Corrective Action Plans

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Finding Number: 2024-001 Condition: On April 4, 2024, the Corporation had a Management and Occupancy Review (MOR) physical inspection at the property and received a rating of 60. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has addressed all of th...
Finding Number: 2024-001 Condition: On April 4, 2024, the Corporation had a Management and Occupancy Review (MOR) physical inspection at the property and received a rating of 60. Planned Corrective Action: Management acknowledges noncompliance in the current fiscal year and has addressed all of the compliance issues and all other findings identified during the MOR inspection by June 2024. Contact person responsible for corrective action: Jill Kolb, Vice President – Housing Accounting Completion Date: June 30, 2024
Assistance Listing No.: 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects - Section 207/223f Corrective Action Plan: In response to the findings regarding unsigned documents, we confirm that we have made multiple attempts to have tenant sign the HUD r...
Assistance Listing No.: 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects - Section 207/223f Corrective Action Plan: In response to the findings regarding unsigned documents, we confirm that we have made multiple attempts to have tenant sign the HUD required documents such as the Recertification Verification, Asset Verification, Enterprise Income Verification (EIV) and Notice and Consent for the Release of the Tenant's Information (HUD 9887 Form). Unfortunately, we have been unable to secure the tenant’s signature due to her current medical situation. The tenant has been in and out of the hospital, which has limited her availability for in_x0002_person meetings. Additionally, the tenant has difficulty walking, which has further complicated the process of arranging a convenient time to sign the necessary paperwork. To prevent similar occurrences in the future, we will continue our efforts to have a robust monitoring and review process and improve our coordination with the tenants. We will explore alternative methods to ensure the HUD documentation is completed as required. Completion Date: Immediately Contact Person: Angie Pearson, Site Manager
View Audit 323747 Questioned Costs: $1
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the...
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The board of directors will continue to closely monitor the financial operations of the Project. Name(s) of the contact person(s) responsible for corrective action: Mary Gilberts, Management Agent Planned completion date for corrective action plan: June 2025
#2024-002 – Material Weakness – Eligibility Coronavirus State and Local Fiscal Recovery Funds, ALN #21.027 Recommendation We recommend verifying each applicant’s enrollment status with all universities prior to disbursement of scholarship funding. View of responsible officials and planned corrective...
#2024-002 – Material Weakness – Eligibility Coronavirus State and Local Fiscal Recovery Funds, ALN #21.027 Recommendation We recommend verifying each applicant’s enrollment status with all universities prior to disbursement of scholarship funding. View of responsible officials and planned corrective action The Foundation receives information directly from PASSHE universities to verify enrollment status of applicants. Universities submit information to the Foundation on an electronic form, which includes Student Name, Student ID, Scholarship Amount, Student Enrollment Status, etc. Authorized officials enter their approval by changing “Pending Review” to either “Scholarship Eligible” or “Not Eligible” on the form and keying in the scholarship amount the student is eligible for based on their verified enrollment status, for example: $1,000 for a part time student or $2,000 for a full-time student. For 4 of the 40 applicants sampled during the audit, a PASSHE university created an inconsistency on the form, having not completed or updated the enrollment status column to be consistent with the final amount they verified approved for payment. The key control, i.e. the University’s entry and approval of the eligible amount, prevented any errors from occurring. The Foundation verified the enrollment status for the four applicants identified in the audit, noting that the scholarships were properly disbursed. Going forward the Foundation has updated its verification process with the universities to ensure proper classification of the applicant’s enrollment status is verified in accordance with the eligibility requirements of the grant.
Plan: A second staff member will review certifications and annual certifications to ensure accuracy based on the required back up documentation. Contact: Christina Morin, Program Director. Anticipated completion date: September 1, 2025.
Plan: A second staff member will review certifications and annual certifications to ensure accuracy based on the required back up documentation. Contact: Christina Morin, Program Director. Anticipated completion date: September 1, 2025.
Inaccurate Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: To ensure that both accurate and timely enrollment reporting is transmitted to the National Student Loan Data System (NSLDS) an NSC / NSLDS enrollment confirmation process will be established and ...
Inaccurate Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: To ensure that both accurate and timely enrollment reporting is transmitted to the National Student Loan Data System (NSLDS) an NSC / NSLDS enrollment confirmation process will be established and implemented by Student Financial Services. For official withdrawals, an additional processing step will be added to the SFS Withdrawal Tracker. The Student Financial Services rep will confirm that the correct withdrawal date has been accurately reported to the National Student Clearinghouse (NSC) by the Registrar’s office and then correctly transmitted to the National Student Loan Data System (NSLDS). If the reported enrollment date does not align with the Last Date of Academic Related Activity, the SFS Representative will notify either the Director of Student Financial Services (Michelle Baker) or the Chief Student Finance Officer (David Burney) to manually adjust the dates in NSLDS. The SFS office will then notify the Registrar’s office that the dates have been manually updated. For unofficial withdrawals, if a student is identified as an unofficial withdrawal (e.g. lack of attendance in a course resulting in an R2T4 calculation being performed) once the withdrawal list has been reported at the end of each semester by the Registrar’s office, the Student Financial Services Representative will confirm that the correct withdrawal date has been accurately reported to the National Student Clearinghouse (NSC) by the Registrar’s office and then correctly transmitted to the National Student Loan Data System (NSLDS). If the reported enrollment date does not align with the Last Date of Academic Related Activity, the SFS Representative will notify either the Director of Student Financial Services (Michelle Baker) or the Chief Student Finance Officer (David Burney) to manually adjust the dates in NSLDS. The SFS office will then notify the Registrar’s office that the dates have been manually updated. Person Responsible for Corrective Action Plan: David Burney, Chief Student Finance Officer Anticipated Date of Completion: Implementation of process will begin 9/30/2024
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2024. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers. Complete review of all previ...
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2024. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers. Complete review of all previous manager's files.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2024. Ongoing Corrective Action: Additional file review after recertifications and move-ins to be compeleted by a different manager. Additional trainings for Income VS Assets for all...
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2024. Ongoing Corrective Action: Additional file review after recertifications and move-ins to be compeleted by a different manager. Additional trainings for Income VS Assets for all managers. Complete review of all previous manager's files.
2024-001 Housing Voucher Cluster – Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in a...
2024-001 Housing Voucher Cluster – Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Our internal audits take place monthly. The HCV department leadership pulls the list of recertifications, interims, and new admissions and samples 10% of each to ensure they have been done correctly, with all information documented. This internal audit includes checking the rent calculation, utilities, verification documents, and tenant/landlord notification. The agency has been completing this internal practice consistently since February 2024. Name(s) of the contact person(s) responsible for corrective action: Morgan Gower Planned completion date for corrective action plan: In progress as of February 2024 and is ongoing.
View Audit 323421 Questioned Costs: $1
OLD TOWNE SQUARE, INC. CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2024 AND 2023 Old Towne Square, Inc 609 SW F Avenue Lawton, OK 73501 Telephone: (580) 353-7392 Fax: (580) 353-6111 Corrective Action Plan Finding: 2024-001-Lack of Adequate Quality Control Regarding Tenant Procedures- Eligibil...
OLD TOWNE SQUARE, INC. CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2024 AND 2023 Old Towne Square, Inc 609 SW F Avenue Lawton, OK 73501 Telephone: (580) 353-7392 Fax: (580) 353-6111 Corrective Action Plan Finding: 2024-001-Lack of Adequate Quality Control Regarding Tenant Procedures- Eligibility Condition: The quality of supervision over tenant file functions, such as calculating tenant rent and Housing Assistance Payments should be timely and sufficient to find errors in calculations or mis-application or mis-understanding of procedures. Corrective Action Planned: I am Rita Love, Executive Director. We will comply with the auditor’s recommendation. Person responsible for corrective action: Rita Love, Executive Director Telephone: (580) 353-7392 Old Towne Square, Inc. Fax: (580) 353-6111 609 SW F Avenue Lawton, OK 73501 Anticipated Completion Date: By November 30, 2024
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended March 31, 2024. Finding 2024-001 Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Compliance Requirements A/B - Activities Allowed or Unallowed and Allowable Costs/Cost Principles, C – Cash Management, E – Eligibility, L – Reporting, and N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management reported that the failure(s) involved records related to the period managed by the predecessor management company. We will request and keep all required documentation from HUD and establish processes and procedures to ensure compliance with the Regulatory Agreement. Anticipated Completion Date September 30, 2024
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation
Finding 479547 (2024-002)
Significant Deficiency 2024
Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing...
Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application. The supervisor will also review the application to ensure that all signatures and demographic data has been included. o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.
2024-001 Sliding Fee Discount Determination Name of Contact Person: Vice President and Chief Financial Officer: Gurjeet Sandhu Corrective Action: Golden Valley Health Centers: • Is providing immediate re-training to staff on issues identified beginning June 11, 2024. • Continues to provide o...
2024-001 Sliding Fee Discount Determination Name of Contact Person: Vice President and Chief Financial Officer: Gurjeet Sandhu Corrective Action: Golden Valley Health Centers: • Is providing immediate re-training to staff on issues identified beginning June 11, 2024. • Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. • Has updated procedures for the Sliding Fee Discount Program approval process in which all sliding fee required documents are first reviewed and approved by a Clinic Supervisor or Center Manager for program compliance. This process was implemented in October 2023, which was at the mid-point of the current fiscal year and will assist in addressing any issues and training proactively. • Will continue ongoing Sliding Fee Audit Tracers and Chart Audits to assess staff knowledge, provide feedback, and offer guidance, as needed. Proposed Completion Date: October 31, 2024
Plan: A procedure will be implemented and documented to ensure that all tenant income and expenses are reviewed by a second individual to ensure accuracy. Anticipated Completion Date: 09/30/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
Plan: A procedure will be implemented and documented to ensure that all tenant income and expenses are reviewed by a second individual to ensure accuracy. Anticipated Completion Date: 09/30/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
Graham County Department of Social Services to scan and review participant information to ensure accuracy upon information being entered into NC FAST.
Graham County Department of Social Services to scan and review participant information to ensure accuracy upon information being entered into NC FAST.
Finding 2023-003 Inadequate Internal Control over Federal Procurement and Suspension and Debarment Federal award: Assistance Listing No. 21.027, Coronavirus State and Local Fiscal Recovery Funds Auditor Description of Condition and Effect During the audit, we noted that the Organization had not esta...
Finding 2023-003 Inadequate Internal Control over Federal Procurement and Suspension and Debarment Federal award: Assistance Listing No. 21.027, Coronavirus State and Local Fiscal Recovery Funds Auditor Description of Condition and Effect During the audit, we noted that the Organization had not established and implemented sufficient controls over procurements charged to the federal program. The Organization could not provide sufficient documentation demonstrating that: • The rationale for the procurement method and contractor selection was documented; • Potential conflicts of interest were evaluated; • Applicable contractors were verified as not suspended, debarred, or otherwise excluded; • Required federal provisions were included in applicable contracts; and • Contractor performance and compliance with contract terms were appropriately monitored. The absence of appropriately designed and implemented controls creates a reasonable possibility that material noncompliance with federal procurement or suspension and debarment requirements could occur and not be prevented, or detected and corrected, on a timely basis. This could result in unsupported procurement decisions, transactions with excluded or otherwise ineligible contractors, contracts that omit required federal provisions, or inadequate oversight of contractor performance. Auditor Recommendation Management should adopt written federal procurement procedures and implement a standardized review process for procurements charged to federal awards. The process should address and document the procurement method and contractor selection, potential conflicts of interest, contractor eligibility, required federal contract provisions, and oversight of contractor performance. Documentation should be retained with each procurement file and be subject to appropriate management review and approval. Proposed Corrective Action The Organization agrees with the finding. Management will adopt written federal procurement procedures and use a standardized checklist for each procurement charged to a federal award. The checklist will document the procurement method, contractor selection and price basis, evaluation of potential conflicts of interest, contractor eligibility verification, applicable federal contract provisions, and contractor oversight. A designated management reviewer will approve the completed procurement file, and the supporting records will be retained in accordance with the applicable award requirements. Responsible Person: Anticipated Completion Date: June 30, 2027
Finding 1239037 (2023-001)
Material Weakness 2023
Upmc
PA
Condition: With the decommissioning of the related CHIP Application Processing System (CAPS) on April 17, 2023, by the Pennsylvania Department of Human Services (PA DHS), the evidence to support UPMC’s completion of these processes is not available for the period January 1, 2023 to April 16, 2023. P...
Condition: With the decommissioning of the related CHIP Application Processing System (CAPS) on April 17, 2023, by the Pennsylvania Department of Human Services (PA DHS), the evidence to support UPMC’s completion of these processes is not available for the period January 1, 2023 to April 16, 2023. PA DHS is unable to provide all the required data from the archived version of CAPS, including certain enrollee or application data points; notes and commentary documented by the MCOs; and evidence of the date/time procedures were performed. This information is necessary to test internal controls over compliance and compliance over eligibility and special tests and provisions. Therefore, EY was not able to support internal controls over compliance and compliance over the eligibility or the special tests and provisions compliance requirements through re-performance and issued a disclaimer of opinion based on the scope limitation. Corrective Action Plan: UPMC follows the processes and procedures set forth by Pennsylvania Department of Human Services. As such, no corrective action will be taken.
Organization’s response: The Organization concurs with the finding and will implement our recommendation immediately. Corrective Action Plan: The Organization will implement enhanced internal controls over compliance with federal award requirements by establishing a formal compliance calendar that i...
Organization’s response: The Organization concurs with the finding and will implement our recommendation immediately. Corrective Action Plan: The Organization will implement enhanced internal controls over compliance with federal award requirements by establishing a formal compliance calendar that includes all key reporting deadlines, including audit and FAC submission requirements. Responsibilities for each compliance requirement will be clearly assigned to specific personnel. Management will monitor the calendar regularly to ensure all deadlines are met. Additionally, the Organization will implement a review process to ensure submissions are accurate, complete, and timely. Contact: BreNita Jackson, Executive Director
FINDING #2023-001 LATE PAYMENT OF CONSTRUCTION COSTS FROM LOUISIANA HOUSING FINANCE AGENCY LOAN AND INELIBIBLE COSTS Recommendation: We recommend that the entity develop internal controls that will prevent this occurrence in the future. Views of Responsible Officials and Planned Corrective Action: M...
FINDING #2023-001 LATE PAYMENT OF CONSTRUCTION COSTS FROM LOUISIANA HOUSING FINANCE AGENCY LOAN AND INELIBIBLE COSTS Recommendation: We recommend that the entity develop internal controls that will prevent this occurrence in the future. Views of Responsible Officials and Planned Corrective Action: Management will adopt controls to prevent this in the future. In July 2024, the sponsor issued a check for the construction payable balance.
o Implement standardized intake and eligibility verification procedures. o Utilize eligibility checklists and required supporting documentation. o Verify client eligibility before services are provided or costs are charged to federal awards. o Train staff on eligibility requirements and documentatio...
o Implement standardized intake and eligibility verification procedures. o Utilize eligibility checklists and required supporting documentation. o Verify client eligibility before services are provided or costs are charged to federal awards. o Train staff on eligibility requirements and documentation standards. o Establish supervisory review of eligibility determinations. o Conduct periodic monitoring and internal reviews to ensure continued compliance. o Address identified deficiencies timely through corrective actions and staff training.
o Develop a formal audit and compliance reporting calendar. o Identify all federal reporting deadlines and required submissions. o Assign responsibility for monitoring reporting deadlines. o Conduct periodic status meetings with finance staff and auditors. o Monitor audit progress regularly to ident...
o Develop a formal audit and compliance reporting calendar. o Identify all federal reporting deadlines and required submissions. o Assign responsibility for monitoring reporting deadlines. o Conduct periodic status meetings with finance staff and auditors. o Monitor audit progress regularly to identify and address delays. o Establish internal deadlines in advance of federal reporting due dates.
o Verify vendor and contractor eligibility through SAM.gov prior to contract award. o Perform periodic reviews of vendor eligibility throughout the contract period. o Maintain documentation of suspension and debarment checks within procurement files. o Incorporate suspension and debarment verificati...
o Verify vendor and contractor eligibility through SAM.gov prior to contract award. o Perform periodic reviews of vendor eligibility throughout the contract period. o Maintain documentation of suspension and debarment checks within procurement files. o Incorporate suspension and debarment verification into procurement approval procedures. o Provide staff training regarding federal procurement requirements.
Management’s Response All participant eligibility documents are now in house and stored in a secure location on the NIBC server Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
Management’s Response All participant eligibility documents are now in house and stored in a secure location on the NIBC server Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
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