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Corrective Action Plans

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Finding 10531 (2023-002)
Significant Deficiency 2023
Village Cooperative of the Northland
MO
HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring
The Cooperative will make required deposits to the General Operating Reserve.
The Cooperative will make required deposits to the General Operating Reserve.
View Audit 14220
Finding 10508 (2023-004)
Significant Deficiency 2023
United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health
KS
Subrecipient Monitoring HUD Housing Programs Reporting
Finding 2023.004 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken Health contracted with an interim Chief Financial Officer in January 2023. The interim CFO de...
Finding 2023.004 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken Health contracted with an interim Chief Financial Officer in January 2023. The interim CFO departed in February 2023 and was unable to provide the organization with work source documents for the 2022 UDS submission. Effective January 2024, the current Chief Financial Officer and the electronic medical records specialist (IT) will ensure all source documentation for the UDS submission is saved on the organization’s shared file drive to support the annual UDS submission.
View Audit 14201
Finding 10504 (2023-003)
Significant Deficiency 2023
United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health
KS
Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs
Finding 2023.003 - Activities Allowed or Unallowed Recommendation The Organization should establish a system of internal controls to ensure that all employees are being paid the correct amounts. Action Taken United Methodist Western Kansas Mexican-American Ministries Inc. d/b/a Genesis Family Heal...
Finding 2023.003 - Activities Allowed or Unallowed Recommendation The Organization should establish a system of internal controls to ensure that all employees are being paid the correct amounts. Action Taken United Methodist Western Kansas Mexican-American Ministries Inc. d/b/a Genesis Family Health implemented PayCom in January 2023. With this system update, the organization has implemented an automated process to ensure changes to employee pay rates are approved and adjusted timely. This process requires all changes to employee’s compensation being entered into the PayCom (payroll system) by the departmental managers/supervisors. Changes in pay are automatically flagged for review and approval by the human resources department. These changes improved internal controls to ensure all employee rate changes are implemented timely and employees are being paid the correct amount.
View Audit 14201
Finding 10500 (2023-002)
Significant Deficiency 2023
United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health
KS
Subrecipient Monitoring Eligibility HUD Housing Programs
Finding 2023.002 - 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 The proficiency of all billing staff respon...
Finding 2023.002 - 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 The proficiency of all billing staff responsible for applying sliding fee discounts and ensuring proper calculations based on family size and income will be evaluated. The organization implemented an Onboarding and Enrollment department in June 2023 to review clinic schedules prior to the patient’s appointment. The onboarding and enrollment staff meet with each new patient to review and verify insurance information, check Medicaid eligibility, ensure fully completed registrations and complete application for any slide fee discounts applicable based on income and family size. Billing staff reviews this information and applies the appropriate discount to the patient charges. This crosschecking process will improve internal controls related to the sliding fee discount process.
View Audit 14201
Finding 10446 (2023-001)
Significant Deficiency 2023
McSherrystown Interfaith Housing Corporation
PA
HUD Housing Programs Significant Deficiency
McSherrystown Interfaith Housing Corporation 40 E. High Street, Gettysburg, PA 17325 Phone (717) 334-1518 • Fax (717) 334-8326 TDD/TTY Relay Service: 1-800-654-5984 www.adamscha.org CORRECTIVE ACTION PLAN December 28, 2023 McSherrystown Interfaith Housing Corporation respectfully submits the follow...
McSherrystown Interfaith Housing Corporation 40 E. High Street, Gettysburg, PA 17325 Phone (717) 334-1518 • Fax (717) 334-8326 TDD/TTY Relay Service: 1-800-654-5984 www.adamscha.org CORRECTIVE ACTION PLAN December 28, 2023 McSherrystown Interfaith Housing Corporation respectfully submits the following corrective action plan for the year ended September 30, 2023. Cognizant or Oversight Agency for Audit: Mortgage Insurance Rental Housing, ALN #14.134 Name and address of independent public accounting firm: Hamilton & Musser, PC 176 Cumberland Parkway Mechanicsburg, PA 17055 Audit Period: October 1, 2022 - September 30, 2023 The finding from the September 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Findings - Financial Statement Audit: None Findings and Questioned Costs - Major Federal Award Programs Audit: #2023-001 - Significant Deficiency-Reconciliation of Escrow Accounts Mortgage Insurance Rental Housing, ALN #14.134 Recommendation We recommend that McSherrystown Interfaith Housing Corporation make an entry to record escrow activity during the year and implement similar monthly adjustments going forward. View of responsible officials and planned corrective action We agree that this compliance requirement is listed in the compliance supplement. We will implement additional procedures to capture escrow activity during the year. Additional training has been provided to the Accounting staff. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call McSherrystown Interfaith Housing Corporation Executive Director, Stephanie McIIwee at (717) 334-1518.
View Audit 14113
Finding 10402 (2023-001)
Material Weakness 2023
First Baptist Church Capitol Hill Homes, Inc. D/b/a Kelly Miller Smith Towers
TN
Questioned Costs HUD Housing Programs Reporting
Auditee Response: The Board of Directors and management worked with the auditors to submit and certify to the FAC the Single Audit Reporting Packages for the years ended April 30, 2022 and 2021. This was completed on July 31, 2023. The Audit Committee of the Board of Directors will insure that fu...
Auditee Response: The Board of Directors and management worked with the auditors to submit and certify to the FAC the Single Audit Reporting Packages for the years ended April 30, 2022 and 2021. This was completed on July 31, 2023. The Audit Committee of the Board of Directors will insure that future Single Audit Reporting Packages for the year ending April 30, 2023 and beyond with be remitted in accordance with federal regulations. The Board of Directors and management will work with the prior auditors to insure that missing FAC submissions for the years ended April 30, 2020 and prior will be submitted and certified as applicable and in accordance with federal regulation.
View Audit 14064 Questioned Costs: $1
Finding 10392 (2023-003)
Material Weakness 2023
Alpha One
ME
Questioned Costs HUD Housing Programs Material Weakness
Management will seek approval from the funding Agency for the questioned costs and return funds if costs are not approved.
Management will seek approval from the funding Agency for the questioned costs and return funds if costs are not approved.
View Audit 14054 Questioned Costs: $1
Finding 10370 (2023-001)
Significant Deficiency 2023
Kearsarge Elderly Housing, Inc.
NH
HUD Housing Programs Internal Control / Segregation of Duties
Condition: The certifier for HUD forms should be a current employee with oversight in the area the form pertains to. HUD forms must be certified by an authorized user. Plan: A procedure will be implemented to ensure that changes in certifiers on forms at Projects are made in a timely fashion. Ant...
Condition: The certifier for HUD forms should be a current employee with oversight in the area the form pertains to. HUD forms must be certified by an authorized user. Plan: A procedure will be implemented to ensure that changes in certifiers on forms at Projects are made in a timely fashion. Anticipated Completion Date: Completed June 30, 2023 Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer
View Audit 14019
Finding 10328 (2023-001)
Material Weakness 2023
Southwest R-V School District
MO
Internal Control / Segregation of Duties HUD Housing Programs
CORRECTIVE ACTION PLAN September 14, 2023 UNITED STATES DEPARTMENT OF EDUCATION UNITED STATES DEPARTMENT OF AGRICULTURE Southwest R-V School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Contact information for the individual responsible fo...
CORRECTIVE ACTION PLAN September 14, 2023 UNITED STATES DEPARTMENT OF EDUCATION UNITED STATES DEPARTMENT OF AGRICULTURE Southwest R-V School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Contact information for the individual responsible for the corrective action: Tosha Tilford, Superintendent Southwest R-V School District 300 N Myrtle Street Washburn, MO 65772 (417) 826-5410 Independent Public Accounting Firm: The CPA Group, PC, 217 4th Street, Monett, MO 65708 Audit Period: Year ended June 30, 2023 The findings from the June 30, 2023, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT Material Weakness – Internal Control over Financial Reporting - Segregation of duties Finding 2023-001 Recommendation: We realize Because of limited resources and personnel, management may not be able to achieve a proper segregation of duties; however, our professional standards require that we bring this lack of segregation of duties to your attention in this report. Action Taken: The limited number of available personnel prohibits segregation of incompatible duties and the District does not have the resources to hire additional accounting personnel. Completion Date: Not applicable Sincerely, Tosha Tilford, Superintendent Southwest R-V School District
View Audit 14007
Finding 10292 (2023-001)
Significant Deficiency 2023
St. Matthew Manor - West, Inc.
TN
Questioned Costs Subrecipient Monitoring HUD Housing Programs
Statement of condition 2023-001: During the year ended September 30, 2023, the Project paid expenses totaling $695 on behalf of an entity under common management without HUD approval. Recommendation: Management should have the other project reimburse $695. Action(s) taken or planned on the findi...
Statement of condition 2023-001: During the year ended September 30, 2023, the Project paid expenses totaling $695 on behalf of an entity under common management without HUD approval. Recommendation: Management should have the other project reimburse $695. Action(s) taken or planned on the finding: On December 18, 2023, the finding was cleared as $695 was repaid to the Project. Completion date: December 18, 2023
View Audit 13940 Questioned Costs: $1
Pittsfield Lowry, LLC
IL
HUD Housing Programs
Identifying Number: 2023-002 Finding: The Organization calculated surplus cash of $31,225 as of September 30, 2020 and surplus cash of $39,082 as of September 30, 2021, which includes the undeposited amount from September 30, 2020. This amount was not deposited into a residual receipts fund accou...
Identifying Number: 2023-002 Finding: The Organization calculated surplus cash of $31,225 as of September 30, 2020 and surplus cash of $39,082 as of September 30, 2021, which includes the undeposited amount from September 30, 2020. This amount was not deposited into a residual receipts fund account. The Organization calculated surplus cash of $149,237 as of September 30, 2022, which includes the undeposited amount from September 30, 2021. The Organization has not deposited this amount into a separate residual receipts fund account within 90 days of the fiscal year-end. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Surplus cash was caused by a release from the replacement reserve and a timing difference between the release of the reserve and the addition of building improvments. Building improvements and a related payable were recorded during the year ended September 30, 2023. As of September 30, 2023, the Organization did not have any surplus cash. The construction payable will be paid in full in the near future.
View Audit 13911
Pittsfield Lowry, LLC
IL
HUD Housing Programs
Identifying Number: 2023-001 Finding: The Organization received approval from HUD to begin the construction of a dining room and physical therapy addition to the mortgaged property. This approval was contingent on the Organization meeting certain conditions set forth by HUD. One such condition wa...
Identifying Number: 2023-001 Finding: The Organization received approval from HUD to begin the construction of a dining room and physical therapy addition to the mortgaged property. This approval was contingent on the Organization meeting certain conditions set forth by HUD. One such condition was that the total cost of the project be funded by a contribution from Community Living Options, Inc. (CLO), and that this contribution would not be paid back to CLO. The Organization has recorded a payable owed to CLO and therefore did not meet the terms of the HUD approval. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. The Organization is in the process of appealing HUD conditions and approval. Management has had multiple communications since March 2014 with their lender to resolve this finding, however it still remains unresolved. Management most recently corresponded with their lender in October 2021 to resolve the finding and is currently waiting on HUD’s review for completion. Approval based on the proposed payment terms by the Organization has not yet been received.
View Audit 13911
Marion Williamson County Parkway, LLC
IL
HUD Housing Programs
Identifying Number: 2023-001 Finding: The Organization expanded the licensed bed size of the mortgaged property by 12 skilled nursing beds before obtaining an approval from HUD. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management ...
Identifying Number: 2023-001 Finding: The Organization expanded the licensed bed size of the mortgaged property by 12 skilled nursing beds before obtaining an approval from HUD. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management has had multiple communications since May 2013 with their lender to resolve this finding, however it still remains unresolved. Management most recently corresponded with the lender in March 2022 to resolve the finding, and an application to HUD for approval of the license change was filed. Management is currently waiting on HUD’s review for completion.
View Audit 13909
Jerseyville North State, LLC
IL
HUD Housing Programs
Identifying Number: 2023-001 Finding: The Organization reduced the licensed bed size of the mortgaged property by 6 skilled nursing beds before obtaining an approval from HUD. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management is in th...
Identifying Number: 2023-001 Finding: The Organization reduced the licensed bed size of the mortgaged property by 6 skilled nursing beds before obtaining an approval from HUD. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management is in the process of obtaining after-the-fact approval from HUD to resolve this finding by sending a letter of request to HUD with additional information on the bed change.
View Audit 13906
Elko Ruby Vista, LLC
IL
HUD Housing Programs
Identifying Number: 2023-002 Finding: The Organization calculated surplus cash of $6,186 as of September 30, 2019. This amount was not deposited into a separate residual receipts fund account. The Organization calculated surplus cash of $20,565 as of September 30, 2020, which includes the undeposite...
Identifying Number: 2023-002 Finding: The Organization calculated surplus cash of $6,186 as of September 30, 2019. This amount was not deposited into a separate residual receipts fund account. The Organization calculated surplus cash of $20,565 as of September 30, 2020, which includes the undeposited amount from September 30, 2019. The Organization has not deposited this amount into a separate residual receipts fund account within 90 days of the fiscal year-end. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Surplus cash was caused by timing differences. As of September 30, 2023, the Organization did not have any surplus cash. Prior surplus cash amounts caused by timing differences were not significant. Management does not believe that HUD will have a negative response as the Organizaiton does not have any surplus cash as of year ended September 20, 2023.
View Audit 13903
Elko Ruby Vista, LLC
IL
HUD Housing Programs
Identifying Number: 2023-001 Finding: The Organization did not receive HUD approval prior to starting a construction project to add an addition completed in May 2014, which encompasses 22 additional assisted living beds. The costs of the portion of the completed project that has not been approved to...
Identifying Number: 2023-001 Finding: The Organization did not receive HUD approval prior to starting a construction project to add an addition completed in May 2014, which encompasses 22 additional assisted living beds. The costs of the portion of the completed project that has not been approved totaled $2,501,965, which is included as a liability in the advance from member. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management is in the process of obtaining after-the-fact approval from HUD to resolve this finding by sending a letter of request to HUD with additional information on the additions. Management has had multiple communications since July 2015 with their lender to resolve this finding, however it still remains unresolved. Management most recently corresponded with their lender in October 2021 and is currently waiting on their lender and HUD’s review for completion. Management does not believe that HUD will have a negative response as construction projects and bed changes of similar nature have been approved for other HUD projects.
View Audit 13903
Finding 10228 (2023-001)
Significant Deficiency 2023
Saint Joseph Housing Corporation
PA
HUD Housing Programs Procurement, Suspension & Debarment
Finding 2023-001: Comments on the Finding and Each Recommendation: The Corporation did not refund the security deposit for two residents within 30 days after the move-out date. Management should ensure that upon termination of a resident's lease the process for determining security deposit refun...
Finding 2023-001: Comments on the Finding and Each Recommendation: The Corporation did not refund the security deposit for two residents within 30 days after the move-out date. Management should ensure that upon termination of a resident's lease the process for determining security deposit refunds are completed within 30 days of the move-out date. Action(s) taken or planned on the finding: Management concurs with the finding and agrees with the auditor's recommendation. Management has controls in place to ensure processing of security deposit refunds are completed within 30 days of the move-out date.
View Audit 13880
Inter-Church Council Housing Corporation
NC
HUD Housing Programs
The property made a payment on October 18, 2023 to correct the amount in the reserve for replacement account and will keep track of required payments each month.
The property made a payment on October 18, 2023 to correct the amount in the reserve for replacement account and will keep track of required payments each month.
View Audit 13863
Village at Hickory Glen Apartments
TX
HUD Housing Programs Reporting
Finding 2023-001 – Surplus cash should be funded to the residual receipts account within 60 days of year end. Management inadvertently deposited $6,268 into the reserve for replacement account on November 29, 2022 instead of depositing $6,269 into the residual receipts account. When management rea...
Finding 2023-001 – Surplus cash should be funded to the residual receipts account within 60 days of year end. Management inadvertently deposited $6,268 into the reserve for replacement account on November 29, 2022 instead of depositing $6,269 into the residual receipts account. When management realized the mistake, they made another deposit of $6,268 into the residual receipts account in February 2023, however they have an additional deposit in the reserve for replacement account as of September 30, 2023.Response: Management plans to withdraw the extra deposit in the reserve for replacement account and will calculate surplus cash and fund the residual receipts account with the required amount on a timely basis.
View Audit 13824
Dauphin County Voa Living Center, INC (creekside Village)
VA
Cash Management HUD Housing Programs
Management agrees with the finding. The residual receipts account deficiency will be funded in the amount of $18,738, $1,515, and $10,164. Management will ensure that the residual receipts account is properly funded in the future
Management agrees with the finding. The residual receipts account deficiency will be funded in the amount of $18,738, $1,515, and $10,164. Management will ensure that the residual receipts account is properly funded in the future
View Audit 13735
Dauphin County Voa Living Center, INC (creekside Village)
VA
HUD Housing Programs Cash Management
Management agrees with the finding. The excess funds were accrued to submit to HUD.
Management agrees with the finding. The excess funds were accrued to submit to HUD.
View Audit 13735
Chesapeake Voa Living Center, INC
VA
Cash Management HUD Housing Programs
Management agrees with the finding. The residual receipts account deficiency was funded on July 27, 2023 in the amount of $37,556. Management will ensure that the residual receipts account is properly funded in the future
Management agrees with the finding. The residual receipts account deficiency was funded on July 27, 2023 in the amount of $37,556. Management will ensure that the residual receipts account is properly funded in the future
View Audit 13680
Chesapeake Voa Living Center, INC
VA
HUD Housing Programs Cash Management
Management agrees with the finding. The excess funds were accrued to submit to HUD.
Management agrees with the finding. The excess funds were accrued to submit to HUD.
View Audit 13680
Robeson County Housing Authority
NC
Questioned Costs HUD Housing Programs
The files in question will be adjusted during the tenant’s annual recertification. The housing managers (along with internal audit team members) will attend yearly rent recalculation refresher courses and check for errors when recalculating rent. For the first file in question, the total overpayment...
The files in question will be adjusted during the tenant’s annual recertification. The housing managers (along with internal audit team members) will attend yearly rent recalculation refresher courses and check for errors when recalculating rent. For the first file in question, the total overpayment of $1,430 has been credited to the tenant’s account. The internal audit team will conduct internal tenant file reviews monthly. The Housing Director will discuss file management during monthly staff meetings. The Authority plans to implement these procedures effective January 1, 2024.
View Audit 13675 Questioned Costs: $1
Finding 9987 (2023-002)
Significant Deficiency 2023
Rannie Webster Foundation
NH
HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties
Silverstone Living (SL) recognized several operational opportunities for the sustainability of the Foundation, which is the reason why the affiliation occurred. These opportunities were three-fold: increasing census to fill beds which have been unoccupied for some time, maximizing the reimbursemen...
Silverstone Living (SL) recognized several operational opportunities for the sustainability of the Foundation, which is the reason why the affiliation occurred. These opportunities were three-fold: increasing census to fill beds which have been unoccupied for some time, maximizing the reimbursement for services already being provided, and the control and reduction of expenses. In the short amount of time since the affiliation with SL, the average daily census has increased over the prior 3-year period by nearly 7% for Assisted Living services, and nearly 9% for skilled and nursing services. This equates to over $1,000,000 in additional annual revenues because of the census increase alone. SL believes that there is potential to further increase census as we continue to stabilize and onboard additional clinical staffing. SL recently brought on an individual skilled in coding maximization to ensure the Foundation receives the appropriate reimbursement for the services being provided which was previously lacking. On the expense side, SL renegotiated rates with staffing agencies for clinical positions as well as the contracted rehabilitation services to reduce the amounts being charged which has resulted in nearly $40,000 per month in savings from the earlier part of the calendar year. SL also brought the Foundation under its umbrella in the areas of employee benefits and facility insurance, negating any premium increases and a reduction of over $50,000 in Workers Compensation insurance premiums in the coming year. Through attrition, SL also worked to restructure and eliminate several non-clinical positions for operational efficiency and will continue to review staffing needs as turnover occurs. SL is continuing to transition administrative functions such as payroll and accounting onto its systems, further reducing outside contracted services and systems over the coming months. Through this multi-pronged approach, we are seeing dramatic improvements in the financial outlook of the Foundation. During the 3-month fiscal period beginning 2024 compared to the same period in 2023, there has been a $670,000 improvement in income from operations, which we believe will trend throughout the remainder of the new fiscal year, and into the future.
View Audit 13626
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