Corrective Action Plans

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Finding 2025-005 – Tenant Files – Eligibility – ALN 14.871 Housing Choice Voucher Program – Noncompliance and Material Weakness Corrective Action Plan: Immediate Corrective Actions are: • Begin targeted quality-control reviews of HCV and public housing files; • Correct missing or incomplete document...
Finding 2025-005 – Tenant Files – Eligibility – ALN 14.871 Housing Choice Voucher Program – Noncompliance and Material Weakness Corrective Action Plan: Immediate Corrective Actions are: • Begin targeted quality-control reviews of HCV and public housing files; • Correct missing or incomplete documentation; • Verify income calculations and deductions; • Confirm citizenship and identity documentation; • Confirm HAP contracts and EIV reports; • Confirm inspections and annual recertifications; • Review lead-based paint disclosures; and document corrective actions. Following the adoption of updated formal policies and procedures – implement long term corrective actions. Long Term: • Establish a formalized, organization-wide QA/QC and Monitoring Framework that includes: o File Reviews o Wait List QC Checklists & Wait List Archive Requirements o IMS/PIC Reporting Controls o Procurement Reviews o Financial Reviews o Internal Audit Checklists o Internal Monitoring Schedule o Corrective Action Tracking • Create a structured monitoring schedule to verify that internal controls continue to operate exactly as designed. • Develop a standardized reporting template to log control exceptions, track communication protocols, and document the successful remediation of identified deficiencies. • Develop standardized onboarding program that incorporates training on core organizational policies, ethical expectations and foundational internal control responsibilities. • Develop Agency-Wide Training Calendar and CE Requirements and Annual Policy Certifications and employ a system to track and archive all. Person Responsible: Jennifer Oberlin, Executive Director, with oversight and approval by the Board of Commissioners, where applicable. Anticipated Completion Date: February 26, 2027
Finding 2025-002 – Policies and Procedures Require Review and Update – ALN 14.871 Housing Choice Voucher Program, ALN 14.850 Low Rent Public Housing, ALN 14.872 Capital Fund Program – Significant Deficiency Corrective Action Plan: Strengthening Board governance, ethical expectations, policy ownershi...
Finding 2025-002 – Policies and Procedures Require Review and Update – ALN 14.871 Housing Choice Voucher Program, ALN 14.850 Low Rent Public Housing, ALN 14.872 Capital Fund Program – Significant Deficiency Corrective Action Plan: Strengthening Board governance, ethical expectations, policy ownership, accountability, and delegated authority. Initial Deliverables • Code of Ethics; • Conflict-of-Interest Policy; • Whistleblower and Reporting Policy; • Delegation of Authority Matrix; • Spending and Approval Authority Matrix; • Signature Authority Matrix; • Policy Development and Review Policy; • Board Governance Framework; • Annual policy acknowledgment process; and • Governance training plan. Standardize the Housing Authority’s major operating processes and reduce reliance on undocumented institutional knowledge. Initial Deliverables • Standard Operating Procedure framework; • Priority SOP inventory; • Housing Choice Voucher processing SOPs; • Public housing occupancy and recertification SOPs; • Waiting-list administration SOPs; • Inspection scheduling and tracking procedures; • Intake and communication procedures; • Position-responsibility matrix; • Updated job descriptions; • Workload assessment; • Staff onboarding procedures; and • Cross-training plan. Improve financial accuracy, safeguarding of assets, segregation of duties, reconciliations, reporting, and management review. Initial Deliverables • Financial Policies and Procedures Manual; • Accounts-payable controls; • Check-run and payment-review procedures; • Payroll approval procedures; • Cash-handling procedures; • Laundry-revenue procedures; • Bank and general-ledger reconciliation procedures; • Monthly and annual financial-review checklist; • Audit-adjustment reconciliation procedures; • Fixed-asset and nonexpendable-equipment inventory procedures; • Capitalization policy update; • Investment policy update; • Creative Housing financial-accounting review; • Inter-entity transaction policy; • Corrective-action plan for questioned costs; • Financial close calendar; • CFO and Executive Director review responsibilities; and • Board financial dashboard. Person Responsible: Jennifer Oberlin, Executive Director, with oversight and approval by the Board of Commissioners, where applicable. Anticipated Completion Date: • Phase 1: Target Date of completion: November 30, 2026 o Implementation and Communication about the Red Flags Ethics Hotline o Identification and creation of needed policies and structural tools o Updating of current policies as needed • Phase 2: Target Date of Completion: April 30, 2027 o Training on new policies/expectations and accountability standards.
Finding 2025-004 – Procurement Deficiencies – Procurement and Suspension and Debarment – ALN 14.850 Low Rent Public Housing, ALN 14.872 Capital Fund Program – Noncompliance and Material Weakness Corrective Action Plan: Adopt the Local Public Agency provisions of the Kentucky Model Procurement Code c...
Finding 2025-004 – Procurement Deficiencies – Procurement and Suspension and Debarment – ALN 14.850 Low Rent Public Housing, ALN 14.872 Capital Fund Program – Noncompliance and Material Weakness Corrective Action Plan: Adopt the Local Public Agency provisions of the Kentucky Model Procurement Code contained in KRS 45A.345 through KRS 45A.460 as the Housing Authority's in conjunction with applicable federal requirements and HUD regulations as our procurement framework. Immediate Corrective Actions: o Require written procurement planning before major purchases; o Verify the correct procurement method based on the total anticipated contract value; o Require complete documentation of competition; o Document sole-source determinations when applicable; o Require Board approval for major procurements as established by revised policy; o Preserve bids, quotes, evaluations, approvals, contracts, and payment records; o Review pending procurements before award. Create a Procurement and Contract Administration Manual to include: • Procurement thresholds and approval requirements; • Board-approval requirements for major procurements; • Independent Cost Estimate procedures; • Cost and price analysis procedures; • Small-purchase procedures; • Sealed-bid procedures; • Competitive-proposal procedures; • Sole-source and noncompetitive procurement procedures; • Emergency procurement procedures; • Procurement planning checklist; • Solicitation templates; • Evaluation and scoring forms; • Conflict-of-interest certifications; • Procurement-file checklist; • Contract monitoring procedures; • Change-order procedures; • Invoice-review procedures; • Contract-closeout checklist; and Procurement training. Person Responsible: Jennifer Oberlin, Executive Director, with oversight and approval by the Board of Commissioners, where applicable. Anticipated Completion Date: October 30, 2026
Finding 2025-006 – Tenant Files – Eligibility – ALN 14.850 Low Rent Public Housing Program – Noncompliance and Material Weakness Corrective Action Plan: Immediate Corrective Actions are: • Begin targeted quality-control reviews of HCV and public housing files; • Correct missing or incomplete documen...
Finding 2025-006 – Tenant Files – Eligibility – ALN 14.850 Low Rent Public Housing Program – Noncompliance and Material Weakness Corrective Action Plan: Immediate Corrective Actions are: • Begin targeted quality-control reviews of HCV and public housing files; • Correct missing or incomplete documentation; • Verify income calculations and deductions; • Confirm citizenship and identity documentation; • Confirm HAP contracts and EIV reports; • Confirm inspections and annual recertifications; • Review lead-based paint disclosures; and document corrective actions. Following the adoption of updated formal policies and procedures – implement long term corrective actions. Long Term: • Establish a formalized, organization-wide QA/QC and Monitoring Framework that includes: o File Reviews o Wait List QC Checklists & Wait List Archive Requirements o IMS/PIC Reporting Controls o Procurement Reviews o Financial Reviews o Internal Audit Checklists o Internal Monitoring Schedule o Corrective Action Tracking • Create a structured monitoring schedule to verify that internal controls continue to operate exactly as designed. • Develop a standardized reporting template to log control exceptions, track communication protocols, and document the successful remediation of identified deficiencies. • Develop standardized onboarding program that incorporates training on core organizational policies, ethical expectations and foundational internal control responsibilities. • Develop Agency-Wide Training Calendar and CE Requirements and Annual Policy Certifications and employ a system to track and archive all. Person Responsible: Jennifer Oberlin, Executive Director, with oversight and approval by the Board of Commissioners, where applicable. Anticipated Completion Date: February 26, 2027
Finding 2025-003 – Public Housing Advance to Creative Housing Limited Partnership – ALN 14.850 Low Rent Public Housing Program – Noncompliance and Material Weakness Corrective Action Plan: • Determine the status and appropriate repayment plan for the questioned public housing advance; • Obtain and r...
Finding 2025-003 – Public Housing Advance to Creative Housing Limited Partnership – ALN 14.850 Low Rent Public Housing Program – Noncompliance and Material Weakness Corrective Action Plan: • Determine the status and appropriate repayment plan for the questioned public housing advance; • Obtain and reconcile mortgage-note statements; • Determine the correct accounting and financial-statement presentation; • Obtain missing prior-year financial and tax records; • review inter-entity transactions; and • Establish written approval requirements for future advances, loans, or transfers. Person Responsible: Jennifer Oberlin, Executive Director, with oversight and approval by the Board of Commissioners, where applicable. Anticipated Completion Date: November 30, 2026
Corrective Action Plan: The City of Charleston will implement internal controls and procedures to ensure all required reports are prepared, reviewed, and submitted within the program’s required timeframes, and with the correct amounts. Anticipated Completion Date: Fiscal Year 2026
Corrective Action Plan: The City of Charleston will implement internal controls and procedures to ensure all required reports are prepared, reviewed, and submitted within the program’s required timeframes, and with the correct amounts. Anticipated Completion Date: Fiscal Year 2026
Corrective Action Plan for Finding 2025-002 Finding Title: Noncompliance with Single Audit Report Submission Requirements Federal Program(s): All programs included in the FY 2025 Single Audit Contact Person Responsible for Corrective Action: Dr. Veronica Morley, Superintendent Anticipated Completion...
Corrective Action Plan for Finding 2025-002 Finding Title: Noncompliance with Single Audit Report Submission Requirements Federal Program(s): All programs included in the FY 2025 Single Audit Contact Person Responsible for Corrective Action: Dr. Veronica Morley, Superintendent Anticipated Completion Date: March 31, 2027 Corrective Action Plan: Management concurs with the finding. The delay in submitting the Single Audit reporting package to the Federal Audit Clearinghouse was due delayed completion of audited financial statements. The school is in the process of getting current with audited financials statements.
Condition: The Town incurred and charged expenditures totaling $30,826 to a FEMA Public Assistance project after the approved period of performance ended on October 31, 2024. The Town submitted a formal request to extend the period of performance on September 8, 2025. As of March 19, 2026, FEMA had ...
Condition: The Town incurred and charged expenditures totaling $30,826 to a FEMA Public Assistance project after the approved period of performance ended on October 31, 2024. The Town submitted a formal request to extend the period of performance on September 8, 2025. As of March 19, 2026, FEMA had communicated that the extension request has been denied. However, FEMA reimbursed the Town for the expenditures incurred after October 31, 2024. As of the date of this audit report, FEMA has not indicated whether the reimbursement will ultimately be retained or subject to recovery. Corrective Action Plan Corrective Action Planned: The Town will implement a grant expenditure review checklist requiring pre-approval for any costs beyond the approved period; train all grant staff on compliance requirements; update internal controls. The Town will also document all correspondence whether that be by phone, email or written correspondence with FEMA when it comes to deadline extensions. The Town’s FEMA-funded recovery projects are complex, multi-year projects associated with rebuilding the community. Many projects have extended beyond their original completion dates due to factors including the pandemic, supply-chain and world trade impacts, weather, labor availability, construction timelines, and contract procurement requirements. In addition, frequent turnover among FEMA personnel assigned to the Town’s recovery projects has at times resulted in changes in points of contact, delays in responses, and extended processing times for approvals, determinations, and extension requests. These circumstances have contributed to the length and complexity of administering projects that already require significant coordination over multiple years. The Town has continued to work closely with FEMA throughout this process and has received approvals for extensions on recovery projects. In this instance, the expenditures identified in the finding occurred after the original October 31, 2024 period and were ultimately reimbursed by FEMA. Name(s) of Contact Person(s) Responsible for Corrective Action: Aimee Beleu, Finance Director Anticipated Completion Date: The corrective action will be implemented to take effect for the audit of the FY 2025-26 financial statements.
Condition: The Town did not submit its single audit reporting package or data collection form within the required timeline. Corrective Action Plan Corrective Action Planned: The Town will establish internal deadlines to submit the report at least 30 days before the federal due date. The responsibili...
Condition: The Town did not submit its single audit reporting package or data collection form within the required timeline. Corrective Action Plan Corrective Action Planned: The Town will establish internal deadlines to submit the report at least 30 days before the federal due date. The responsibility to track audit milestones and communicate progress to management weekly will be assigned to the Grant Accountant, and the Town will schedule earlier engagement with the external auditor and ensure all required documentation is accurately prepared. The Town’s delay in submitting the Single Audit was due in part by the timing of the prior-year audit, which was not received until late and compressed the timeline for beginning and completing the subsequent audit. This occurred during a period of significant turnover within the Finance Department, including the loss of institutional knowledge related to grant reporting, audit preparation, and year-end closing procedures. The department has since restructured and expanded staffing, strengthened training, and developed additional procedures, workbooks, and guides to improve continuity and reduce reliance on individual staff knowledge. The Town has also improved its grant tracking and audit preparation processes, including standardized project account structures, enhanced reconciliation workbooks, and earlier preparation of the SEFA and supporting documentation. Finance is in the process of FY 2025-26 closing process earlier so that reconciliations, year-end adjustments, grant documentation, and audit schedules can be completed well in advance of fieldwork and prevent prior-year audit delays from continuing into future audit cycles. Name(s) of Contact Person(s) Responsible for Corrective Action: Aimee Beleu, Finance Director Anticipated Completion Date: The corrective action will be implemented to take effect for the audit of the FY 2025-26 financial statements.
CORRECTIVE ACTION PLAN NOVEMBER 30, 2025 U. S. Department of Housing and Urban Development K.P.C. Apartments, Phase II (the "Project") respectfully submits the following corrective action plan for the year ended November 30, 2025. Audit Firm: Harper, Rains, Knight & Company, P.A. 1052 Highland Colon...
CORRECTIVE ACTION PLAN NOVEMBER 30, 2025 U. S. Department of Housing and Urban Development K.P.C. Apartments, Phase II (the "Project") respectfully submits the following corrective action plan for the year ended November 30, 2025. Audit Firm: Harper, Rains, Knight & Company, P.A. 1052 Highland Colony Parkway, Suite 100 Ridgeland, MS 39157 Audit Period: Year Ended November 30, 2025 Audit Finding Reference: 2025-001 Planned Corrective Action Management will submit a request to HUD for authorization of the distribution of the residual receipt funds. Name of Contact Person: If the U. S. Department of Housing and Urban Development for audit has questions regarding this plan, please call Rick Greene at 601-714-8349. Sincerely, K.P.C. Apartments, Phase II By Inventive Property Management Company
Corrective action planned: All required funding source information will be included in partner contracts moving forward. Corrective action plan is 2 fold: 1. OCH will email all 2026 subawardees the required funding source information and save this documentation within the appropriate contract folder...
Corrective action planned: All required funding source information will be included in partner contracts moving forward. Corrective action plan is 2 fold: 1. OCH will email all 2026 subawardees the required funding source information and save this documentation within the appropriate contract folder. 2. OCH will update it’s contract templates to include funding source information and all future contracts will include this within the contract. Anticipated completion date: By August 31, OCH will communicate funding source information with current 2026 subawardees. By September 1, OCH will update contract templates to include funding source information and all future contracts will have this information included in the contract. Contact person responsible for corrective action: Miranda Burger
Responsible Official: Marcos A. Rivera Sánchez, Executive Director Management acknowledges the condition identified in the audit: the perpetual inventory system calculates inventory costs using the weighted average method, while the entity's established methodology for valuing USDA Foods is FIFO. Be...
Responsible Official: Marcos A. Rivera Sánchez, Executive Director Management acknowledges the condition identified in the audit: the perpetual inventory system calculates inventory costs using the weighted average method, while the entity's established methodology for valuing USDA Foods is FIFO. Because the system does not support FIFO, inventory costs must be recalculated manually at year end, resulting in significant adjustments and indicating that perpetual inventory records maintained during the year do not reconcile to USDA-assigned costs. To address this issue, management will implement the following corrective actions consistent with the audit recommendation: - Evaluate and configure the inventory system to apply the FIFO costing method or adopt a system capable of reflecting USDA-assigned costs. - Develop and implement formal written procedures requiring periodic reconciliation between the perpetual inventory, accounting records, and USDA costs assignments. - Document and investigate any differences identified during reconciliations to ensure accurate, complete, and compliant inventory records in accordance with 7 CFR 250.19. These actions are intended to eliminate the need for significant manual adjustments at year end, strenghten inventory valuation controls, and ensure compliance with USDA requirements. Anticipated Completion Date: December 31, 2026.
Effective immediately, New St. Paul Head Start Agency, Inc. will use the agency’s internal calendar system to provide the Fiscal Director with advance notification of all SF-425 report due dates.
Effective immediately, New St. Paul Head Start Agency, Inc. will use the agency’s internal calendar system to provide the Fiscal Director with advance notification of all SF-425 report due dates.
Views of Responsible Officials and Planned Corrective Action: Management acknowledges that, for certain reimbursement requests, documentation evidencing review and approval prior to submission was not retained. Management notes, however, that the underlying expenditures included in the reimbursement...
Views of Responsible Officials and Planned Corrective Action: Management acknowledges that, for certain reimbursement requests, documentation evidencing review and approval prior to submission was not retained. Management notes, however, that the underlying expenditures included in the reimbursement requests were valid, properly recorded in the general ledger, and supported by appropriate accounting records. No questioned costs were identified, and the amounts requested for reimbursement were consistent with allowable program expenditures. Management believes the condition was limited to documentation of review rather than the absence of an actual review process. Reimbursement requests were prepared using underlying financial records and submitted based on incurred costs; however, evidence of supervisory review was not consistently retained during a period of staffing transition. Upon identification, management evaluated its cash management and drawdown processes and reinforced expectations related to documentation and retention of review and approval. Review and approval of reimbursement requests are now consistently evidenced through electronic or physical sign off, and supporting documentation is maintained in a centralized and accessible manner. In addition, management has reinforced alignment of drawdown activity with underlying accounting records to ensure consistency between reimbursement requests, financial reporting, and the general ledger. Management believes this condition represents a documentation gap during a defined period rather than a systemic breakdown in internal control over compliance. The underlying control activities—preparation of drawdowns based on recorded expenditures and supervisory oversight—were in place and functioning, and the enhancements implemented ensure consistent documentation and retention of those controls going forward. Management will continue to monitor these processes as part of ongoing financial operations to ensure compliance with applicable requirements, including 2 CFR Part 200. Management respectfully notes that this condition was limited to the retention of documentation evidencing review and approval and did not impact the allowability of costs, the accuracy of reimbursement requests, or compliance with program requirements. All expenditures were properly supported and recorded, and no questioned costs were identified.
Views of Responsible Officials and Planned Corrective Action: Management acknowledges that certain required financial and narrative reports were not submitted within the prescribed timelines and that documentation supporting the preparation and review of one cumulative report was not retained. Manag...
Views of Responsible Officials and Planned Corrective Action: Management acknowledges that certain required financial and narrative reports were not submitted within the prescribed timelines and that documentation supporting the preparation and review of one cumulative report was not retained. Management notes, however, that all required reports were ultimately completed and submitted, and no questioned costs were identified. Management believes the condition reflects a lapse in consistent execution and documentation of existing reporting processes during a period of staffing transition, rather than a fundamental breakdown in the underlying control environment. The underlying financial data supporting the reports was complete and accurate, and the delays did not impact the allowability of expenditures or program compliance. Upon identification, management conducted a review of reporting processes and reinforced controls to ensure greater consistency, timeliness, and documentation. Reporting requirements and due dates are maintained in a centralized tracking system accessible to Program, Finance, and Compliance staff, and cross-functional coordination occurs regularly to monitor progress and upcoming deadlines. Management has strengthened oversight by clarifying ownership of reporting deliverables, reinforcing expectations for timely submission, and requiring documented evidence of preparation and review prior to submission. Additional emphasis has been placed on timely escalation of potential delays and maintaining complete documentation to support all reporting activities. Management believes these enhancements address the execution and documentation gaps identified and significantly reduce the likelihood of recurrence. These processes have been incorporated into ongoing operations and will continue to be monitored to ensure compliance with grant requirements and applicable regulations, including 2 CFR Part 200.
Views of Responsible Officials and Planned Corrective Action: Management acknowledges that documentation supporting the review and approval of a reimbursement request was not retained, and that drawdown activity during the period did not consistently align with the timing of incurred expenditures. M...
Views of Responsible Officials and Planned Corrective Action: Management acknowledges that documentation supporting the review and approval of a reimbursement request was not retained, and that drawdown activity during the period did not consistently align with the timing of incurred expenditures. Management notes that this condition was identified during a period of staffing transition and resulted in a lapse in documentation and timeliness, rather than an absence of underlying financial controls. Management further notes that the expenditure underlying the reimbursement request were valid, properly recorded in the general ledger, and supported by appropriate accounting records. The condition was limited to documentation of review and the timing of drawdown activity, and no questioned costs were identified. Upon identification, management evaluated and reinforced its cash management and drawdown processes. Drawdown requests are now consistently prepared based on underlying accounting records and aligned with incurred expenditures. A formal review and approval step has been implemented and is now required prior to submission, with evidence of review retained electronically or physically for audit purposes. In addition, management has strengthened oversight of drawdown timing to better align reimbursements with the period in which costs are incurred, reducing the risk of delayed submissions and ensuring consistency with related financial reporting. Management believes this condition represents a lapse in execution and documentation during a defined period rather than a systemic breakdown in control design. Enhancements implemented have addressed the identified gaps and established a more consistent and well documented process for drawdown preparation, review, and submission in accordance with applicable requirements, including 2 CFR Part 200.
Views of Responsible Officials and Planned Corrective Action: Management acknowledges that the Federal Financial Report (FFR) was not submitted within the required 90-day timeframe, resulting in noncompliance with the reporting requirements of the grant agreement. While the organization maintained a...
Views of Responsible Officials and Planned Corrective Action: Management acknowledges that the Federal Financial Report (FFR) was not submitted within the required 90-day timeframe, resulting in noncompliance with the reporting requirements of the grant agreement. While the organization maintained a centralized system for tracking reporting deadlines and conducted regular cross-functional coordination between Program, Finance, and Compliance teams, management recognizes that controls over monitoring and escalation were not sufficiently rigorous to ensure timely submission in all instances. This occurred during a period of elevated staffing transition, which contributed to a lapse in the consistent execution and monitoring of reporting timelines; however, management recognizes that controls should be sufficiently robust to operate effectively regardless of personnel changes. Upon identification of the delay, management evaluated the underlying processes and determined that enhancements were needed to strengthen accountability, improve visibility of critical deadlines, and ensure timely followthrough. Management notes that this condition was limited to the timeliness of submission and did not impact the accuracy of the report or result in questioned costs. Management has since reinforced its reporting oversight by enhancing coordination across responsible teams, clarifying ownership of deliverables, and strengthening internal monitoring practices. This includes implementing more structured tracking of key reporting deadlines, reinforcing expectations around advance preparation and review, and increasing senior-level oversight to ensure that upcoming deadlines are proactively managed and met. In addition, management has emphasized timely escalation of potential delays to ensure corrective action can be taken prior to due dates. Management believes these enhancements address the control gaps identified and significant reduce the likelihood of recurrence. Reporting timelines are now more actively monitored as part of ongoing financial and compliance operations, and management will continue to assess the effectiveness of these processes to ensure adherence to grant requirements and compliance with applicable regulations, including 2 CFR Part 200.
Views of Responsible Officials and Planned Corrective Action: Management confirms that the procurement activities themselves were completed only after the appropriate review and approval processes had occurred; however, sufficient supporting documentation evidencing those procedures could not be loc...
Views of Responsible Officials and Planned Corrective Action: Management confirms that the procurement activities themselves were completed only after the appropriate review and approval processes had occurred; however, sufficient supporting documentation evidencing those procedures could not be located during the audit process. This condition occurred during a period of significant staffing transition and turnover, which contributed to inconsistencies in documentation retention and adherence to established federal procurement documentation requirements. Management recognizes that internal controls and compliance procedures must remain effective regardless of personnel changes and accepts responsibility for strengthening these controls to ensure consistent compliance. Upon identification of this issue, management conducted an assessment of the underlying procurement and documentation processes and determined that enhancements were necessary to improve accountability, standardize documentation practices, strengthen supervisory review, and reinforce staff training related to federal procurement requirements. Management emphasizes that the deficiency related to the retention and completeness of procurement documentation, rather than to the execution of the procurement process itself. Management believes the evaluation, selection, and approval activities were conducted in accordance with applicable federal procurement guidelines and standards. Management is currently reviewing procurement policies and procedures to ensure alignment with federal requirements related to quotations, vendor evaluation and selection, approval protocols, and document retention. Additional corrective actions include reinforcing documentation standards, clarifying approval responsibilities, and implementing enhanced monitoring procedures to help prevent recurrence.
Finding 2025-002 – Subrecipient Monitoring Federal Agency: Department of Treasury Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – ALN #21.027 Condition: As part of its subrecipient monitoring process, the County obtained and reviewed the subrecipient’s audit report, which ide...
Finding 2025-002 – Subrecipient Monitoring Federal Agency: Department of Treasury Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – ALN #21.027 Condition: As part of its subrecipient monitoring process, the County obtained and reviewed the subrecipient’s audit report, which identified findings related to federal program expenditures. Although the County ultimately communicated with the subrecipient regarding the findings, requested a corrective action plan, and performed and documented follow-up procedures, these actions were not completed timely. The follow-up procedures ultimately performed did not identify any additional issues or unresolved matters. Criteria: Internal controls over subrecipient monitoring should ensure that audit findings are communicated, corrective action is requested, and follow-up procedures are completed and documented within an established timeframe. The control should also provide a means to track the status of these activities through resolution. Cause: The County did not have an effective process to track the timing of subrecipient monitoring follow-up activities and ensure that communication, corrective action requests, and related documentation were completed timely. Effect: The delay in completing and documenting follow-up reduced the timeliness and transparency of the County’s monitoring process and could have delayed corrective action by the subrecipient. The follow-up procedures ultimately performed did not identify any additional issues or unresolved matters. Repeat Finding: Yes. This finding is a continuation of Finding 2024-002. The County obtained and reviewed the required subrecipient audit reports during 2025; however, it did not timely follow up on audit findings. Recommendation: The County should establish a documented tracking process for subrecipient audit findings that identifies responsible personnel, required actions, target completion dates, and current status. The County should also require timely communication with subrecipients, requests for corrective action plans, completion of follow-up procedures, and retention of supporting documentation. Periodic supervisory review should be performed to confirm that follow-up activities are completed and documented within the established timeframe. Management’s Response: The County accepts the finding and is implementing corrective actions to address the issue and strengthen its subrecipient monitoring procedures. The Office of Innovation, Strategy and Performance is implementing a documented tracking process for subrecipient audit findings. The process will identify responsible personnel, required corrective actions, target completion dates, and the status of each item. To provide ongoing oversight, the Controller’s Office will perform quarterly reviews of this process to verify that all required monitoring activities have been completed and appropriately documented within established timeframes. The Controller’s Office, in collaboration with the Office of Innovation, Strategy and Performance, conducted a comprehensive review of all ARPA subrecipient audits submitted to the Federal Audit Clearinghouse (FAC) since the inception of the ARPA program (2021 to present). The Office of Innovation, Strategy and Performance is compiling all monitoring records, correspondence, and follow-up activities conducted to date for subrecipients with audit findings related to Assistance Listing Number (ALN) 21.027. Additional follow-up will be performed, as necessary, to verify that corrective actions have been implemented and that identified issues have been fully resolved. To strengthen ongoing monitoring efforts, the County has developed a tracking schedule that identifies each subrecipient’s fiscal year-end date. Using this schedule, the Office of Innovation, Strategy and Performance will perform quarterly reviews to monitor audit submission requirements and follow up with any subrecipient that has not submitted its audit to the FAC within the required nine-month period following its fiscal year-end. The County will incorporate a reporting question into the third-quarter 2026 Subrecipient Report requiring subrecipients to indicate whether they were subject to the Single Audit requirement in their most recent fiscal year and if so, if the audit was submitted to the FAC. The corrective actions described above will help ensure that the County’s ARPA subrecipient monitoring process is comprehensive, well documented, and performed in a timely manner. The Controller’s Office will continue to work closely with the Office of Innovation, Strategy and Performance throughout the remainder of the ARPA program to ensure the County fulfills its subrecipient monitoring responsibilities. Responsible Person(s): Fonta Reilly, Valerie Vellon Anticipated Completion Date: December 31, 2026
The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accor...
The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accordance with those requirements.
Finding 2025-001 — Special Tests and Provisions – Sliding Fee Discount Program Federal Program: Health Center Program Cluster, ALN 93.224 Federal Agency: U.S. Department of Health and Human Services (Health Resources and Services Administration) Condition (as reported): The Organization’s Board-appr...
Finding 2025-001 — Special Tests and Provisions – Sliding Fee Discount Program Federal Program: Health Center Program Cluster, ALN 93.224 Federal Agency: U.S. Department of Health and Human Services (Health Resources and Services Administration) Condition (as reported): The Organization’s Board-approved sliding fee discount schedule was not configured correctly within the eClinicalWorks (eCW) billing system, resulting in patient sliding fee discounts that were not calculated in accordance with the Organization’s approved schedule. Name of Contact Person Responsible for Corrective Action: Hope Beemer, Chief Financial Officer 513.318.1188 | hope.beemer@centerpointhealth.org Corrective Action Taken: The Organization has corrected the condition identified in the finding. Specifically: • In 2025, Centerpoint Health utilized an outside vendor for billing services. To strengthen internal oversight and accountability, billing was brought in-house in January 2026 with the hiring of a Director of Revenue Cycle Management. By April 2026, all billing and revenue cycle operations were fully transitioned to Centerpoint Health’s internal team. • The Board of Directors reviewed and approved an updated sliding fee discount schedule in May 2026, which was implemented in the eClinicalWorks (eCW) billing system with an effective date of February 1, 2026. • Prior to implementation, management verified that the approved schedule was accurately configured in eCW by comparing system-generated discounts to the Board-approved schedule across each discount tier. • Patient encounters affected during 2025 were reviewed and discounts are adjusted where necessary. This was completed by August 2026. Ongoing Controls to Prevent Recurrence: • Any change to the sliding fee discount schedule in eCW requires a secondary, independent review and approval before the change is activated. • Management performs a quarterly reconciliation of system-generated sliding fee discounts to the current Board-approved schedule and investigates and resolves any exceptions. • The sliding fee discount schedule is reviewed and approved by the Board of Directors at least annually and is updated for changes in the Federal Poverty Guidelines. • Billing and front-desk staff receive annual training on the sliding fee discount policy and schedule. Anticipated Completion Date: • Completed. The updated Board-approved sliding fee discount schedule was implemented effective February 1, 2026, and the ongoing monitoring controls described above are in effect.
Management is working to formally document their procurement policies and conflict of interest policies in regards to federal expenditures.
Management is working to formally document their procurement policies and conflict of interest policies in regards to federal expenditures.
The Authority will strengthen its annual payment standard review procedures to ensure payment standards are supported by current FMRs and any required HUD approval or notification is obtained and retained before implementation. HUD approval of 120% payment standards has been obtained for the 2026 pr...
The Authority will strengthen its annual payment standard review procedures to ensure payment standards are supported by current FMRs and any required HUD approval or notification is obtained and retained before implementation. HUD approval of 120% payment standards has been obtained for the 2026 program year. Anticipated completion date: December 31, 2026. Responsible contact person: Ola Stepp, Executive Director.
The Authority will strengthen its Housing Choice Voucher file review procedures to ensure executed leases, rent reasonableness determinations, gross income calculations, and utility allowances are properly documented and reviewed. Anticipated completion date: December 31, 2026. Responsible contact p...
The Authority will strengthen its Housing Choice Voucher file review procedures to ensure executed leases, rent reasonableness determinations, gross income calculations, and utility allowances are properly documented and reviewed. Anticipated completion date: December 31, 2026. Responsible contact person: Ola Stepp, Executive Director.
In order to avoid this situation happening in the future, instruction will be provided to all personnel emphasizing that every purchase should be made through a purchase order. This will ensure that we follow the BGCPR formal procedure and ensure better internal control is being followed. In additio...
In order to avoid this situation happening in the future, instruction will be provided to all personnel emphasizing that every purchase should be made through a purchase order. This will ensure that we follow the BGCPR formal procedure and ensure better internal control is being followed. In addition, we will emphasize that no shipment should be received if such purchase is not in accordance with the specification disclosed in the purchase order. Contact Person: Purchase and procurement personnel Carlos Rivera Paul Barreras Amarilis Rodríguez (PACNA’s Project Manager) Team: Finance Team Anticipated Completion Date: September 30, 2026
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