Corrective Action Plans

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FINDING No. 2025-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account i...
FINDING No. 2025-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2026.
Establish and maintain a formal year-end closing calendar with internal milestones and deadlines aligned to the FAC submission due date. Document year-end closing procedures (including required tasks, timelines, and supporting documentation). Assign clear responsibilities for closing tasks and for p...
Establish and maintain a formal year-end closing calendar with internal milestones and deadlines aligned to the FAC submission due date. Document year-end closing procedures (including required tasks, timelines, and supporting documentation). Assign clear responsibilities for closing tasks and for preparation, review, and submission of the Single Audit reporting package and data collection form. Monitor progress through periodic status updates and management review to ensure timely completion of the year-end close and timely submission to the Federal Audit Clearinghouse (FAC).
Management will continue strengthening accounting practices and internal controls over federal funds transactions to promote accurate, complete, and timely financial information. Management will also coordinate with the Puerto Rico Department of the Treasury to facilitate timely recording of remitta...
Management will continue strengthening accounting practices and internal controls over federal funds transactions to promote accurate, complete, and timely financial information. Management will also coordinate with the Puerto Rico Department of the Treasury to facilitate timely recording of remittances in PRIFAS and to support implementation and use of processes/system functionality that enables timely preparation of financial reports required by oversight entities.
Corrective Action Planned: In July 2023, the Organization implemented ADP Work Force Now to systematically capture hours worked, the supervisor's approval and audit trail to reflect the work performed. In May 2026, the Organization hired a subcontractor, Dapt to synchronize the employee hours worked...
Corrective Action Planned: In July 2023, the Organization implemented ADP Work Force Now to systematically capture hours worked, the supervisor's approval and audit trail to reflect the work performed. In May 2026, the Organization hired a subcontractor, Dapt to synchronize the employee hours worked on their time sheets and allocated into the cost centers/programs they worked on. The new timesheet will also reflect the employee and supervisor’s approval, as completed in ADP. Testing begins with the months of May and June 2026. Name(s) of Contact Person(s) Responsible for Corrective Action: Betsey Knapp, Director of Budgets and Contracts; Alvin Sinckler, Chief Financial Officer Anticipated Completion Date: June 30, 2026.
The Organization should implement an effective monitoring system to keep track of the compliance calendar, which includes financial reporting deadlines, and automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Orga...
The Organization should implement an effective monitoring system to keep track of the compliance calendar, which includes financial reporting deadlines, and automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. Additionally, the Organization should implement a system that will file documents in an organized manner and make them easily accessible to the Organization and auditors. Furthermore, the Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight.
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
Finding 2025-005 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public Housing Capital Fund Program Federal Assistance Listing Numbers: 14.872 Noncompliance - C. Cash Management Non Compliance Material to the Financial Statements: No Significant deficiency i...
Finding 2025-005 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public Housing Capital Fund Program Federal Assistance Listing Numbers: 14.872 Noncompliance - C. Cash Management Non Compliance Material to the Financial Statements: No Significant deficiency in Internal Control over Compliance for Cash Management Criteria: In accordance with 2 CFR 200.305, payment methods for federal awards must minimize the time elapsing between the transfer of federal funds and the disbursement of those funds by the recipient. Federal funds drawn under the Public Housing Capital Fund Program should be limited to amounts needed to meet the Authority’s immediate cash requirements for allowable program expenditures. Accordingly, the Authority should implement procedures to ensure grant funds are not drawn in advance of actual or imminent eligible expenditures. Condition: The Authority drew down federal funds in advance of immediate cash needs for allowable program expenditures. As of year end, a portion of the funds drawn remained unexpended and was reported as unearned revenue in the financial statements. This indicates that federal funds were received prior to the incurrence of eligible expenditures. Context: During review of the financial statements, the Authority was noted to have unexpended federal funds on hand at year end that had been drawn prior to the disbursement of allowable program costs. Specifically, amounts recorded as unearned revenue represented federal funds received in advance of immediate cash needs. This condition was identified through review of drawdown activity, general ledger balances, and year end financial reporting records. Known Questioned Costs: $134,883. Cause: The Authority did not have adequate internal controls in place to monitor the timing of grant drawdowns in relation to actual program cash needs and allowable expenditures. As a result, federal funds were requested and received prior to the incurrence of eligible costs under the Public Housing Capital Fund Program. Effect: The Authority was not in compliance with federal cash management requirements governing the timing of federal fund drawdowns. As a result, federal funds were held in advance of immediate cash needs, increasing the risk of improper cash management and noncompliance with Uniform Guidance and HUD requirements. Recommendation: We recommend the Authority strengthen its internal controls over cash management to ensure federal funds are drawn only for immediate cash needs related to allowable program expenditures. Management should implement monitoring and review controls over grant drawdown activity, including periodic reconciliation of drawdowns to incurred expenditures, to ensure compliance with 2 CFR 200.305 and HUD requirements. Authority's Response: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ralph Staley, CFO is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring and is expected to be completed by December 31, 2026.
Finding 2025-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in...
Finding 2025-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 733 units. Of a sample size of twenty-one (21) tenant files, the following was noted: • Citizenship declaration was missing in 1 file • Original application was missing in 1 file • HUD Form 9886 was missing in 1 file • Lead based paint form was missing in 1 file • HUD form 50058 was missing in 1 file • Verification of income was missing in 1 file • Verification of assets was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: $11,005 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority experienced high turnover and did not properly train employees in the Public and Indian Housing department, which resulted in the Authority having a limited capacity to perform the required maintenance of tenant files, and properly maintain and monitor a system of internal controls that reasonably assures the program is in compliance. Effect: The Authority is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files in the Public and Indian Housing Program. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are hired and trained on tenant file maintenance so that documents are accumulated, stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the deficiencies in the Public and Indian Housing Program and has implemented a quality control program. The Authority will continue to train staff on the proper maintenance of tenant files and implement additional internal control procedures that will ensure compliance with federal regulations. Sean Buchanan, Deputy Operating Officer is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring and is expected to be completed by December 31, 2026.
Finding 2025-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871 & 14.879 Noncompliance – N. Special Tests and Provisions – HQS Enforcement Non Compliance Material to the Financial Statements: Yes Mater...
Finding 2025-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871 & 14.879 Noncompliance – N. Special Tests and Provisions – HQS Enforcement Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: HQS Enforcement. The PHA must inspect the unit leased to a family at least annually to determine if the unit meets the Housing Quality Standards (HQS) and the Authority must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussions with management, the Authority did not properly abate (6) housing assistance payments. Context: Of a sample size of twenty-five (25) failed inspections, the Authority did not properly abate six (6) out of twenty-five (25) housing assistance payments. As a result, the Authority was not in compliance with the HQS as required by 24 CFR sections 982.158(d) and 982.405(b). Known Questioned Costs: $75,656. Cause: There is a material weakness in internal controls over compliance for the special tests and provisions type of compliance related to HQS enforcement, due to high turnover. This, in addition to software limitations, has resulted in the Authority having a limited capacity to properly maintain and monitor a system of internal controls that reasonably assures program compliance. Effect: The Authority is in material non-compliance with the special tests and provisions type of compliance related to HQS enforcement in the Housing Voucher Cluster. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are hired and trained on HQS enforcement that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the deficiencies in the administration of programs within the Housing Voucher Cluster and has implemented a process to prevent the same issues from occurring. The Authority will also continue to train staff on HQS enforcement and enhance its internal control procedures that will ensure compliance with federal regulations. Tonya Crawley, HCV Program Director is responsible for ensuring proper internal controls are in place to prevent material weaknesses from occurring and is expected to be completed by December 31, 2026.
Finding 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 & 14.879 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in I...
Finding 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 & 14.879 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 2,208 units. Of a sample size of thirty-four (34) tenant files, the following was noted: • HUD form 9886 was unable to be provided in 2 files • Citizen Declaration Section 214 form was unable to be provided in 4 files • Signed lease was unable to be provided in 4 files • Lead based paint form was unable to be provided in 1 file Known Questioned Costs: $19,212 Cause: There is a material weakness in internal controls over the eligibility type of compliance related to the maintenance of tenant files in the Housing Voucher Cluster. The Authority experienced high turnover and did not properly train employees in the HCV department, which resulted in the Authority having a limited capacity to perform the required maintenance of tenant files, and properly maintain and monitor a system of internal controls that reasonably assures the program is in compliance. Effect: The Authority is in material non-compliance with the eligibility requirements of the Housing Voucher Cluster programs. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are hired and trained on tenant file maintenance so that documents are accumulated, stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the deficiencies related to the administration of Housing Voucher Cluster and will train staff on the proper maintenance of tenant files and implement internal control procedures that will ensure compliance with federal regulations. Tonya Crawley, HCV Program Director is responsible for ensuring proper internal controls are in place to prevent material weaknesses from occurring and is expected to be completed by December 31, 2026.
CORRECTIVE ACTION PLAN FINDING 2025-002 Finding Subject: COVID-19- Coronavirus State and Local Fiscal Recovery Funds Contact Person Responsible for Corrective Action: Valeriano F. Gomez Contact Phone Number and Email Address: 219-391-8220 Views of Responsible Officials: Option 1: “We concur with the...
CORRECTIVE ACTION PLAN FINDING 2025-002 Finding Subject: COVID-19- Coronavirus State and Local Fiscal Recovery Funds Contact Person Responsible for Corrective Action: Valeriano F. Gomez Contact Phone Number and Email Address: 219-391-8220 Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: Previous corrective action read as follows: To ensure proper implementation of the policies and procedures in place related to SLFRF reporting, in future, no submittal of reports will be approved without the City Controller and a Senior Staff Accountant reviewing and approving the P & E reports…… issue arose when City Departments responsive for entering data in P & E reports and Staff Accountant documentation differed , adding to issue both groups were not together in same room to assist each other with reporting . Corrective Action Plan: 1. All future SLFRF Quarterly reports shall require advance meetings before the data entering day; to ensure correct reporting. Meetings shall include all personnel reviewing and entering information (City department personnel and Controllers office personnel, to include two from the Controller’s Office; Controller, or Deputy City Controller and Senior City Accountant. 2. These Staff meeting shall address any differences in reporting documentation, and prepare for any editing and revising data to correct issues from previous P & E reporting, in next available report (Sec. V. Editing and Revising Data P & E Report User Guide) 3. No data shall be entered / submitted on entry day for future Quarterly P & E reports without Controller personnel present and having reviewed and confirmed data. Anticipated Completion Date: Controllers Office and City Departments involved in reporting are presently working to address and correct issues in past reporting, completion is anticipated when upcoming 2nd Quarterly Report for 2026 is opened and issues are addressed.
CORRECTIVE ACTION PLAN FINDING 2025-001 Finding Subject: COVID-19- Coronavirus State & Local Fiscal Recovery Funds- Suspension & Debarment. Contact Person Responsible for Corrective Action: Valeriano F. Gomez Contact Phone Number and Email Address: 219-391-8220 Views of Responsible Officials: Option...
CORRECTIVE ACTION PLAN FINDING 2025-001 Finding Subject: COVID-19- Coronavirus State & Local Fiscal Recovery Funds- Suspension & Debarment. Contact Person Responsible for Corrective Action: Valeriano F. Gomez Contact Phone Number and Email Address: 219-391-8220 Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: On August 22, 2024, the East Chicago Board of Works passed a City Suspension / Debarment Policy where by all city boards were instructed to follow through with a similar resolutions or actions to implement the policy city wide. Unfortunately, an effective system of internal controls was not implemented to ensure compliance; it was more of a self-regulating process, which resulted in only one person in one city department following through on verifications. In order to establish, maintain, and ensure compliance of city’s policy, the City of East Chicago Board of Works will implement the following internal controls for all City Departments and Boards 1. Require a Certification form regarding Suspension and Debarment to be part of all pre-bid packets, and contracts before approval. (presented and passed in May 28, 2026 BOW meeting). 2. Correspondence from E.C. Board of Works to all City Board Presidents and Secretaries to enter in to record at next meeting previous passed Suspension & Debarment policy and new form; with instruction to include in all future related proposals / contracts. (will be introduced, discussed, and implemented at June 11, 2026 BOW meeting.) 3. Correspondence from E.C. Board of Works to all City Board Attorneys to ensure their reviews of pre-bid documents / proposals / contracts brought before their Boards include Suspension & Debarment requirements. (to be approved at June 11,2026 BOW meeting). 4. Correspondence from E.C. Board of Works to City Law Department to ensure all proposals / contracts sent to City Boards shall include all related Suspension & Debarment requirements. (to be approved at June 11, 2026 BOW meeting). Anticipated Completion Date: June 2026, new requirements (new form, and instructive correspondence to City Boards, secretaries, attorneys, & Law dept.) following BOW June 11, meeting introduction.
Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in the Ingham County, Michigan Single Audit report for the year ended December 31, 2025, and corrective actions to be completed. 2025-002 – Procurement, Suspension and Debarm...
Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in the Ingham County, Michigan Single Audit report for the year ended December 31, 2025, and corrective actions to be completed. 2025-002 – Procurement, Suspension and Debarment Auditor Description of Condition and Effect. While the County indicated that they have been completing suspension and debarment checks on County vendors in the past, evidence of these suspension and debarment checks was not retained and made available for audit. As a result of this condition, the County was exposed to the risk that disbursements of federal awards would be made to vendors suspended or debarred by the federal government and subject to disallowance by the grantor. Auditor Recommendation. We recommend that the County verify that any of their vendors with $25,000 spent with federal funds were not suspended or debarred and that documentation of these procedures be retained. Corrective Action. The County will review vendors over $25,000 spent with federal funds to ensure that they are not suspended or debarred and retain documented support for the procedures performed. Responsible Person. Andrea Shetenhelm, Interim Finance Director Anticipated Completion Date. December 31, 2026
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
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