Corrective Action Plans

Finding 1228333 (2025-003)

Material Weakness 2025

Housing Authority of the City of Williston

ND

HUD Housing Programs

Contact Person Heidi Johnson, Board President Corrective Action Plan The Authority will be more diligent in completing rent reasonableness forms for each tenant, as required. Completion Date Effective immediately.

View Audit 410027

Finding 1228331 (2025-002)

Material Weakness 2025

Housing Authority of the City of Williston

ND

HUD Housing Programs

Contact Person Heidi Johnson, Board President Corrective Action Plan The Authority will be more diligent in completing HQS quality control re-inspections on a sample of tenant units each year, as required. Completion Date Effective immediately.

View Audit 410027

Finding 1228329 (2025-001)

Material Weakness 2025

Central Tribes of the Shawnee Area, Inc.

OK

Subrecipient Monitoring Reporting Significant Deficiency § 200.328

Management agrees with the finding. The report was submitted late due to an oversight. Management has reviewed the reporting requirements and established a tracking process to ensure that required reports and their due dates are monitored. Responsibility for each report has been clearly assigned, an...

Management agrees with the finding. The report was submitted late due to an oversight. Management has reviewed the reporting requirements and established a tracking process to ensure that required reports and their due dates are monitored. Responsibility for each report has been clearly assigned, and management will review the status of upcoming submissions to help ensure that reports are submitted timely. Management will continue to monitor compliance with reporting deadlines and take appropriate action if a potential delay is identified. Person responsible for Corrective Action: Sonya Birdshead, Executive Director. Anticipated Completion Date: August 31, 2026

View Audit 410025

Finding 1228317 (2025-018)

Material Weakness 2025

County of Floyd, Virginia

VA

Reporting Material Weakness

The County agrees with this recommendation and will verify the expenditures as well as the Cardinal Report for reporting.

View Audit 410022

Finding 1228314 (2025-017)

Material Weakness 2025

County of Floyd, Virginia

VA

The County has reviewed, updated, and verified spending spreadsheet for submission and will maintain until all expenditures are completed.

View Audit 410022

Finding 1228311 (2025-016)

Material Weakness 2025

County of Floyd, Virginia

VA

Procurement, Suspension & Debarment

The County agrees with the recommendation and will develop one procurement manual that applies to all departments.

View Audit 410022

Finding 1228304 (2025-002)

Material Weakness 2025

Yazoo County School District

MS

Allowable Costs / Cost Principles Cash Management Material Weakness

2025-002 a. Name of Contact Person Responsible for Corrective Action: Dr. Terri Rhea, Superintendent b. Corrective Action Planned: We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, including compliance with state and fe...

2025-002 a. Name of Contact Person Responsible for Corrective Action: Dr. Terri Rhea, Superintendent b. Corrective Action Planned: We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, including compliance with state and federal grant requirements. c. Anticipated Completion Date: Immediately.

View Audit 410019

Finding 1228303 (2025-001)

Material Weakness 2025

Saint Michael's Clinics, Inc.

NJ

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Clinic management team acknowledges that from the audit selection made of 60 patients, 15 selections had findings. We agree with you that seven (7) of the 15 did not meet either, the six-month recertification requirements or had missing proof of income findings. We agree and are not contesting patie...

Clinic management team acknowledges that from the audit selection made of 60 patients, 15 selections had findings. We agree with you that seven (7) of the 15 did not meet either, the six-month recertification requirements or had missing proof of income findings. We agree and are not contesting patient selection numbers: 25, 27, 31, 38, 52, 56 and 59. We will address this in our corrective action plan. Staff have completed the six-month recertifications and gathered the missing income data Four (4) of the findings related to certification data being collected and uploaded in the hospital EPIC electronic medical records but were not formally signed by a case manager. We are in partial compliance with the data requirements, but we needed to finalize and ensure that controls are in place, so the service provider must sign the note. We had situations where the provider passed away or left the Peter Ho clinic, due to relocation. Staff have since completed the notes and we have developed a report within our EMR to notify the service provider that the note requires signature. The four missing signatures by the service provider were patient selections: 9, 24, 29, 41. Four (4) of the findings related to not having the original HIV diagnosis confirmed on the patient not successfully migrated into the new electronic medical record, EPIC. For three of these patients, the staff could not find the original HIV diagnosis on the chart. The patients were treated properly, but the original data was not retained. This was caused by not all data being successfully migrated when Peter Ho updated its EMR during CY 2021. The Peter Ho Clinic switched from Centricity to EPIC during 2021. The selected patients have been treated at Peter Ho prior to CY 2021. We did provide other supporting documentation that the patient has HIV, but we could not find the original documentation. The four patient selections that fell into this category are: 19, 30, 34 and 39. The corrective action plan as developed for CY 2024 will be continued to be reinforced and followed. A few new bullets have been added below to further assist in meeting the compliance guidance. A detailed plan of correction is identified below: • Quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. This process will remain in place. • Assistant Manager will implement an EPIC (EMR) precheck process for current assessments. All future assessments will have proof of diagnosis, proof of income, proof of ID, proof of address and proof of insurance on the template to include the dates in which those documents were collected. (new) • Data Analyst(s) generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Lead will remain directly accountable to review the progress of re-certifications. Further monitoring by the Assistant Manager of the clinic will continue. • An EPIC (EMR) report of unsigned encounters will be generated biweekly and reviewed by staff for open encounters and notes to be signed. (new) • The CCC-Lead and the Assistant Manager will continue to monitor retention of income verification documentation to ensure compliance purposes. • Document scanners will be provided to individual Certified Case Counselors to alleviate late or missed filings, documents will be scanned directly into EMR at the time of capture. • The Clinic staff will continue follow up with the patients that were non-compliant during the prior year audit and asked for the missing information. The medical record will be updated with any new information received. • Chart review for all upcoming appointments will be performed to capture/locate missing diagnosis because of data transfer failure from old EMR. If diagnosis is missing, rapid testing to be performed by the Counseling and Testing Department at that time to continue current treatment. (new) Contact Person: Mark Brown, Office Manager, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2026

View Audit 410017

Finding 1228301 (2025-005)

Material Weakness 2025

Blackburn University Dba Blackburn College

IL

Student Financial Aid Cash Management

Condition: The College retained interest earnings in excess of $500 in its federal bank account during fiscal year 2025. This represents noncompliance with Cash Management requirements and is a repeat finding (2024-009). Corrective Action Plan The institution has strengthened internal controls, moni...

Condition: The College retained interest earnings in excess of $500 in its federal bank account during fiscal year 2025. This represents noncompliance with Cash Management requirements and is a repeat finding (2024-009). Corrective Action Plan The institution has strengthened internal controls, monitoring, and procedures to ensure compliance with federal cash management requirements and to prevent recurrence in future audit periods. The institution has revised its cash management procedures to ensure timely identification and return of excess interest earnings. • To prevent recurrence, the institution will maintain a lower balance in the federal funds account to minimize interest accrual. • Any interest exceeding $500 at fiscal year-end will be returned promptly in accordance with federal requirements. • Processes now include calculating interest earned on a routine basis and confirming compliance with the $500 threshold prior to fiscal year-end. Staff Training Staff responsible for federal funds management have been retrained on cash management requirements under 34 CFR 668.163, including thresholds for retained interest and required timelines for returning excess funds. System and Manual Checks The Business Office has implemented manual tracking of interest earned on federal funds accounts. A year-end reconciliation process has been enhanced to verify that any interest exceeding $500 is identified and returned within required timeframes. Monitoring and Compliance Ongoing monitoring includes: • Periodic review of bank account balances and interest accrual • Record of interest calculation for FY2025 • Bank statements supporting interest earned • Internal reconciliation and review documentation Responsible Person for Correction Action Plan: Deana Rogers, Vice President of Administration & Finance Implementation Date for Corrective Action Plan: Immediate and ongoing

View Audit 410013

Finding 1228300 (2025-004)

Material Weakness 2025

Blackburn University Dba Blackburn College

IL

Student Financial Aid

Condition: During our testing of forty individuals receiving federal work study, we noted three individuals (7.5%) working during scheduled class hours. We consider this condition to be an instance of noncompliance relating to the Activit ies Allowed or Unallowed compliance requirement and is a repe...

Condition: During our testing of forty individuals receiving federal work study, we noted three individuals (7.5%) working during scheduled class hours. We consider this condition to be an instance of noncompliance relating to the Activit ies Allowed or Unallowed compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2024-008. Statistical sampling was not used in making sample selections. Corrective Action Plan The Work Office acknowledges the finding regarding students working during scheduled class hours and recogn izes this as a repeat finding from the prior audit period (2024-008). In response, the Work Office has implemented enhanced internal contro ls and strengthened oversight processes. These actions include: • formalized procedures prohibiting students from working during schedu led class times without prior documented class cancellation • implementation of a centralized class cancellation tracking log • enhanced payroll review processes and • expanded training for students, supervisors, and faculty Additionally, monitoring activities have been increased through routine payroll reviews and ongoing coordi nation between the Work Office and Provost Office The Work Office believes these corrective actions appropriately address the root cause of the finding and has established controls designed to ensure compliance with federal requirements and prevent recurrence in future audit periods. Clear expectations and documentation requirements have been established and communicated across campus. Process Improvement The Work Office, in coordination with the Provost Office, has strengthened procedures to ensure students are not permitted to work during scheduled class times. A formal process has been implemented requiring verification and documentation of any class cancellation prior to a student working during a scheduled class period. A centra lized class cancellation tracking log has been established and is jo intly maintained by the Work Office and Provost Office to ensure consistency and oversight. Staff Training The Dean of Work and Provost have enhanced tra ining and communication efforts to ensure all stakeholders understand compliance requirements. • Students: Informed through monthly department meetings and electronic communication that they are prohibited from working during scheduled class times. • Student Supervisors/Managers: Reinforce policies and monitor student work schedules. • Faculty: Continuously notified by the Provost of their responsibility to report class cancel lations to both the Provost Office and Work Office. • Supervisors: Receive ongoing training through monthly Supervisor Training sessions, including compliance requirements, payroll accuracy and review of payroll reports prior to submission, and maintenance of documentation standards and tracking logs. Documentation procedures are available in a shared drive accessible to supervisors. The Work Office and Provost Office will dedicate time to educating and reminding students and faculty that students are not allowed to work during schedu led class time, and how to report a cancelled class. The Work Office wi ll dedicate time to double-checking the student payrol l reports before sending them to Human Resources. System and Manual Controls • The Work Office has implemented additional internal controls designed to prevent and detect noncompliance, including • Secondary review of al l student payroll reports by the Work Office prior to submission to Human Resources • Verification of student work hours against class schedules • Requirement that students submit documentation (facu lty email or Learning Management System announcement) prior to working during a cancelled class time • Maintenance of a centralized exception log for all approved class cancellations Monitoring and Compliance Ongoing monitoring procedures have been established to ensure continued compliance, including: • Regular payroll reviews conducted by the Dean of Work • Coordination between the Work Office and Provost Office to verify reported class cancel lations ensures faculty compliance with class cancellation reporting requirements • Monthly Supervisor Training to reinforce compliance expectations by routine oversight activities that provide continuous reinforcement of institutional and federal requirements. • Continuous communication to students, supervisors, and faculty regard ing pol icy requirements Responsible Person(s) for Correction Action Plan: Leslie Johnson, Dean of Work - Responsible for student education, payroll review, and prevention of overpayments Laura Wiedlocher, Provost - Responsible for faculty communication and enforcement of class cancellation reporting Student Supervisors/Managers - Responsible for reinforcing policies and monitoring student compliance Implementation Date for Corrective Action Plan: Corrective actions were implemented throughout the 2024-2025 academic year and will continue on an ongoing basis.

View Audit 410013

Finding 1228299 (2025-003)

Material Weakness 2025

Blackburn University Dba Blackburn College

IL

Student Financial Aid

Condition: We tested eight drop students and found one incorrect refund calculations. We consider this to be an instance of non-compliance. Corrective Action Plan Procedure Revision and Clarification The Financial Aid Office has updated its R2T4 procedures to clearly define how scheduled breaks are ...

Condition: We tested eight drop students and found one incorrect refund calculations. We consider this to be an instance of non-compliance. Corrective Action Plan Procedure Revision and Clarification The Financial Aid Office has updated its R2T4 procedures to clearly define how scheduled breaks are arranged. Procedures now specify that break periods must include all consecutive days between the last day of class before the break and the day before classes resume, including applicable weekend days. This aligns with federal guidance that scheduled breaks of five or more consecutive days must include interven ing weekends when no classes are held. Standardized Academic Calendar Usage A standardized, institutionally approved academic calendar has been implemented for R2T4 calculations. This calendar explicitly identifies: • Start and end dates of all scheduled breaks • Inclusion of weekend days where applicable Staff will use this calendar when determining both total and completed days in Step 2 of the R2T4 calculation. R2T4 Calculation Checklist Implementation A mandatory checklist has been implemented for all R2T4 calculations to ensure: • Accurate identification of scheduled breaks greater than 5 consecutive days • Inclusion of all appropriate days, including prior weekends when applicable • Correct calculation of both completed and total days Staff Training All financial aid staff have completed targeted training on R2T4 calculation requirements, with emphasis on: • Proper identification and treatment of scheduled breaks • Inclusion of weekends as part of a break when classes are not in session • Accurate completion of Step 2 of the R2T4 calculation Secondary Review Process A secondary review by another staff member is now required for all R2T4 calculations prior to finalization . This review specifically verifies the accuracy of break dates and day counts. Ongoing Monitoring and Quality Assurance The Financial Aid Office will conduct periodic internal audits of R2T4 calculations to ensure compliance with federal regu lations. Any discrepancies will be corrected immediately and used as part of continuous staff training. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 03/25/26

View Audit 410013

Finding 1228298 (2025-002)

Material Weakness 2025

Blackburn University Dba Blackburn College

IL

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking

Condition: We tested forty fi les, thirty-five of which were Federal Direct Loan recipients, and two students received incorrect subsidized and unsubsidized loan amounts. We consider this to be an instance of non-compliance and is repeated from the prior year finding at 2024-004. Corrective Action P...

Condition: We tested forty fi les, thirty-five of which were Federal Direct Loan recipients, and two students received incorrect subsidized and unsubsidized loan amounts. We consider this to be an instance of non-compliance and is repeated from the prior year finding at 2024-004. Corrective Action Plan While this is listed as a repeat finding, the cause was different in that the condition occurred due to staff not using the student's remaining enrolled credits to correctly prorate aid for the final semester. The Financial Aid Office has reviewed this finding and implemented the following corrective measures: Process Improvement We have revised our procedures to require a mandatory review of remaining enrolled credits when it is determined that aid eligibility for any final period of enrollment is shorter than a full academic year. This ensures proration is calculated accurately in accordance with federal regulations. Staff Training All financial aid staff have received targeted training on proration requirements for shortened academic years, with an emphasis on using remaining enrolled credits in the calculation process. System and Manual Checks A secondary review step has been added to our awarding process. Any student identified as being in a final academic period will have their aid calculation reviewed and approved by a senior staff member prior to disbursement. Monitoring and Compliance We will conduct periodic internal audits of student files involving shortened academic years to ensure continued compliance. Any discrepancies identified will be corrected immediately and used as training opportunities. Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 03/25/26

View Audit 410013

Finding 1228281 (2025-004)

Material Weakness 2025

MacOn-Bibb County

GA

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2025 – 004 Airport Improvement Program (AIP) – Assistance Listing 20.106 – Reporting Name of Contact Person Responsible for Corrective Action Plan: Doug Faour, Airport Director Corrective Action Plan: Management will implement a process to ensure all required reports are submitted as required in a t...

2025 – 004 Airport Improvement Program (AIP) – Assistance Listing 20.106 – Reporting Name of Contact Person Responsible for Corrective Action Plan: Doug Faour, Airport Director Corrective Action Plan: Management will implement a process to ensure all required reports are submitted as required in a timely manner. Anticipated Completion Date: Fiscal year 2026

View Audit 410012

Finding 1228276 (2025-003)

Material Weakness 2025

MacOn-Bibb County

GA

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.328 § 200.329

2025 – 003 Community Development Block Grant (CDBG) – Assistance Listing 14.218 – Reporting Name of Contact Person Responsible for Corrective Action Plan: Wanzina Jackson, Economic and Community Development Director Corrective Action Plan: Management will implement a process to ensure all required r...

2025 – 003 Community Development Block Grant (CDBG) – Assistance Listing 14.218 – Reporting Name of Contact Person Responsible for Corrective Action Plan: Wanzina Jackson, Economic and Community Development Director Corrective Action Plan: Management will implement a process to ensure all required reports are submitted as required in a timely manner. Anticipated Completion Date: Fiscal year 2026

View Audit 410012

Finding 1228274 (2025-001)

Material Weakness 2025

Redevelopment Authority of Allegheny County

PA

Reporting Internal Control / Segregation of Duties

Financial Statement Finds: Accounting Records Criteria: The accounts of the Authority should include all significant transactions in the period of benefit. Condition: During the audit, certain audit adjustments were required to record transactions in the period of benefit for the General Fund, Speci...

Financial Statement Finds: Accounting Records Criteria: The accounts of the Authority should include all significant transactions in the period of benefit. Condition: During the audit, certain audit adjustments were required to record transactions in the period of benefit for the General Fund, Special Projects Fund, and EDF Fund. Effect: The financial records for the General Fund, Special Projects Fund, and EDF Fund did not reflect the financial activity in the period of benefit, which could result in a material misstatement of the financial statements. This is a repeat finding from a previous year – Finding 2024-001. Recommendation: The Authority should ensure that internal control procedures over financial reporting are sufficient to identify and record all transactions in the period of benefit. Management Response: The Authority has initiated additional levels of review in order to sufficiently identify and record all transactions in the period of benefit.

View Audit 410008

Finding 1228272 (2025-002)

Material Weakness 2025

Senior Residence at Kapolei 2, Inc.

HI

HUD Housing Programs

This issue occurred during Bob Tanaka, Inc.’s period of managing the project. Bob Tanaka, Inc. was replaced by Hawaii Affordable Properties, Inc. on January 1, 2025, and instructions have been given to the new property management company to maintain the tenant waiting list in accordance with 24 CFR ...

This issue occurred during Bob Tanaka, Inc.’s period of managing the project. Bob Tanaka, Inc. was replaced by Hawaii Affordable Properties, Inc. on January 1, 2025, and instructions have been given to the new property management company to maintain the tenant waiting list in accordance with 24 CFR Section 891.410(a). The wait list will be reviewed at quarterly site inspections.

View Audit 410007

Finding 1228271 (2025-001)

Material Weakness 2025

Senior Residence at Kapolei 2, Inc.

HI

HUD Housing Programs

The noncompleted replacement reserve contributions were due to the Project not receiving PRAC subsidies during 2025. This left the Project with not enough revenue to fund normal operations, and a replacement reserve withdraw was allowed by HUD to cover operating cash shortfalls. The issue with recei...

The noncompleted replacement reserve contributions were due to the Project not receiving PRAC subsidies during 2025. This left the Project with not enough revenue to fund normal operations, and a replacement reserve withdraw was allowed by HUD to cover operating cash shortfalls. The issue with receiving the PRAC subsidies was resolved by the property managers in April 2026 and the Project is now paying back the replacement reserve withdraw for the shortfall and catch up with replacement reserve contributions. Continuing monitoring of the Project's financial statements and replacement reserve contributions will be performed on a monthly basis.

View Audit 410007

Finding 1228263 (2025-002)

Material Weakness 2025

Housing and Redevelopment Authority of Owatonna

MN

Eligibility Internal Control / Segregation of Duties Reporting

Recommendation: We recommend the HRA implement controls over all areas of the federal program so that segregation of duties are in place and working. Views of Responsible Officials: The HRA is aware of the limited segregation of duties as a result of our limited number of staffing. There is no disag...

Recommendation: We recommend the HRA implement controls over all areas of the federal program so that segregation of duties are in place and working. Views of Responsible Officials: The HRA is aware of the limited segregation of duties as a result of our limited number of staffing. There is no disagreement with the audit finding.

View Audit 410002

Finding 1228262 (2025-002)

Material Weakness 2025

Humphreys County School District

MS

Allowable Costs / Cost Principles § 200.302 § 200.403

2025-002 a. Name of Contact Person Responsible for Corrective Action: LaKenya Thomas– Executive Director of Finance & Business Affairs b. Corrective Action Planned: We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability and t...

2025-002 a. Name of Contact Person Responsible for Corrective Action: LaKenya Thomas– Executive Director of Finance & Business Affairs b. Corrective Action Planned: We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability and to ensure compliance with all state and federal grant requirements. c. Anticipated Completion Date: Immediately.

View Audit 410001

Finding 1228261 (2025-002)

Material Weakness 2025

Greater Seacoast Community Health

NH

Special Tests & Provisions Subrecipient Monitoring Reporting

Finding Number: 2025-002 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we identified four instances in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, in two instances, sliding fee adjustments we...

Finding Number: 2025-002 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we identified four instances in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, in two instances, sliding fee adjustments were applied based on individual procedure codes rather than the date of service. In one additional instance, an incorrect sliding fee adjustment was applied to the patient's balance. Collectively, these three errors resulted in patients being charged $311 more than required under the Organization's sliding fee discount program. We also identified one patient who received a sliding fee discount without an active sliding fee application for the applicable date of service and was therefore not eligible for the discount. Individual(s) Responsible for Corrective Action: Dean Correnti, CFO Planned Corrective Action: Sliding fee schedule is completed by the Dental Practice Manager on a case-by-case status. On a monthly basis, they are to be presented to the CFO for him to sign off on to verify all is correct. Any adjustments will be made quickly and correctly. The current policy for sliding fees has been updated, reviewed, and signed off by all parties involved. Anticipated Completion Date: Completed on March 1, 2026

View Audit 409999

Finding 1228259 (2025-001)

Material Weakness 2025

Prime Healthcare Foundation, Inc. and Subsidiaries

CA

Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.317 § 200.318 § 200.319

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the fed...

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company implemented the procurement policy it created on September 30, 2025, in response to prior audit findings 2024-001 and 2024-003, which occurred after the end of the federal award year for this program, that addresses this finding. This procurement policy complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest and governs the actions of its employees who select, award and administer procurement contracts. This policy includes procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised in accordance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and limits contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with related to this finding were not included on the SAM Exclusions listing. The Company has now filed the Notice of Federal Interest (“NFI”), and provided the NFI to the appropriate HRSA Grants Management Specialist. The Company also updated its procurement policy to ensure that, regardless of the award amount, it files an NFI against the property deed prior to construction of any project in the appropriate public records office of the jurisdiction in which the property is located and provides a copy to the appropriate HRSA Grants Management Specialist. Contact Person: Ela Lena, Chief Executive Officer of Southern Regional Hospital Expected completion date: Provide training to all employees who are relevant to the procurement process of federal contracts by September 30, 2026.

View Audit 409994

Finding 1228258 (2025-013)

Material Weakness 2025

District of Columbia Housing Authority

MD

HUD Housing Programs Special Tests & Provisions

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Material Weakness in Internal Control over Compliance for Special Tests and Provisions –Waiting List Recommendation: We recommend the Authority implements controls over the waiting list process to ensure all documentation is maint...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Material Weakness in Internal Control over Compliance for Special Tests and Provisions –Waiting List Recommendation: We recommend the Authority implements controls over the waiting list process to ensure all documentation is maintained at the time of each applicant is selected from the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: DCHA will re-establish the nonoperational Eligibility and Continued Occupancy Division (ECOD). ECOD will be responsible for waitlist management for the agency along with screening applicants for eligibility. Having these functions under one distinct division will allow DCHA to have standard operating procedures and workflows that are consistent with HUD’s regulations and requirements regarding waitlist management. Periodic quality assurance reviews by the Quality Assurance team will be conducted to identify deficiencies, provide corrective training, and ensure documentation is readily available to support HUD monitoring and audit requirements. Name(s) of the contact person(s) responsible for corrective action: Carolyn Kornegay Punter; Aisha Thompson; and Khaliah Payne. Planned completion date for corrective action plan: June 30, 2027 – End of 3rd Quarter, FY2027.

View Audit 409993

Finding 1228255 (2025-012)

Material Weakness 2025

District of Columbia Housing Authority

MD

HUD Housing Programs Special Tests & Provisions

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Material Weakness in Internal Control over Compliance for Special Tests and Provisions –Annual HQS Inspections Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are completed in accordan...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Material Weakness in Internal Control over Compliance for Special Tests and Provisions –Annual HQS Inspections Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are completed in accordance with their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The manager of inspections position will be backfilled by a person who is qualified to manage and assist the inspections supervisors with ensuring that all HQS initial, annual, biennial, and special inspections are scheduled, completed, and documented within HUDrequired timeframes. Supervisors will monitor inspection due dates through weekly compliance reports, assign overdue inspections for immediate completion. HCVP’s Quality Assurance division will conduct quality assurance reviews to verify timely processing of inspections. Name(s) of the contact person(s) responsible for corrective action: Carolyn Kornegay Punter; Aisha Thompson; Inspections Manager (Person TBD); and Khaliah Payne. Planned completion date for corrective action plan: March 31, 2027 – End of 2nd Quarter, FY2027.

View Audit 409993

Finding 1228252 (2025-011)

Material Weakness 2025

District of Columbia Housing Authority

MD

HUD Housing Programs Special Tests & Provisions

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Material Weakness in Internal Control over Compliance for Special Tests and Provisions --HQS Enforcement Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be c...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Material Weakness in Internal Control over Compliance for Special Tests and Provisions --HQS Enforcement Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements controls to ensure abatement is timely for units that do not correct the cited HQS deficiencies within the required timeframes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The manager of inspections position will be backfilled by a person who is qualified to direct and assist the inspection supervisors ensure that all HQS initial, annual, biennial, and special inspections are scheduled, completed, and documented within HUD-required timeframes. Supervisors will monitor inspection due dates through weekly compliance reports, assign overdue inspections for immediate completion, and conduct quality assurance reviews to verify timely processing. For units that fail HQS, staff will issue the required owner and participant notifications, accurately document all failed deficiencies and correction deadlines, and place the unit under Housing Assistance Payment (HAP) abatement, when required, in accordance with HUD regulations and DCHA policy. Supervisors will verify that abatement actions are timely, properly documented in Yardi and supported by complete case file documentation before the case is closed. Name(s) of the contact person(s) responsible for corrective action: Carolyn Kornegay Punter; Aisha Thompson; Inspections Manager (Person TBD); and Khaliah Payne. Planned completion date for corrective action plan: March 31, 2027 – End of 2nd Quarter, FY2027.

View Audit 409993

Finding 1228249 (2025-010)

Material Weakness 2025

District of Columbia Housing Authority

MD

HUD Housing Programs

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Material Weakness in Internal Control over Compliance -Eligibility Recommendation: We recommend the Authority staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Material Weakness in Internal Control over Compliance -Eligibility Recommendation: We recommend the Authority staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The Housing Choice Voucher Program will implement corrective measures to ensure all biennial recertifications are completed within HUD-required timeframes. The program will identify and prioritize all overdue recertifications, redistribute caseloads as necessary, conduct targeted outreach to participants to obtain required documentation, ensure third party verification of reported income is obtained and monitor progress through weekly supervisory reviews. Staff will receive refresher training on recertification requirements and processing procedures, and management will implement routine quality control reviews and performance tracking to prevent future delays. These actions are intended to eliminate the current backlog, improve compliance, ensure accurate Housing Assistance Payments and tenant rent calculations, and establish sustainable processes for timely completion of all future biennial recertifications. Name(s) of the contact person(s) responsible for corrective action: Carolyn Kornegay Punter; Aisha Thompson; Anton Shaw; and Khaliah Payne. Planned completion date for corrective action plan: December 31, 2026 – End of 1st Quarter, FY2027.

View Audit 409993

Corrective Action Plans

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