Corrective Action Plans

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Corrective Action Plan - ACH payments not approved by the Board. Contact person - Executive Director. Corrective action planned - The PHA will implement the control procedure of attaching ACH supporting documentation to a copy of the bank statement and obtaining approval from a Board member authoriz...
Corrective Action Plan - ACH payments not approved by the Board. Contact person - Executive Director. Corrective action planned - The PHA will implement the control procedure of attaching ACH supporting documentation to a copy of the bank statement and obtaining approval from a Board member authorized to sign checks. Anticipated completion date - Within the next fiscal year.
Corrective Action Plan - Financial statements contained material misstatements. Contact person - Executive Director. Corrective action planned - The PHA will hire an outside fee accountant or an employee with accounting experience. Anticipated completion date - Within the next fiscal year.
Corrective Action Plan - Financial statements contained material misstatements. Contact person - Executive Director. Corrective action planned - The PHA will hire an outside fee accountant or an employee with accounting experience. Anticipated completion date - Within the next fiscal year.
Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be ...
Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be notified about the matter and while the amount is adjusted through the monthly mortgage payment, Management will continue to make monthly deposits of $812.00 through 2023 fiscal year to cover the deficiency. The responsible person for the corrective action plan is Carmen G Rivera, Blanco’s Administrative Director. The estimated completion date for the finding is May 31, 2024. Management will ensure deposits to the replacement reserve account are made on a monthly basis as stated in the use agreement.
Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be ...
Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be notified about the matter and while the amount is adjusted through the monthly mortgage payment, Management will continue to make monthly deposits of $812.00 through 2023 fiscal year to cover the deficiency. The responsible person for the corrective action plan is Carmen G Rivera, Blanco’s Administrative Director. The estimated completion date for the finding is May 31, 2024. Management will ensure deposits to the replacement reserve account are made on a monthly basis as stated in the use agreement.
U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Nonco...
U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The Authority was not able to locate 1 of the 61 participant files selected for audit testing. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: During 2023, the Housing Choice Voucher Department moved physical locations from the 10th Floor of 1414 Santa Fe to 201 S Victoria. Also, during this time, all of the historical paper files were being scanned for digital storage. During this time, paperwork for one of the participants re-certification and inspection were misplaced and not able to be located during audit fieldwork. We do not anticipate this issue in the future since there will not be another office move, and all recertification paperwork moving forward is being scanned and attached in our software Anticipate Completion Date: January 2024
The Organization documents decisions and the Board votes through corporate resolutions. Nevertheless, to better document the Board’s monitoring and control of team performance, the Organization intends to resume preparing minutes for Board meetings going forward. Meetings are to be held at least onc...
The Organization documents decisions and the Board votes through corporate resolutions. Nevertheless, to better document the Board’s monitoring and control of team performance, the Organization intends to resume preparing minutes for Board meetings going forward. Meetings are to be held at least once every four months, according to the Organization’s internal regulations.
The Organization initially had difficulty identifying a qualified firm to carry out the Single Audit for the year ended December 31, 2023. During the first half of 2024, the Organization contacted a total of 17 firms to request quotes, in a process that proved especially difficult given that many di...
The Organization initially had difficulty identifying a qualified firm to carry out the Single Audit for the year ended December 31, 2023. During the first half of 2024, the Organization contacted a total of 17 firms to request quotes, in a process that proved especially difficult given that many did not have experience auditing Non-Profit entities or did not respond. The Organization also consulted with peer Non-Profits entities with similar budgets to obtain recommendations, and from all these efforts only one proposal was received. This prolonged search process significantly delayed the start of the audit. Nevertheless, the Organization entered into a formal agreement with a certified public accounting (CPA) firm to perform the Single Audit. In addition, as this was the Organization’s first audit, additional time was required to compile the requested documents. With a clear understanding now of the documentation requirements, the process is expected to be significantly quicker in future audits. Furthermore, the Organization has already agreed with the same firm to perform the Single Audit for subsequent years going forward.
Finding Number: 2023-005 Planned Corrective Action: The Authority has updated our allocation plan and added actual percentages to the plan. A/P was unaware that all employee benefits were at a different percentage; has since then been remedied. Anticipated Completion Date: April 15, 2025 Responsible...
Finding Number: 2023-005 Planned Corrective Action: The Authority has updated our allocation plan and added actual percentages to the plan. A/P was unaware that all employee benefits were at a different percentage; has since then been remedied. Anticipated Completion Date: April 15, 2025 Responsible Contact Person: Sherrie Boudinot
Finding Number: 2023-004 Planned Corrective Action: The extension was granted and the housing authority kept in contact by email to HUD in regard to the lengthy audit process due to former executive director. Our plan is to be timelier once these issues are rectified. Anticipated Completion Date: Ma...
Finding Number: 2023-004 Planned Corrective Action: The extension was granted and the housing authority kept in contact by email to HUD in regard to the lengthy audit process due to former executive director. Our plan is to be timelier once these issues are rectified. Anticipated Completion Date: May 31, 2025 Responsible Contact Person: Sherrie Boudinot, Zackary Dye
Finding Number: 2023-003 Planned Corrective Action: The Authority has contracted with the Inspection Group and has contracted with HAPCAP to also do inspections to ensure that all inspections are done in time. The Authority has designated a staff person to keep track of abatements and to send an i...
Finding Number: 2023-003 Planned Corrective Action: The Authority has contracted with the Inspection Group and has contracted with HAPCAP to also do inspections to ensure that all inspections are done in time. The Authority has designated a staff person to keep track of abatements and to send an inspector out to do a reinspection within the permitted time frames. If the unit fails a second inspection, in most cases the HAP is abated, or a formal extension is granted on occasion. Anticipated Completion Date: October 2024 Responsible Contact Person: Erica Flanders
Finding Number: 2023-002 Planned Corrective Action: The Authority is now in contract with the Nelrod company to do Authority Rent Reasonableness. Anticipated Completion Date: August 2024 Responsible Contact Person: Zackary Dye/Erica Flanders
Finding Number: 2023-002 Planned Corrective Action: The Authority is now in contract with the Nelrod company to do Authority Rent Reasonableness. Anticipated Completion Date: August 2024 Responsible Contact Person: Zackary Dye/Erica Flanders
Finding 573311 (2023-002)
Significant Deficiency 2023
Management has instructed the department managers involved with grants to work with the Finance Director and Senior Accountant for all future grant accounting and reporting to ensure that grant expenditures are properly recorded and reported in the correct period. The Senior Accountant will complete...
Management has instructed the department managers involved with grants to work with the Finance Director and Senior Accountant for all future grant accounting and reporting to ensure that grant expenditures are properly recorded and reported in the correct period. The Senior Accountant will complete GFOA’s Generally Accepted Accounting Principles for Grants in August 2026. As of the date of this letter, Management is working to identify other grants-related training appropriate for the Senior Accountant, the Utility Manager, and the Director of Development Services and Capital Projects, all of whom are involved in grant proposals, management, expenditures, accounting and required reporting. Meetings with all three department managers will be scheduled to coordinate administration and deadlines for the City’s new and existing grants as grant reporting deadlines occur. Responsible Personnel Name and Position: Jill Taura, Interim Finance Director Expected Implementation Date of Corrective Action Plan: Fiscal year 2026
Finding No. 2023-01: Tenant income is to be reconciled to reports run by the Enterprise Income Verification system (EIV) Recommendation: Management should use the EIV system properly to verify tenant employment and income during recertifications and calculate subsidy payments correctly. Action Taken...
Finding No. 2023-01: Tenant income is to be reconciled to reports run by the Enterprise Income Verification system (EIV) Recommendation: Management should use the EIV system properly to verify tenant employment and income during recertifications and calculate subsidy payments correctly. Action Taken or Planned: Management is conducting proper reconciliation between EIV system and tenant declared income at recertification. Responsible Person: Monique Brown, Manager Completion Date: May 31, 2023
View Audit 363827 Questioned Costs: $1
Finding 572057 (2023-003)
Significant Deficiency 2023
Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directl...
Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directly with the Director of Clinical Operations, Kei Wee, to conduct a comprehensive review of the Center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and definition of family size. The Clinical Operations Director, Kei Wee, will develop and implement a step-by-step standard operating procedure (SOP) for staff to consistently assess and apply sliding fee discounts. The SOP will include clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director, Kei Wee's management team, will conduct monthly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to management for corrective follow-up and provide training for registration/front-desk staff and billing personnel on the updated policy and procedures as needed.
No corrective action plan is need as this was a singular one-time event involving provider relief funding from HRSA. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: N/A
No corrective action plan is need as this was a singular one-time event involving provider relief funding from HRSA. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: N/A
View Audit 362889 Questioned Costs: $1
Finding No. 2023-004 HUD Low Income Housing Preservation and Resident Homeownership Act of 1990 Federal Assistance Listing Number #99.999 Uniform Guidance Compliance Requirement Code: N- Special Tests and Provisions Criteria In accordance with the Use Agreement, Housing Quality Standards require th...
Finding No. 2023-004 HUD Low Income Housing Preservation and Resident Homeownership Act of 1990 Federal Assistance Listing Number #99.999 Uniform Guidance Compliance Requirement Code: N- Special Tests and Provisions Criteria In accordance with the Use Agreement, Housing Quality Standards require that the Owner shall maintain the property in good repair and condition. Condition Management did not have in place proper procedures and controls to ensure that HQS inspections were performed during the year ended December 31, 2023. Cause Management did not perform HQS inspections during the year ended December 31 2023. Effect or Potential Effect Housing units may be out of compliance with HUD Quality Standards. Questioned Costs: Not applicable. Context In connection with the procedures applied to tenant file testing there were 3 instances of the 3 files tested where the passing HQS inspections were not performed during the year ended December 31, 2023. Repeat Finding: No Recommendation Management should resume making sure all units meet the HUD Housing Quality Standards and ensure that the responses to any findings are cleared timely. Views of Responsible Officials REACH did return to doing HQS Inspections in 2023, with staffing shortages it is possible that not every unit was inspected in 2023. Specifically, around the 3 instances of the 3 files tested after the finding were provided to REACH we provided the annual inspection for unit #11 at Beacon. For unit #5 at Beacon the annual inspection was not in the current resident file that was tested because the unit was vacant at the time of 2023 annual inspection. The annual inspection for the last file at Taylor this inspection was missed due to staffing changes at the time. REACH continued to reestablish our annual unit inspection process post COVID in 2024.
Finding No. 2023-003 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Uniform Guidance Compliance Requirement Code: E-Eligibility Criteria Each owner must comply with the requirements set forth in 24 CFR Part 92 regulations as outlined in the "Compliance in HOME Re...
Finding No. 2023-003 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Uniform Guidance Compliance Requirement Code: E-Eligibility Criteria Each owner must comply with the requirements set forth in 24 CFR Part 92 regulations as outlined in the "Compliance in HOME Rental Projects: A Guide for Property Owners" published by HUD which requires the property to maintain the contracted number of HOME units as well as the designated splits in bedroom size and High Home/Low Home unit ratios. Condition The owner did not make available to HOME tenants the contracted number and type of HOME units. Cause Management’s policies with respect to maintaining the number and split of contracted HOME units were not consistently followed. Effect or Potential Effect The procedures for determining and maintaining the correct HOME units within the property were not applied. This could result in ineligible tenants occupying HOME designated units. Questioned Costs: Not applicable. Context In connection with the procedures applied to our HOME units testing, one of the five properties tested did not meet the contracted HOME units size portfolio (there should be four 3-bedroom units (there are 5); and there should be three 4-bedroom units (there are 2)). Repeat Finding: Yes - Finding 2022-003 Recommendation Management should follow procedures in place to ensure consistent application and adherence to the requirements in accordance with the “Compliance in HOME Rental Projects: A Guide for Property Owners” published by HUD. Views of Responsible Officials A unit will be re-classified the next time there is a vacant unit of the corresponding size/type.
Finding No. 2023-002 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Uniform Guidance Compliance Requirement Code: E-Eligibility Criteria Tenant lease files are required to be maintained and tenant eligibility determined in accordance with the Compliance in State ...
Finding No. 2023-002 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Uniform Guidance Compliance Requirement Code: E-Eligibility Criteria Tenant lease files are required to be maintained and tenant eligibility determined in accordance with the Compliance in State of Oregon Housing and Community Services HOME Program Compliance Manual. Condition In connection with our lease file review we noted four instances of eight tenants tested where management did not provide support that they performed a 3rd party income verification in accordance with policy. Cause Management’s policies with respect to recertifications and eligibility and the maintenance of tenant lease files in accordance with Compliance in State of Oregon Housing and Community Services HOME Program Compliance Manual were not consistently followed. Effect or Potential Effect This could result in units being rented to ineligible tenants. Questioned Costs: Not applicable. Context In connection with the procedures applied to our HOME units testing, four of the eight tenants tested did not have the a 3rd party income verification in accordance with policy. Repeat Finding: Yes - Finding 2022-002 Recommendation Management should establish procedures and monitor compliance with those procedures to ensure that recertifications and correct income verification procedures are performed timely, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of Compliance in State of Oregon Housing and Community Services HOME Program Compliance Manual. Views of Responsible Officials For the properties in Washington, they have several sources of HOME funds based on the issuing jurisdiction State, County or City that adds a layer of complexity to the recertification process and due to staffing turnover, both at the properties and REACH main office some of the HOME 3rd party income verifications were missed at recertification. Management has established policies and procedures for complying with the HOME program which includes a centralized tracker for HOME certifications.
Finding No. 2023-001 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Uniform Guidance Compliance Requirement Code: N-Special Tests and Provisions Criteria During the period of affordability (i.e., the period for which the nonfederal entity must maintain subsidized...
Finding No. 2023-001 HUD HOME Investment Partnerships Program Federal Assistance Listing Number #14.239 Uniform Guidance Compliance Requirement Code: N-Special Tests and Provisions Criteria During the period of affordability (i.e., the period for which the nonfederal entity must maintain subsidized housing) for HOME assisted rental housing, the participating jurisdiction must perform on-site inspections to determine compliance with property standards and verify the information submitted by the owners no less than (a) every three years for projects containing one to four units, (b) every two years for projects containing five to 25 units, and (c) every year for projects containing 26 or more units. The participating jurisdiction must perform on-site inspections of rental housing occupied by tenants receiving HOME/HOME-ARP-assisted tenant- based rental assistance to determine compliance with housing quality standards (24 CFR sections 92.209(i), 92.251(f), and 92.504(d)). Condition The owner did not ensure passing HQS inspections were performed during 2023. Cause Management did not have in place proper procedures and controls to ensure that HQS inspections were performed during the year ended December 31, 2023. Effect or Potential Effect Housing units may be out of compliance with HUD Quality Standards. Questioned Costs: Not applicable. Context In connection with the procedures applied to tenant file testing there were 8 instances of the 8 files tested where the passing HQS inspections were not performed during the year ended December 31, 2023. Repeat Finding: Yes - Finding 2022-001 Recommendation Management should resume making sure all units meet the HUD Housing Quality Standards and ensure that the responses to any findings are cleared timely. Views of Responsible Officials REACH did return to doing HQS Inspections in 2023. With staffing shortages, it is possible that not every unit was inspected in 2023. REACH continued to reestablish our annual unit inspection process post COVID in 2024. For the finding related to Addy St. This property is managed by a 3rd party management company, REACH’s Asset Management team will work with the management company to ensure all inspections are happening.
Re: Independent Audit FYE September 30, 2023—Management Response Dear Mr. Zenk: This letter serves as the Muskegon Housing Commission’s follow-up and completed response to the finding reported in the Independent Audit FYE September 30, 2023.Finding 2023-001 Section 8 Housing Choice Voucher Program T...
Re: Independent Audit FYE September 30, 2023—Management Response Dear Mr. Zenk: This letter serves as the Muskegon Housing Commission’s follow-up and completed response to the finding reported in the Independent Audit FYE September 30, 2023.Finding 2023-001 Section 8 Housing Choice Voucher Program Tenant Files were missing supporting documents and not timely recertified. Corrective Action: MHC has worked to make corrections to all files and get them in correct order. All recertifications are started 120 days prior to the date. Beginning July 1, 2024 all files will have a checklist completed and the Executive Director will sign and verify all documents are included. We will utilize the checklists attached and make any updates as needed per regulations.
Condition: The Organization could not provide one salary authorization from for sample selection of 40 employees. Corrective Action Planned: The Organization has implemented a process to ensure that all salary authorizations are properly obtained and stored. When there is any change in an employee...
Condition: The Organization could not provide one salary authorization from for sample selection of 40 employees. Corrective Action Planned: The Organization has implemented a process to ensure that all salary authorizations are properly obtained and stored. When there is any change in an employee's status or salary, an Employee Status Form is completed and signed by the employee, their supervisor, and Human Resources, and when required by the COO and CEO. Additionally, the salary authorization form is added to a secure shared file drive. The shared file drive includes a section where all salary changes are listed. Both HR and Finance initial off to confirm that each salary change is supported by the proper documentation during the payroll review process. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll and finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervi...
Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll and finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors' approval to time recorded by employees. Corrective Action Planned: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employee's time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. The entire process is fully documented, with approvals recorded within the ADP by employees and supervisors and the shared file drive where HR and Finance intimal off on the reviewed payroll times, ensuring a traceable record of the entire payroll approval process. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Condition: The Organization did not maintain property documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting ...
Condition: The Organization did not maintain property documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties and best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review as also implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in ...
Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal control and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner....
Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
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