Corrective Action Plans

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Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include a fully executed HAP contract and tenancy addendum, including a review of the tenant file before the family moves in. Expl...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include a fully executed HAP contract and tenancy addendum, including a review of the tenant file before the family moves in. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The identified files predate newer controls that SHA has introduced to the leasing process. Workflows currently require the attachment of a lease and HAP contract for completion. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Plan has been implemented and the continuous elements remain in place.
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure NSPIRE inspections are conducted on schedule. These controls should include assigning a responsible individual to manage the inspection schedul...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure NSPIRE inspections are conducted on schedule. These controls should include assigning a responsible individual to manage the inspection schedule, as well as monitoring and following up on all inspection dates to prevent delayed or missed inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA was in the process of completing its corrective action plan in 2025 and addressing past due inspections. These inspections were correctly identified as part of the action plan and addressed, but the audit period took place prior to the action plan being completed. The inspections non-compliance workgroup from the previous year’s action plan has concluded its work and resolved outstanding inspections non-compliance. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Was in progress during this audit period and is now complete with the continuous aspects of the plan remaining in place.
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure enforcement of HQS. These controls should include assigning a responsible individual to manage the reinspection schedule and to monitor and fol...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure enforcement of HQS. These controls should include assigning a responsible individual to manage the reinspection schedule and to monitor and follow up on all reinspection dates, preventing inconsistent and missed reinspection. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The shift from HQS to NSPIRE protocol created a confusing inspection record with duplicate inspection entries. SHA has completed a review of all same day inspection entries and found no other examples of the first identified exception. In 2025 and 2026 SHA has strengthened oversight of inspections non-compliance processes. New workflows display units by category of action needed. Staff are able to see clearly what action is required and supervisors and the compliance team review the workflows regularly for accountability. The inspections non-compliance workgroup from the previous year’s action plan has concluded its work and resolved outstanding inspections non-compliance. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Was in progress during this audit period and is now complete.
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing eligibility, in accordance with federal regulation and Authority policy....
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing eligibility, in accordance with federal regulation and Authority policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA has adopted the HUD form 9886-A which does not expire. Due to SHA’s triennial review process, not all participants have been required to sign the new 9886-A and update SHA General Release of Information. All participants will be updated to the new forms at the end of the triennial cycle. Additionally, all elements of the 2025-002 action plan apply to this finding. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Continuous.
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure housing inspections are performed when due. Such controls should include assigning a responsible individual to manage the inspection schedule and to...
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure housing inspections are performed when due. Such controls should include assigning a responsible individual to manage the inspection schedule and to monitor and follow up on all inspection dates to prevent missed inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA was in the process of completing its corrective action plan in 2025 and addressing past due inspections. This unit was appropriately identified as needing inspection and added to the action plan. Prior to an inspection the participant left the program and no inspection was necessary as the unit was no longer under a HAP contract. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Was in progress during this audit period and is now complete.
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing eligibility, in accordance with federal regulation and Authority policy. Expl...
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing eligibility, in accordance with federal regulation and Authority policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA has added multiple additional elements to a total quality management approach to certification processing. An additional occupancy manager was hired in 2025 to increase oversight capacity for eligibility and certification processes. Also 5 additional certification specialists are in training to add overall work capacity, with training planned to be completed in August of 2026. The additional certification specialists will mitigate the impacts of staff turnover and large caseloads. A rollout of KPI reporting and accountability measures is currently underway and will be completed by September 2026. The reporting includes individual level review of current work in multiple areas as well as manager review templates for increased visibility and accountability. Monthly trainings in 2026 will highlight documentation and timeline requirements. The one tenant file noted for lack of supporting documentation that the reexamination was complete is a project-based voucher unit operated by the Housing Operations Department under Move to Work activity 15.A.01. This activity enables the Authority to manage project-based voucher units under the public housing program regulations. The corrective action plan for this issue reflects this activity. Housing Operations has recently implemented a new Electronic Filing System Guide and updated procedures outlining electronic filing and record retention requirements. The updated procedure establishes a requirement for supervisors to regularly audit the quality, accuracy, and timeliness of file documentation. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa and Dave Wellings Planned completion date for corrective action plan: Continuous. Compliance will provide staff with refresher training on the new filing system guide and procedures, as well as Rent Calculation Training that includes guidance on income determination and income verification standards. Compliance will continue to conduct regular audits of public housing eligibility and recertification files to ensure ongoing adherence to HUD requirements and SHA policy.
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing income eligibility, in accordance with federal regulation and Authority polic...
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing income eligibility, in accordance with federal regulation and Authority policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Housing Operations has recently implemented a new Electronic Filing System Guide and updated procedures outlining electronic filing and record retention requirements. The updated procedure establishes a requirement for supervisors to regularly audit the quality, accuracy, and timeliness of file documentation. Compliance will provide staff with refresher training on the new filing system guide and procedures, as well as Rent Calculation Training that includes guidance on income determination and income verification standards. Compliance will continue to conduct regular audits of public housing eligibility and recertification files to ensure ongoing adherence to HUD requirements and SHA policy. Name(s) of the contact person(s) responsible for corrective action: Dave Wellings Planned completion date for corrective action plan: Year end 2026 and then on-going training and internal audit procedures.
Condition The Authority's Single Audit and reporting package was delayed for the year ended December 31, 2024 beyond the nine-month due date, as a result of delays in reconciling federal and state award activity with the Commonwealth. Corrective Action Plan Corrective Action Planned: Fiscal year 202...
Condition The Authority's Single Audit and reporting package was delayed for the year ended December 31, 2024 beyond the nine-month due date, as a result of delays in reconciling federal and state award activity with the Commonwealth. Corrective Action Plan Corrective Action Planned: Fiscal year 2024 represented a significant transition period for the Authority. During the year, the Board of Directors appointed a new Chief Financial Officer and engagement a new auditor. The transition required substantial effort to transfer institutional knowledge, review historical accounting records, reconcile significant grant activity and establish a new audit process. As a result of these transition activities, the Authority’s 2024 financial statements were not certified until September 29, 2025, leaving insufficient time to complete and submit the required Single Audit reporting package by the required due date. The Authority’s 2025 Audit was presented to the Board of Directors for acceptance during the July board meeting and will be filed shortly thereafter. Management has implemented the necessary procedures and revised its audit timeline to ensure compliance with all future reporting requirements. Accordingly, the Authority expects to remain fully compliance with the filing deadlines prescribed under the Uniform Guidance for the 2025 and all subsequent audit periods. Name(s) of Contact Person(s) Responsible for Corrective Action: Chief Financial Officer Anticipated Completion Date: August 2026
Name of auditee: St. Mark’s Terrace Dundee Housing Development Fund Corporation TIN: 014-EE011 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2025 CAP prepared by: Jaimi Shoemaker Executive Director Current Finding on the Schedule of Findings and Questioned Costs an...
Name of auditee: St. Mark’s Terrace Dundee Housing Development Fund Corporation TIN: 014-EE011 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2025 CAP prepared by: Jaimi Shoemaker Executive Director Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (1) Finding 2025-001 (a) Comments on the finding and recommendation: Management agrees with the finding. Management also agrees with the recommendation. Please see below for action taken. (b) Action taken: Management deposited the delinquent amount of $2,053 to the residual receipts account on May 13, 2026.
2025-005 Special Tests Corrective action planned: WBC Management agrees with this finding. WBC has created and hired for a new position, Revenue Cycle Manager (RCM). The RCM has oversight of Revenue generated through the FQHC Clinics. As part of this oversight, the RCM is implementing training for F...
2025-005 Special Tests Corrective action planned: WBC Management agrees with this finding. WBC has created and hired for a new position, Revenue Cycle Manager (RCM). The RCM has oversight of Revenue generated through the FQHC Clinics. As part of this oversight, the RCM is implementing training for Front Office staff that are responsible for gathering and inputting client data related to calculation of the Slide. In addition to internal training of Front Office staff, WBC will be engaging an external expert to review and revise applicable policies and procedures to ensure alignment with best practices. The RCM is also responsible for conducting periodic internal reviews of documentation supporting Slide calculations to ensure support matches with the calculated Slide rate. Anticipated completion date: 2026, July Contact person responsible for corrective action: Amee Markwardt, Executive Director
2025-004 Reporting Corrective action planned: WBC Management agrees with this finding. WBC had to switch EHRs during 2023 and 2024, which required our Dental, Medical, and Behavioral Health programs to use their own separate EHR to alleviate critical functional and capacity deficiencies that were ca...
2025-004 Reporting Corrective action planned: WBC Management agrees with this finding. WBC had to switch EHRs during 2023 and 2024, which required our Dental, Medical, and Behavioral Health programs to use their own separate EHR to alleviate critical functional and capacity deficiencies that were caused by our previous EHR. This resulted in significantly more complexity when calculating our UDS numbers. The process involved combining all of our patient demographics and accounting for overlapping (duplicate encounters) by hand. This was made all the more difficult by name misspellings and other errors during data entry. Relating to our prior year finding, WBC had contracted with a third party to implement a custom population health tool to automate our UDS reporting. The contractor did not meet specified deliverable requirements, so reporting was again done manually, which resulted in the errors. White Bird Clinic has been working to evaluate population health tools to aggregate patient data to provide more accurate UDS and clinical quality reporting. In 2026, through the help of our HCCN, Health Efficient, we contracted with Relevant Health to implement their population health tool to streamline and accurately report our population health and our UDS reporting. The Relevant platform is in use by over 100 FQHCs across the country. This tool will aggregate patient data from each EHR, account for duplicates, and accurately report combined UDS demographics from all our systems. They are very experienced with UDS and UDS+ reporting, so the system is designed to seamlessly provide accurate and consistent UDS metrics and address duplicate clients from multiple EHRs. Anticipated completion date: 2026, July Contact person responsible for corrective action: Tyler Stewart, Director of IT
2025-003 Internal Control Over Payroll Charged to Federal Awards Corrective action planned: WBC Management agrees with this finding. With the onboarding of a new Director of Human Resources, best practices around payroll documentation have been implemented. This includes individual forms for all wag...
2025-003 Internal Control Over Payroll Charged to Federal Awards Corrective action planned: WBC Management agrees with this finding. With the onboarding of a new Director of Human Resources, best practices around payroll documentation have been implemented. This includes individual forms for all wage changes per employee. Approval is documented with Supervisors’ signatures on these forms. The wage form is used to update the payroll system and a final accuracy review is performed by the HR Director to verify the updated rated matches the approved change form. The approved wage forms are securely stored in the Human Resources files. Anticipated completion date: 2026, July Contact person responsible for corrective action: Jonathan Gunther, Director of Finance
The agency acknowledges the findings related to the timeliness of vendor payments, financial reporting, and the availability of accounting records during the audit period. These issues were largely the result of a significant transition period for the organization, including changes in leadership, t...
The agency acknowledges the findings related to the timeliness of vendor payments, financial reporting, and the availability of accounting records during the audit period. These issues were largely the result of a significant transition period for the organization, including changes in leadership, turnover in key finance and operations roles, and the implementation of new financial software. Managing these changes at the same time created temporary disruptions in our accounting workflows, transaction processing, and reporting timelines. Since then, we have taken the necessary steps to address these challenges and strengthen our accounting and reporting processes. All key finance and operations positions have now been filled, including critical accounting and business management roles, which has improved oversight, accountability, and the timely processing of financial transactions. We have also stabilized our financial systems and strengthened internal processes related to reconciliations, vendor payments, transaction recording, and grant reporting. We believe these corrective actions have addressed the root causes identified in this finding and have significantly improved our ability to meet the accounting, reporting, and audit requirements of our federal, state, and NYC funding sources moving forward. We will continue to monitor our internal controls and reporting timelines to ensure ongoing compliance and stronger operational efficiency.
Planned Corrective Action: The District recognizes and understands the incorrect calculation of the Federal indirect cost rate applicable to the 2024-25 fiscal year and has prepared subsequent indirect rate calculations for the fiscal years 2025-26 and 2026-27 that included other expenditures (i.e. ...
Planned Corrective Action: The District recognizes and understands the incorrect calculation of the Federal indirect cost rate applicable to the 2024-25 fiscal year and has prepared subsequent indirect rate calculations for the fiscal years 2025-26 and 2026-27 that included other expenditures (i.e. charter school expenditure) that were incorrectly omitted in the rate for the 2024-25 fiscal year. Anticipated completion date: July 1, 2025 Responsible Contact Person: Walter Copeland, CFO
Views of Reasonable Officials and Corrective Actions Organization will engage in assessing specific staffing needs (FY26), seeking additional funds (FY26 & FY27),and increasing the capacity of the team in charge of providing services in accounting and organizational funds(FY27) in order to achieve a...
Views of Reasonable Officials and Corrective Actions Organization will engage in assessing specific staffing needs (FY26), seeking additional funds (FY26 & FY27),and increasing the capacity of the team in charge of providing services in accounting and organizational funds(FY27) in order to achieve accurate and timely reporting. Name(s) of the Contact Person(s) Responsible for Corrective Action Rafael A Torruella, Ph.D.- Executive Director Anticipated Completion Date During FY 2025-2026 & FY2026-2027
Management is Responsible for Obtaining and Retaining Patient Intake Forms to Remain Compliant with Sliding Fee Discount Requirements Management’s view: Management agrees with the condition described. Proposed corrective action: Management will strengthen procedures for obtaining and retaining patie...
Management is Responsible for Obtaining and Retaining Patient Intake Forms to Remain Compliant with Sliding Fee Discount Requirements Management’s view: Management agrees with the condition described. Proposed corrective action: Management will strengthen procedures for obtaining and retaining patient intake documentation to ensure ongoing compliance with sliding fee discount requirements. Front-desk and registration staff will be retrained on intake form completion and annual renewal requirements, with clear accountability assigned for verifying documentation at each patient visit. A weekly compliance monitoring report will be implemented to identify missing or outdated intake forms before they age past the current review period, allowing for timely follow-up. Registration workflows will be refined to build in a review checkpoint at the point of service, and the Organization will add dedicated intake staffing capacity to provide consistent oversight of this function going forward. These steps will strengthen controls and ensure patient intake documentation is properly obtained, updated, and retained in compliance with sliding fee discount requirements. Anticipated correction date: Some corrective action was implemented in Q1 and Q2 2026. This is expected to be fully implemented effective by Q4 2026. Responsible official: Kathryn Rogers, Executive Vice President
The Metcalfe County Fiscal Court will establish internal controls over the federal expenditure process when a third-party entity is involved to ensure all compliance and recording requirements are met. Although the Metcalfe County Fiscal Court was in compliance with federal requirements when tested ...
The Metcalfe County Fiscal Court will establish internal controls over the federal expenditure process when a third-party entity is involved to ensure all compliance and recording requirements are met. Although the Metcalfe County Fiscal Court was in compliance with federal requirements when tested by a single audit, having these procedures in place will ensure that all future federal expenditures will remain in compliance.
Authority's Response and Planned Corrective Action Plan: The Authority agrees with the finding and will implement procedures to perform and document annual utility allowance reviews in accordance with HUD requirements and maintain supporting documentation for future reviews. Tyler Martin, Executive ...
Authority's Response and Planned Corrective Action Plan: The Authority agrees with the finding and will implement procedures to perform and document annual utility allowance reviews in accordance with HUD requirements and maintain supporting documentation for future reviews. Tyler Martin, Executive Director, is responsible for ensuring the deficiencies have been rectified by June 30, 2026.
Authority's Response and Planned Corrective Action Plan: The Authority has recognized the material weakness in the Project Based Rental Assistance program and will implement internal control procedures that will ensure compliance with federal regulations. Tyler Martin, Executive Director, is respons...
Authority's Response and Planned Corrective Action Plan: The Authority has recognized the material weakness in the Project Based Rental Assistance program and will implement internal control procedures that will ensure compliance with federal regulations. Tyler Martin, Executive Director, is responsible for ensuring the deficiencies have been rectified by June 30, 2026.
Authority's Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Project Based Rental Assistance program to ensure that established internal control policies are being followed on a timely basis. Tyler Mart...
Authority's Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Project Based Rental Assistance program to ensure that established internal control policies are being followed on a timely basis. Tyler Martin, Executive Director, is responsible for ensuring the deficiencies have been rectified by June 30, 2026.
Authority's Response and Planned Corrective Action Plan: The Authority agrees with the finding and will strengthen payroll review procedures to ensure compensation is properly authorized, documented, and reconciled to Board-approved salary schedules. Tyler Martin, Executive Director, is responsible ...
Authority's Response and Planned Corrective Action Plan: The Authority agrees with the finding and will strengthen payroll review procedures to ensure compensation is properly authorized, documented, and reconciled to Board-approved salary schedules. Tyler Martin, Executive Director, is responsible for ensuring the deficiencies have been rectified by June 30, 2026.
Eligibility for the Child Nutrition Cluster (Federal Award) Implement system edits or procedural checks to prevent duplicate eligibility entries for the same student, including unique student identifiers and warning prompts. Periodically run and review reports identifying potential duplicate records...
Eligibility for the Child Nutrition Cluster (Federal Award) Implement system edits or procedural checks to prevent duplicate eligibility entries for the same student, including unique student identifiers and warning prompts. Periodically run and review reports identifying potential duplicate records (same student ID, name, date of birth) and investigate and clear duplicates. Provide training to Nutrition Services staff on maintaining an unduplicated eligibility file and correcting errors. Responsible Party - Child Nutrition Analyst Target Completion - December 31, 2026
Time & Effort Documentation. Due to the timing of the retirement of the SPED Administrative Assistant who was responsible for documenting the time & effort of staff paid for from the SPED 240 Grant, the necessary paperwork/documentation was not collected as required. The Corrective Action Plan will ...
Time & Effort Documentation. Due to the timing of the retirement of the SPED Administrative Assistant who was responsible for documenting the time & effort of staff paid for from the SPED 240 Grant, the necessary paperwork/documentation was not collected as required. The Corrective Action Plan will consist of training the new SPED Administrative Assistant on this requirement, and to have multiple check-ins during the year with the Director of Support Services and the SPED Administrative Assistant on this requirement. Lastly, we are taking the additional step to add language into each annual payroll contract of staff funded from the SPED 240 Grant, that they are funded, and to what proportion, by that grant. This will be overseen by the School Business Administrator in concert with the Director of Support Services, and will be effective for the FY26 Single Audit cycle.
The Partnership will implement controls to ensure that program costs are not incurred or charged to federal awards until formal award and budget approval has been received. This will include a required verification step within the finance function prior to cost authorization, documented evidence of ...
The Partnership will implement controls to ensure that program costs are not incurred or charged to federal awards until formal award and budget approval has been received. This will include a required verification step within the finance function prior to cost authorization, documented evidence of approval dates, and staff training on allowability and timing requirements. Existing procedures will be updated to prevent premature charging of expenditures and to ensure ongoing compliance with Uniform Guidance.
The Partnership will develop and implement comprehensive written subrecipient monitoring and procurement policies aligned with Uniform Guidance. Procedures will include verification of suspension and debarment status (e.g., SAM.gov), incorporation of required compliance terms in subaward agreements,...
The Partnership will develop and implement comprehensive written subrecipient monitoring and procurement policies aligned with Uniform Guidance. Procedures will include verification of suspension and debarment status (e.g., SAM.gov), incorporation of required compliance terms in subaward agreements, tracking of subrecipient funding by program, implementation of a risk-based monitoring framework, and documentation of monitoring activities including financial and programmatic reviews. Staff will be trained on these updated procedures, and compliance reviews will be centralized within the finance and administrative function.
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