate payments for this unit. It was also noted one instance of a unit failing inspection, and not passing within the 30 day window. However, the Authority never put the unit into abatement. Recommendation – We recommend that the Authority review their recertification process and their process for reporting the reinspection, and review the abatement process to ensure units are properly put into abatement when inspections are failed or incomplete. Action Taken – Chester County Housing Authority management agrees with the above recommendation and has instituted policies and procedures designed to address this finding. (Please see the list of approved policies and procedures.)

View Audit 323046

Finding 500259 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of New Bern

NC

Procurement, Suspension & Debarment HUD Housing Programs Significant Deficiency

Finding No. 2023-003: Missing Procurement Documentation (Significant Deficiency) Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: The agency will assess the procurement process and implement internal controls where necessary.

View Audit 323042

Finding 500258 (2023-002)

Significant Deficiency 2023

Housing Authority of the City of New Bern

NC

Special Tests & Provisions Cash Management HUD Housing Programs

Finding No. 2023-002: Obligation Requirement for Capital Fund Program Drawdowns (Significant Deficiency Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: Our fee accountant will access the capital fund obligation and treasury process and implement corrective a...

Finding No. 2023-002: Obligation Requirement for Capital Fund Program Drawdowns (Significant Deficiency Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: Our fee accountant will access the capital fund obligation and treasury process and implement corrective actions, including adding internal controls and training.

View Audit 323042

Finding 500257 (2023-001)

Material Weakness 2023

Housing Authority of the City of New Bern

NC

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Finding No. 2023-001: Fraudulent Payroll Activities Resulting in Theft (Material Weakness) Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: Our fee accountant and payroll consultant will access the payroll process and implement corrective actions, including a...

Finding No. 2023-001: Fraudulent Payroll Activities Resulting in Theft (Material Weakness) Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: Our fee accountant and payroll consultant will access the payroll process and implement corrective actions, including adding internal controls and training.

View Audit 323042 Questioned Costs: $1

Finding 500256 (2023-001)

Material Weakness 2023

Neighborhood Legal Services Michigan

MI

Period of Performance Subrecipient Monitoring Allowable Costs / Cost Principles

View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accountin...

View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.

View Audit 323035

Finding 500255 (2023-001)

Significant Deficiency 2023

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303 § 200.403

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pr...

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.

View Audit 323033 Questioned Costs: $1

Finding 500253 (2023-003)

Significant Deficiency 2023

Nationwide Children's Hospital

OH

Reporting Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Finding 2023-003 Grantor: Department of Health and Human Services Federal Program: Oral Diseases and Disorders Research Maternal and Child Health Federal Consolidated Programs Assistance Listing #: 93.121 93.110 Title: Effort Certification Award Year: Fiscal year 2023 1/1/2023 – 12/31/2...

Finding 2023-003 Grantor: Department of Health and Human Services Federal Program: Oral Diseases and Disorders Research Maternal and Child Health Federal Consolidated Programs Assistance Listing #: 93.121 93.110 Title: Effort Certification Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: 1R01DE031756-01A1 2 U03MC28844-09-00 Corrective Action Plan and Anticipate Completion Date • In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has been remediated. Management implemented a new procedure to ensure timely time and effort certification. Management implemented the process for first quarter 2024 to allow time for system updates and training. Responsible person: Aaron Ufferman, Director, Sponsored Projects Completion Date: February 1, 2024

View Audit 323032

Finding 500215 (2023-002)

Significant Deficiency 2023

Nationwide Children's Hospital

OH

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2023-002 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Fringe Rate Analysis – Formula Error Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: Various Management agrees with the recommendation. Ho...

Finding 2023-002 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Fringe Rate Analysis – Formula Error Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: Various Management agrees with the recommendation. However, while there was an error in the underlying data used to evaluate the annual fringe rate, the federal government was not overcharged for fringe benefits. Corrective Action Plan and Anticipate Completion Date Management’s corrective action plan includes: • Management will ensure a more robust review of the underlying formulas. Responsible Person: Natasha Collins, Director of Research Accounting Completion Date: December 31, 2024

View Audit 323032

Finding 500184 (2023-001)

Material Weakness 2023

Nationwide Children's Hospital

OH

Procurement, Suspension & Debarment § 200.214 § 200.303

Finding 2023-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Suspension and Debarment Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: None Corrective Action Plan and Anticipate Completion Date Nation...

Finding 2023-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Suspension and Debarment Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: None Corrective Action Plan and Anticipate Completion Date Nationwide Children’s Hospital (the Corporation) uses a third-party to perform its suspension and debarment checks on a monthly basis. However, we noted the following matters: • The Corporation did not retain the monthly supporting documentation related to the monthly suspension and debarment check. The suspension and debarment checks performed at year-end were retained. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation in Q4 2023 to address this finding. • The Corporation does not have a process to reconcile the vendor list provided to the third-party vendor with the results received from the third-party vendor after the suspension and debarment checks are performed to ensure the listing is complete. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation to address this finding for the annual screening that was performed in Q1 2024 for year 2023. Management also implemented a monthly reconciliation process as quickly as practicable, beginning with January 2024 data. • The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. The Corporation relied on the results of the suspension and debarment checks performed by the third-party vendor without implementing an internal process to ensure the results provided by the third-party vendor were accurate. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented a process to verify the accuracy of the results produced by the third-party vendor. Management implemented the remediation to address the finding in the first quarter of 2024 for 4th quarter 2023 results. Responsible Person: Kathleen Dunn, JD – VP and Chief Compliance Officer Completion Date: January 31, 2024 • In addition, the Corporation performs a suspension and debarment check of all new vendors prior to activating them in the procurement system. The Corporation did not consistently maintain supporting documentation to support the vendor was checked for suspension and debarment before the “new”-vendor was set up in the procurement system. o Management Response In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented an audit process to ensure that screening documentation is maintained. This audit process flagged 2 of these 3 deficient documentation results, and documentation was subsequently uploaded to the file. The third vendor was an insurance company, which prior to mid-2023 was not screened at the time of setup based on vendor type. As of mid-2023, all vendors regardless of vendor type, are being screened at setup. Responsible Person: Mary Beth Colatruglio, CPA – Director of Accounting Completion Date: January 31, 2024

View Audit 323032

Finding 500183 (2023-003)

Material Weakness 2023

Mhub

IL

Cash Management Material Weakness § 200.302 § 200.305

Finding Number: 2023-003 Condition: The Organization does not have written procedures to implement the requirements of CFR 200.305. The advance payment of the Federal award was not maintained in an interest-bearing account and no interest was remitted back to the Federal government. Planned Cor...

Finding Number: 2023-003 Condition: The Organization does not have written procedures to implement the requirements of CFR 200.305. The advance payment of the Federal award was not maintained in an interest-bearing account and no interest was remitted back to the Federal government. Planned Corrective Action: Management is in the process of updating written procedures for Federal award compliance. Management will calculate and remit interest for 2023 to the Department of Health and Human Services Payment Management System (PMS). Contact person responsible for corrective action: Manas Mehandru, COO Anticipated Completion Date: October 15, 2024

View Audit 323030

Finding 500182 (2023-004)

None 2023

North Georgia Angel House Inc.

GA

Student Financial Aid

The Organization agrees with this finding and will strive to issue the required reports whenever possible.

View Audit 323021

Finding 500181 (2023-003)

None 2023

North Georgia Angel House Inc.

GA

The Organization agrees with this finding and will monitor future compliance by ensuring timely submission whenever possible.

View Audit 323021

Finding 500180 (2023-002)

None 2023

North Georgia Angel House Inc.

GA

Reporting Internal Control / Segregation of Duties

Management agrees and is planning on migrating from Little Green Light and moving solely to QuickBooks Online to track all revenue streams.

View Audit 323021

Finding 500179 (2023-001)

None 2023

North Georgia Angel House Inc.

GA

Internal Control / Segregation of Duties

This has the potential to be a recurring item. Due to the size of the Organization’s administration team, total segregation of duties is not practical at this time. The Board will continue to be closely involved in financial reporting and will continue to provide oversight as practical in order to m...

This has the potential to be a recurring item. Due to the size of the Organization’s administration team, total segregation of duties is not practical at this time. The Board will continue to be closely involved in financial reporting and will continue to provide oversight as practical in order to mitigate the risk of misappropriation of assets

View Audit 323021

Finding 500177 (2023-002)

Significant Deficiency 2023

Herbert Brooks Housing Development Fund Company, INC

NY

Questioned Costs HUD Housing Programs Cash Management

Finding Reference Number: 2023-2 Recommendation The Company must deposit $13,918 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Comple...

Finding Reference Number: 2023-2 Recommendation The Company must deposit $13,918 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

View Audit 323019 Questioned Costs: $1

Finding 500176 (2023-001)

None 2023

Northwest Senior Housing Corporation

CT

Procurement, Suspension & Debarment HUD Housing Programs

Corrective Action Plan September 23, 2024 U.S. Department of Housing & Urban Development 20 Church Street, 10 th floor Hartford, CT 06103 Northwest Senior Housing Corporation respectfully submits the following corrective action plan for Susan M. B. Perry Senior Housing's (Project #Ol 7-EE088) year e...

Corrective Action Plan September 23, 2024 U.S. Department of Housing & Urban Development 20 Church Street, 10 th floor Hartford, CT 06103 Northwest Senior Housing Corporation respectfully submits the following corrective action plan for Susan M. B. Perry Senior Housing's (Project #Ol 7-EE088) year ended December 31, 2023, which was audited by: Bailey, Moore, Glazer, Shaefer & Proto LLP 16 Lunar Drive Woodbridge, CT 06525 The sole finding from the 12/31/2023 schedule of findings and questions costs is discussed below and numbered consistently with the numbers assigned in the schedule. FINDINGS - FINANCIAL STATEMENT AUDIT NONE FINDINGS - FEDERAL A WARD PROGRAMS AUDIT DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Finding number 2023-001: 14.157 Supportive Housing for the Elderly Condition: Withdrawals from the replacement reserves totaling $3,065.08 were not supported by invoices or cash disbursements. As a result, the replacement reserve is underfunded by this amount. Recommendation: Care to be taken to track reserve requests to the actual cash disbursements. Action Taken: Upon receipt of an approved replacement reserve draw, the payment status of all listed invoices are reviewed and within three business day of the money being transferred, checks are cut towards any invoices that have not yet been paid. Furthermore, the unsubstantiated $3,065.08 that was drawn from the replacement reserve account was returned to the account on September 25, 2024. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Matthew Fontaine at (860) 951-9411 extension 249. Matthew Fontaine, CPA Managing Agent

View Audit 323018

Finding 500173 (2023-002)

Material Weakness 2023

Minford Gardens Housing Development Fund Company, INC

NY

Questioned Costs Cash Management HUD Housing Programs

Finding Reference Number: 2023-2 Recommendation Management should establish internal controls and procedures to ensure that surplus cash is properly monitored and disbursed. Reporting views of responsible officials Auditee concurs with this finding. Auditee agrees with auditor recommendations. ...

Finding Reference Number: 2023-2 Recommendation Management should establish internal controls and procedures to ensure that surplus cash is properly monitored and disbursed. Reporting views of responsible officials Auditee concurs with this finding. Auditee agrees with auditor recommendations. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management agrees with the recommendation of the auditor and internal controls are being put in place to ensure that surplus cash is deposited into the residual receipts reserve prior to paying down intercompany balances.

View Audit 323017 Questioned Costs: $1

Finding 500172 (2023-001)

Material Weakness 2023

Minford Gardens Housing Development Fund Company, INC

NY

Questioned Costs HUD Housing Programs Cash Management

Finding Reference Number: 2023-1 Recommendation The Company must deposit $586,006 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Com...

Finding Reference Number: 2023-1 Recommendation The Company must deposit $586,006 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

View Audit 323017 Questioned Costs: $1

Finding 500171 (2023-003)

Significant Deficiency 2023

American College of Cardiology Foundation

DC

Questioned Costs Procurement, Suspension & Debarment § 200.320

Management is dedicated to enhancing the competencies of our federal grant personnel. The College will offer focused and comprehensive re-training on both our internal procurement policies and the procurement requirements outlined in the Uniform Guidance to workforce members responsible for procurem...

Management is dedicated to enhancing the competencies of our federal grant personnel. The College will offer focused and comprehensive re-training on both our internal procurement policies and the procurement requirements outlined in the Uniform Guidance to workforce members responsible for procurement under federal awards. This re-training will ensure that all staff members understand protocols and regulations, thereby promoting compliance and efficiency in our procurement processes. The Privacy and Research Compliance Officer will monitor Program Management staff to ensure that price and rate quotations are obtained from a sufficient number of qualified sources. The Legal Department will not move forward in contract drafting until evidence of compliance with the College’s federal procurement policies is confirmed. This collaborative effort ensures informed purchasing decisions based on competitive pricing. Additionally, the Privacy and Research Compliance Officer will maintain evidence of price and rate quotation consistent with procurement policies. Through these initiatives, management aims to ensure procurement that aligns with both internal standards and federal regulations, ultimately supporting the effective and responsible use of federal funds.

View Audit 323015 Questioned Costs: $1

Finding 500170 (2023-002)

Significant Deficiency 2023

American College of Cardiology Foundation

DC

Questioned Costs Allowable Costs / Cost Principles § 200.430

Management is committed to enhancing staff knowledge of Uniform Guidance requirements, particularly concerning allowable costs and cost principles. To achieve this, we will implement additional training sessions for all relevant personnel. These sessions will cover key aspects of compliance, ensurin...

Management is committed to enhancing staff knowledge of Uniform Guidance requirements, particularly concerning allowable costs and cost principles. To achieve this, we will implement additional training sessions for all relevant personnel. These sessions will cover key aspects of compliance, ensuring that staff are well-informed about federal regulations and their implications for our grant management processes. The Controller will ensure the calculation of payroll costs are based solely on the actual hours worked and certified by grant personnel. This practice will help maintain accuracy and accountability in our financial reporting. In addition, the Technical and Internal Controls Accountant will conduct quarterly internal reviews to monitor and verify that payroll costs reported on cost reimbursement invoices are consistent with the actual hours certified by grant personnel. These regular reviews will serve as a critical check to uphold the integrity of our financial processes and ensure compliance with federal guidelines. Through these initiatives, management aims to foster a culture of compliance and accountability, equipping our team with the knowledge and tools necessary to effectively manage grant funds.

View Audit 323015 Questioned Costs: $1

Finding 500169 (2023-001)

Material Weakness 2023

American College of Cardiology Foundation

DC

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward o...

Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward or downward—to ensure it accurately reflects our current cost structure. To maintain compliance and integrity in our financial processes, the Technical and Internal Controls Accountant will oversee the review of costs included in the indirect cost pool to ensure they meet the criteria for allowability. Additionally, this role will involve verifying that invoices utilize the most current indirect cost recovery rate. Furthermore, management will prepare and submit the required indirect cost proposal to the appropriate cognizant agency to finalize our provisional billing rates used in fiscal year 2023, that aligns with our operational needs and complies with federal guidelines. This proactive approach will strengthen our financial management practices and support our ongoing commitment to transparency and accountability in the administration of federal grants.

View Audit 323015 Questioned Costs: $1

Finding 500168 (2023-002)

Significant Deficiency 2023

Stevens County Housing and Redevelopment Authority

MN

Special Tests & Provisions HUD Housing Programs Significant Deficiency

2023-002 1. Correcting Plan The Housing Authority has reviewed the re-inspection requirements and notified applicable staff of the deficiency. Processes will be changed to ensure correct population size is used to determine the required number of HQS re-inspections in the future. 2. Explanation of D...

2023-002 1. Correcting Plan The Housing Authority has reviewed the re-inspection requirements and notified applicable staff of the deficiency. Processes will be changed to ensure correct population size is used to determine the required number of HQS re-inspections in the future. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP Jessica Kirwin – Executive Director 4. Planned Completion Date for CAP Will implement for the December 31, 2024 audit. 5. Plan to Monitor Completion of CAP The Executive Director will monitor completion of the CAP.

View Audit 323009

Corrective Action Plans

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