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Corrective Action Plans

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Rural Housing for the Elderly, Inc.
NH
Eligibility HUD Housing Programs Internal Control / Segregation of Duties
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for July 31, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for July 31, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
View Audit 1082
Snhs Elderly Housing V, Inc.
NH
Eligibility HUD Housing Programs Internal Control / Segregation of Duties
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
View Audit 1072
Rural Housing for the Elderly Ii, Inc.
NH
Eligibility HUD Housing Programs Internal Control / Segregation of Duties
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
Completed corrective action: Manager completed correction and new HUD 50059A recertification's corrected for June 30, 2023. Ongoing Corrective Action: Additional file review after recertifications and move-ins. Additional trainings for Income VS Assets for all managers.
View Audit 1071
Finding 439 (2023-003)
Material Weakness 2023
Housing Authority of the City of Imperial, Nebraska
NE
Internal Control / Segregation of Duties Special Tests & Provisions Eligibility
Finding 2023-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies a...
Finding 2023-003 The Authority agrees with the finding and responds by stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.
View Audit 966
Howard Payne University
TX
Reporting Student Financial Aid Eligibility
Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A review is being completed by the Registrar’s Office to determine if something is in the student record that may prevent a student from being reported correctly. If a common factor can be determined, then ...
Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: A review is being completed by the Registrar’s Office to determine if something is in the student record that may prevent a student from being reported correctly. If a common factor can be determined, then it will be corrected. Until then, Enrollment reporting to NSC will be reviewed twice. Follow up will be done regarding last date of attendance reporting for those students who do fail to complete the semester. Person Responsible for Corrective Action Plan: Karen LaQuey, Director, Student Financial Aid Director; Wendy McNeeley, previous Registrar; Kristina Penland, Registrar Anticipated Date of Completion: 12/12/2023
View Audit 959
Finding 425 (2023-001)
Significant Deficiency 2023
Shands Jacksonville Medical Center, INC
FL
Allowable Costs / Cost Principles Cash Management Eligibility
Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi...
Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi, Vice President and CFO Completion Date: March 31, 2022
View Audit 896
Finding 373 (2023-002)
Material Weakness 2023
Kearney Housing Agency
NE
Eligibility HUD Housing Programs Material Weakness
The Director has added to her monthly checklist to review quality control logs and follow up on any QC reviews that are not being conducted in a timely fashion.
The Director has added to her monthly checklist to review quality control logs and follow up on any QC reviews that are not being conducted in a timely fashion.
View Audit 782
Finding 361 (2023-003)
Significant Deficiency 2023
Sebeka Public Schools
MN
Allowable Costs / Cost Principles Cash Management Eligibility
Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed
Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed
View Audit 736
Finding 249 (2023-001)
Significant Deficiency 2023
Morrison Institute of Technology
IL
Eligibility Reporting
Condition - The institution had the following changes that were required to be updated on their ECAR: • The V.P. of Finance (equivalent to a chief financial officer) was no longer active at the institution as of April 2022. • A Board Member was no longer serving the institution as of May 2021. •...
Condition - The institution had the following changes that were required to be updated on their ECAR: • The V.P. of Finance (equivalent to a chief financial officer) was no longer active at the institution as of April 2022. • A Board Member was no longer serving the institution as of May 2021. • A Board Member was added to the Board in October 2021. These changes to the institution’s ECAR information were not submitted until June 2023, subsequent to inquiry by auditors. Corrective Action Plan - The College will review current procedures and adjust accordingly to ensure timely ECAR updates. Contact Person, Title and Phone Number - Chris Scott, President, (815)-772-7218, Ext. 212 Anticipated Completion Date - August 1, 2023
View Audit 493
Finding 222 (2023-003)
Material Weakness 2023
Mary Lee Charles Place
TX
Questioned Costs HUD Housing Programs Eligibility
Management agrees with the finding and will begin an independent review of each tenant file to include examination of proof of disability paperwork to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the in...
Management agrees with the finding and will begin an independent review of each tenant file to include examination of proof of disability paperwork to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including eligibility requirements and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases. Management has requested proof of disability from the tenant that satisfies HUD guidelines and will not renew lease if it is not received. The training and file review will be completed by November 30, 2023. If the tenant does not produce proof of disability their lease will not be renewed on May 11, 2024.
View Audit 460 Questioned Costs: $1
Finding 165 (2023-002)
Material Weakness 2023
Low Rent Housing Agency of Grinnell, Iowa
IA
Internal Control / Segregation of Duties Special Tests & Provisions Eligibility
Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight boar...
Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board has reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.
View Audit 243
Finding 156 (2023-008)
Material Weakness 2023
Virginia Union University
VA
Eligibility Internal Control / Segregation of Duties
Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financia...
Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financial aid grant to the student's oustanding account balance as a condition of receipt of or eligibility for an emergency financial aid grant funding. The recipient also acknowledges that adding preconditions to receiving a financial aid grant that thwart this requirement may be subjected to oversight and corrective action. In consideration for this award, Recipients agree that they hold these grant funds in trust for students and act in the nature of a fiduciary for students. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. Now that the FY23 audit is finalized, any such compliance issues with students will be taken care of during actual registration process. In the future, any such forms that will need student authorization will be handled during the registration process. Responsbile Person(s): Robin Jefferson, Director of Student Accounts rljefferson@vuu.edu 804 342-3976. Robert Merino, Executive Director of Financial Aid jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.
View Audit 218
Finding 119 (2023-002)
Significant Deficiency 2023
Health Services, Inc.
AL
Special Tests & Provisions Eligibility Significant Deficiency
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 ...
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 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.
View Audit 152
Finding 69 (2023-001)
Significant Deficiency 2023
Freestore Foodbank, Inc. and Affiliates
OH
Eligibility Internal Control / Segregation of Duties
Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, se...
Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, services or “assistance”. The child must be less than 18 years old, or, if a full-time student in a secondary school (or the equivalent level of vocational or technical training), less than 19 years old. Freestore Foodbank Inc. and Affiliates require all individuals receiving food to complete an eligibility form prior to receiving food. Condition: We noted one instance (in a sample of 40 clients) in which an eligibility form was not obtained prior to client receiving food. Planned Corrective Action: Management will perform periodic audits of eligibility forms starting 10/15/2023 to ensure compliance. Management will retrain staff to ensure completeness of the intake process. Furthermore, by 9/30/2023, management will work with the developers of the database to see if controls can be implemented in the software, so food cannot be distributed before the signing of the required form.
View Audit 63
Finding 1206398 (2022-001)
Material Weakness 2022
City of Newark
NJ
Eligibility Matching / Level of Effort / Earmarking
It is recommended that the Budget Expenditure Report for Appropriations and Appropriation Reserves be reconciled with the General Ledger monthly.
It is recommended that the Budget Expenditure Report for Appropriations and Appropriation Reserves be reconciled with the General Ledger monthly.
View Audit 398402
Finding 1206398 (2022-001)
Material Weakness 2022
City of Newark
NJ
Eligibility Matching / Level of Effort / Earmarking
In addition, the differences between Federal and State Program Bar and the Manually maintained worksheet be reconciled and adjusted.
In addition, the differences between Federal and State Program Bar and the Manually maintained worksheet be reconciled and adjusted.
View Audit 398402
Finding 1206398 (2022-001)
Material Weakness 2022
City of Newark
NJ
Eligibility Matching / Level of Effort / Earmarking
Corrective Action and Explanation - The City of Newark will comply with the Auditor's recommendation. Implementation Date: Ongoing.
Corrective Action and Explanation - The City of Newark will comply with the Auditor's recommendation. Implementation Date: Ongoing.
View Audit 398402
Finding 1175693 (2022-002)
Material Weakness 2022
Bristow Housing Authority
OK
Eligibility HUD Housing Programs
Corrective Action Plan Finding: Finding 2022-002-Low Rent Tenant File Deficiencies-Eligibility Condition: We reviewed 25 files, 7 of which were audit year move-ins, and 18 were annual re-examinations. We noted the following exceptions: (a)-We were unable to find any annual inspections for the 18 re-...
Corrective Action Plan Finding: Finding 2022-002-Low Rent Tenant File Deficiencies-Eligibility Condition: We reviewed 25 files, 7 of which were audit year move-ins, and 18 were annual re-examinations. We noted the following exceptions: (a)-We were unable to find any annual inspections for the 18 re-examinations. We did note them for 6 of the 7 move-ins. (b)-We were unable to find the required annual review of the utility allowances. The January 27, 2020 Minutes discuss utility allowances and approve new ones. However, the minutes do not reflect for which period the new allowances covered. In addition, there was no documented analysis of whether utility rates had increased beyond the level which required revision, and whether the allowances changed or instead were a holdover from the old rates. (c)-We were unable to view the waiting list, and thus could not review whether the 7 move-ins reached the top of the list. (d)-5 required Enterprise Income Verifications (EIV) were not present in the proper time frame for the 25 files reviewed. (e)-Of the 25 tenant files we reviewed, non were timely re-examined within the required one year period. (f)-We were unable to review documentation of the review of flat rents. Corrective Action Planned As noted previously, we were not the management during this audit period. Our initial Cooperative Agreement was executed November 14, 2023. We believe we have corrected the noted deficiencies. Person responsible for corrective action: Charles Unsell, Executive Director Telephone: (918) 367-5558 Housing Authority of Bristow, Oklahoma Fax: (918) 367-2341 1110 S. Chestnut Bristow, OK 74010 Anticipated Completion Date- June 30, 2026
View Audit 389594
Finding 1174933 (2022-018)
Material Weakness 2022
Kickapoo Tribe in Kansas
KS
Eligibility Internal Control / Segregation of Duties HUD Housing Programs § 200.303
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.
View Audit 388523
Finding 1173236 (2022-001)
Material Weakness 2022
New Space Nexus
NM
Eligibility Reporting Significant Deficiency
Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9...
Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9 forms will be remediated where permissible. Management will retain evidence of completion and conduct periodic compliance reviews to ensure ongoing adherence. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by January 31, 2023.
View Audit 386730
Finding 1172706 (2022-008)
Material Weakness 2022
Northwest Indian College
WA
Eligibility Reporting Significant Deficiency § 200.303 § 200.328 § 200.329
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
View Audit 385956
Finding 1172528 (2022-004)
Material Weakness 2022
HOMES OF MONTCLAIR ECUMENICAL CORP
NJ
Eligibility Internal Control / Segregation of Duties HUD Housing Programs
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the executive Director left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director, onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
View Audit 385755
Finding 1172526 (2022-002)
Material Weakness 2022
HOMES OF MONTCLAIR ECUMENICAL CORP
NJ
Eligibility HUD Housing Programs Material Weakness
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the Executive Director, left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
View Audit 385755
Finding 1170433 (2022-004)
Material Weakness 2022
Baltimore Medical System, Inc.
MD
Eligibility Internal Control / Segregation of Duties
Finding: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients i...
Finding: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients included under this program are eligible. During the compliance testing of 44 sample items, there was two instances where the Organization applied a sliding fee discount to a patient who had not submitted any documents regarding their income level or family size and we could not determine whether the patient should have been included as a sliding fee patient, and one instance where the patient had properly submitted their forms, but the Organization applied the incorrect sliding fee rate. Currently, there is no known monetary impact, improper expenditure of funds or questioned costs identified. However, if the Organization does not strengthen the internal controls in regard to the eligibility determination process, there is a possible effect on the ability of the Organization to obtain additional funding under this program if ineligible patients are being treated with grant funding. Views of responsible officials and planned corrective actions: Management agrees with the recommendation to review policies, procedures and practices in place over the controls related to obtaining, retaining and reviewing proof of income support for patients. • Train relevant staff on the Sliding Fee eligibility process and supporting documentation requirements. Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO
View Audit 383596
Finding 1167402 (2022-003)
Material Weakness 2022
Compañia de Turismo de Puerto Rico
PR
Allowable Costs / Cost Principles Eligibility Procurement, Suspension & Debarment
Views of responsible officials: Before the approval of budget and the contract petition, the Chief Financial Officer will verify if the vendors are excluded as an authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified ag...
Views of responsible officials: Before the approval of budget and the contract petition, the Chief Financial Officer will verify if the vendors are excluded as an authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the excluded list at least once a year. This verification process will ensure compliance with federal regulations and avoid engaging with vendors who may be suspended or debarred. Additionally, this procedure will be recommended to be included in the review process for quotes or bidding requirements, further enhancing the Company’s ability to comply with federal regulations and maintain responsible vendor relationships.
View Audit 378469
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