Corrective Action Plans

Finding 480648 (2023-005)

Significant Deficiency 2023

WI

HUD Housing Programs Subrecipient Monitoring Eligibility

Action taken in response to finding: ICS will provide additional training to current and new staff regarding the importance of retaining Authorization For Release of Information documentation and the requirement that there are two Authorization forms saved and scanned with each file. ICS will also ...

Action taken in response to finding: ICS will provide additional training to current and new staff regarding the importance of retaining Authorization For Release of Information documentation and the requirement that there are two Authorization forms saved and scanned with each file. ICS will also request that staff review file as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately

View Audit 316843

Finding 480643 (2023-004)

Significant Deficiency 2023

Integrated Community Solutions, Inc.

WI

HUD Housing Programs Subrecipient Monitoring Eligibility

ICS will provide additional training to current and new staff regarding the importance of retaining asset documentation. ICS will also request that staff review files as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. ICS ...

ICS will provide additional training to current and new staff regarding the importance of retaining asset documentation. ICS will also request that staff review files as they are scanning to assure that documentation is included and scanned properly before saving and shredding the paper file. ICS will also encourage staff provide in writing on the documents how they calculated what was entered. They can either circle the amount they are using or if a calculation is necessary they should write the equation on the verification so all parties know how they came to the amount they are entering into the file. Names of the contact persons responsible for corrective action: Matt Roberts and Megan Walker Planned completion date for corrective action plan: Immediately.

View Audit 316843

Finding 480540 (2023-002)

Significant Deficiency 2023

Housing and Redevelopment Authority of the City of Worthington

MN

HUD Housing Programs Internal Control / Segregation of Duties

Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will monitor claims approvals going forward. Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensu...

Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will monitor claims approvals going forward. Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: The planned completion date is December 31, 2024. Plan to Monitor Completion of CAP: The Board will be monitoring this corrective action plan and believes the Executive Director will remedy this finding. Tanner Rogers Executive Director

View Audit 316737

Finding 480539 (2023-001)

None 2023

Housing and Redevelopment Authority of the City of Worthington

MN

HUD Housing Programs

Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will complete the depository agreements. Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensuring...

Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will complete the depository agreements. Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: The planned completion date is December 31, 2024. Plan to Monitor Completion of CAP: The Board will be monitoring this corrective action plan and believes the Executive Director will remedy this finding. Tanner Rogers Executive Director

View Audit 316737

Finding 480510 (2023-001)

Significant Deficiency 2023

Montgomery County Housing Authority

TX

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority has updated the practice to follow the HUD compliance supplement. Amanda Bone, Chief Executive Officer, is responsible for implementing this corrective action by Dece...

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority has updated the practice to follow the HUD compliance supplement. Amanda Bone, Chief Executive Officer, is responsible for implementing this corrective action by December 31, 2024.

View Audit 316701

Finding 480490 (2023-001)

Material Weakness 2023

Lorna Doone Associates, LLC

UT

HUD Housing Programs

a. An inspection will be held at least two times per year (semi-annual inspection).

View Audit 316665

Finding 480486 (2023-002)

Significant Deficiency 2023

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Allowable Costs / Cost Principles HUD Housing Programs Matching / Level of Effort / Earmarking § 200.430

Item 2023-002 - Activities Allowed and Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that all labor reports are reviewed and show formal approval before payroll is submitted. Repeat Finding No Action Taken As of July 20...

Item 2023-002 - Activities Allowed and Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that all labor reports are reviewed and show formal approval before payroll is submitted. Repeat Finding No Action Taken As of July 20, 2024, we have added the Payroll Summary by grant to the grant draw down packet. In addition, we have changed the procedure to reflect that the payroll summary must have either the CFO and/or CEO approval signature prior to grant draw. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sabrina McAfee, CFO at (573) 836-7079.

View Audit 316663

Finding 480482 (2023-001)

Significant Deficiency 2023

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Special Tests & Provisions Subrecipient Monitoring Eligibility

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health...

Section Ill- Federal Award Findings and Questioned Costs Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program and COVID-19 Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2023-001- Special Tests Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken As of May 1, 2023, the Director of Revenue and/or designee runs a slide fee report daily the reflects everyone that applied the day before. Billing personnel separate the report and audit the files to ensure the correct slide has been applied. The paper application is forwarded to the billing department for a third audit if the application is in order and has been uploaded into the patients' files and then it is manually filed. The CFO will perform random audits and will present to the Board and CEO a quarterly report with the results. In addition, As of July 1, 2023, the Access Coordinators who normally collect and process the slide fee discount program applications are now reporting to the finance department with the Director of Revenue supervising and training staff. In addition, there will now be a Lead Access Coordinator in very clinic that will audit and perform additional training where necessary.

View Audit 316663

Finding 480347 (2023-001)

Significant Deficiency 2023

Carearc, INC

KS

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2023.001 - Sliding Fee Scale Documentation Recommendation The Organization 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 CareArc was notified of the 2023 annual audit...

Finding 2023.001 - Sliding Fee Scale Documentation Recommendation The Organization 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 CareArc was notified of the 2023 annual audit finding related to Sliding Fee Discounts being applied incorrectly according to the Health Center Program Compliance Manual and out of compliance with our sliding fee policy. CareArc's CFO was aware of the incorrect slide adjustments during the sampling process of the audit. The two patients on Slide B that should have received 50% discount, only received 49% ($3.00 miscalculation) as our electronic medical records did not identify an internal lab as being all inclusive of the same-day office visit. The corrective action plan was to have the Electronic Medical Records system recognize internal labs as being all inclusive of the same-day office visit. This issue was identified by CareArc through an internal audit in September 2023 and we began working with Health Choice Network (HCN). HCN is our vendor that helps program our electronic medical records system. HCN has helped CareArc correct the system going forward. CareArc is working with HCN on creating a report on historical slide applications to correct accounts earlier in 2023. CareArc was able to manually correct the two identified patient accounts. The corrective action plan is still in process of being implemented by CareArc with the assistance of HCN/EPIC with an estimated completion in September 2024. If there are any question regarding this plan, please e-mail Seresa Howe at showe@carearc.org.

View Audit 316606

Finding 480344 (2023-001)

None 2023

Asi - Reno, Inc.

MN

Questioned Costs HUD Housing Programs Cash Management

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI-Reno, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audi...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI-Reno, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT - NONE; FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT; FINDING 2023-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 The Project withdrew funds from the replacement reserve account that were subsequently reimbursed by the insurance company. Recommendation: The Project should deposit $5,500 into the replacement reserve account. Action Taken: The Project agrees with the finding. Management will deposit $5,500 into the replacement reserve account. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.

View Audit 316599 Questioned Costs: $1

Finding 480343 (2023-001)

None 2023

Asi - Billings, Inc.

MN

Questioned Costs HUD Housing Programs

ASI Billings, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023; The finding...

ASI Billings, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: December 31, 2023; The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT - None, FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - None; DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 In 2 of 25 cash disbursements tested, the Project paid the expense of another project under common management. Recommendation: The Project should carefully review invoices before payment to make sure it only pays the proper amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment. The finding was corrected in January 2024. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.

View Audit 316598 Questioned Costs: $1

Finding 480342 (2023-001)

None 2023

Asi Capitola, Inc.

MN

Questioned Costs HUD Housing Programs

FINDING 2023-001: SECTION 811, FEDERAL ASSISTANCE LISTING NUMBER 14.181 Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy a...

FINDING 2023-001: SECTION 811, FEDERAL ASSISTANCE LISTING NUMBER 14.181 Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Project managers should be aware of the importance of computing the tenant's household income correctly. Action taken: The Project agrees with the finding. Tenant rent was recomputed in January 2024 and management adjusted the April 2024 HUD billing. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.

View Audit 316587 Questioned Costs: $1

Finding 480340 (2023-001)

None 2023

Asi - Minot, Inc.

MN

Questioned Costs HUD Housing Programs

Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Proje...

Condition: One of the tenant files tested contained a mathematical error in computing household income in the process of computing the tenant share of monthly rent. Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Project managers should be aware of the importance of computing the tenant's household income correctly. Action taken: The Project agrees with the finding. Tenant rent was recomputed in January 2024. If the Department of Housing and Urban Development has questions regarding these plans, please call Chuck Reuter at 651-645-7271.

View Audit 316560 Questioned Costs: $1

Finding 480313 (2023-001)

Significant Deficiency 2023

Middleborough Housing Authority

MA

HUD Housing Programs Subrecipient Monitoring Reporting

The Authority had a change in Executive Director and Fee Accountant, which resulted in delayed access to the FASPHA system. The Authority will ensure timely submissions going forward.

View Audit 316534

Finding 480285 (2023-001)

Significant Deficiency 2023

Cambridge Manor Tenant Council

IL

Questioned Costs Internal Control / Segregation of Duties Eligibility

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: James Watt, Senior Vice President, Management Company Completion Date: January 1, 2024

View Audit 316498 Questioned Costs: $1

Finding 480252 (2023-001)

Material Weakness 2023

Westhaven of Englewood, Ltd.

IL

Questioned Costs HUD Housing Programs Reporting

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: Section 8 Housing Assistance Payments, CFDA 14.195 Recommendation: Management should arrange to transfer the amount due to the residual receipts account as soon as possible. Corrective Actions Taken: Management has acknowledged the findin...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: Section 8 Housing Assistance Payments, CFDA 14.195 Recommendation: Management should arrange to transfer the amount due to the residual receipts account as soon as possible. Corrective Actions Taken: Management has acknowledged the finding and promised to transfer the amount due to the residual receipts account as soon as possible. Contact: Greg Miller, Management Agent Anticipated Completion Date: November 30, 2023

View Audit 316486 Questioned Costs: $1

Finding 480251 (2023-001)

Material Weakness 2023

Paradise Haven Homes, Ltd. 071-Eh537

IL

Questioned Costs HUD Housing Programs Reporting

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: Section 8 Housing Assistance Payments, CFDA 14.195 Recommendation: Management should arrange to transfer the amount due to the residual receipts account as soon as possible. Corrective Actions Taken: Management has acknowledged the findin...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2023-001: Section 8 Housing Assistance Payments, CFDA 14.195 Recommendation: Management should arrange to transfer the amount due to the residual receipts account as soon as possible. Corrective Actions Taken: Management has acknowledged the finding and promised to transfer the amount due to the residual receipts account as soon as possible. Contact: Greg Miller, Management Agent Anticipated Completion Date: December 31, 2023

View Audit 316485 Questioned Costs: $1

Finding 480250 (2023-004)

Significant Deficiency 2023

County of Columbus

NC

HUD Housing Programs Reporting Significant Deficiency

2023-004 Significant Deficiency over Reporting Information on the Federal Program: Low Income Housing Assistance Program (Section 8), Assistance Listing Number 14.871, U.S. Department of Housing and Urban Development. Criteria: Public Housing Agencies (PHAs) are required to report submit timely a ...

2023-004 Significant Deficiency over Reporting Information on the Federal Program: Low Income Housing Assistance Program (Section 8), Assistance Listing Number 14.871, U.S. Department of Housing and Urban Development. Criteria: Public Housing Agencies (PHAs) are required to report submit timely a Financial Assessment Sub-system (FASS-PH): GAAP-based unaudited and audited financial information electronically to HUD. Name of Contact Person: Heather Woody, Deputy Finance Director Corrective Action Plan: The County will establish and maintain proper internal controls to ensure financial statements are presented in accordance with GAAP, on a timely basis. The County will then be able to complete timely reporting of the FASS-PH. Proposed Completion Date: July 1, 2024

View Audit 316481

Finding 480100 (2023-001)

Significant Deficiency 2023

Delphi Drug & Alcohol Council, Inc.

NY

Special Tests & Provisions HUD Housing Programs Reporting

U.S. Department of Housing and Urban Development Delphi Drug & Alcohol Council, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bonadio & Co, LLP 100 Corporate Parkway Suite 200 Amherst, Ne...

U.S. Department of Housing and Urban Development Delphi Drug & Alcohol Council, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bonadio & Co, LLP 100 Corporate Parkway Suite 200 Amherst, New York 14226 Audit Period: January 1, 2023 through December 31, 2023 The significant deficiency from the December 31, 2023 schedule of findings and questioned costs is discussed below. It is numbered consistently with the number assigned in the schedule. Federal Award Finding and Questioned Costs Name of Contact Person: Jennifer Cathy, Executive Director Anticipated Completion Date: December 31, 2024 2023-001 – Significant Deficiency Corrective Action Plan: Condition: The rents charged to beneficiaries, who receive rent assistance through the program, must be reasonable in relation to rents being charged for comparable units. The Organization is required to establish the reasonableness of the rents charged by the property owner for comparable unassisted units. Out of 40 program beneficiaries selected for testing, The Organization had a documented rent reasonableness assessment for only 13 of the selections. Recommendation: Management should implement a system and internal control process to ensure the proper reasonableness assessment is being made for each program beneficiary. Current Status: Policies and procedures have been established to properly meet the recommendation. During 2023, the U.S. Department of Housing and Urban Development had performed their own audit of the program and identified this same matter to management. After management was informed of this deficiency, they took direct action during 2023 to implement procedures to prevent this issue in the future. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Ms. Jennifer Cathy at (585) 355-7842.

View Audit 316413

Finding 480078 (2023-006)

None 2023

St Bernard Parish Government

LA

HUD Housing Programs

Name of contact person responsible for corrective action plan: Justin Frank Corrective action planned: The Parish will guarantee that a depository agreement is executed immediately. Anticipated completion date: December 31, 2024

View Audit 316361

Finding 480077 (2023-005)

Significant Deficiency 2023

St Bernard Parish Government

LA

HUD Housing Programs Eligibility Significant Deficiency

Name of contact person responsible for corrective action plan: Andrew Becker Corrective action planned: The Parish will ensure that income verifications are accurately calculated and Federal income eligibility requirements are met. Anticipated completion date: December 31, 2024

View Audit 316361

Finding 479803 (2023-002)

Significant Deficiency 2023

Saugatuck Child Care Services Inc.

CT

Cash Management HUD Housing Programs Significant Deficiency

• Description – Program staff do not prepare a reconciliation of amounts received for a given month with what was actually disbursed on a monthly basis. • Views of Responsible Officials and Planned Corrective Action – Kathy has created an excel report to reconcile the amounts received to what was d...

• Description – Program staff do not prepare a reconciliation of amounts received for a given month with what was actually disbursed on a monthly basis. • Views of Responsible Officials and Planned Corrective Action – Kathy has created an excel report to reconcile the amounts received to what was disbursed. The reconciliation will be maintained on a monthly basis. • Names and Title of Responsible Official – Kathy Sabitsky, Finance Manager • Anticipated Completion Date – This was implemented during fiscal year 2024.

View Audit 316325

Finding 479705 (2023-002)

Significant Deficiency 2023

Allegany County, Maryland

MD

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Allegany County has developed an improved procedure to ensure financial reports are submitted within the due date. Plan includes discussions with department heads in order to better improve and understand the complex reporting process that is required by the funding agency.

View Audit 316261

Finding 479689 (2023-006)

Significant Deficiency 2023

Housing Authority of Newberry

SC

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

2023-006 ALN 14.872 - Capital Funds Program - Special Tests - Environmental Reviews Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive D...

2023-006 ALN 14.872 - Capital Funds Program - Special Tests - Environmental Reviews Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Completion Date: December 31, 2024

View Audit 316234

Finding 479687 (2023-004)

Significant Deficiency 2023

Housing Authority of Newberry

SC

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

2023-004 ALN 14.871 – Housing Voucher Cluster – Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Comple...

2023-004 ALN 14.871 – Housing Voucher Cluster – Eligibility Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Jessica Holcomb, Executive Director Projected Completion Date: December 31, 2024

View Audit 316234

Corrective Action Plans

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