Corrective Action Plans

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Finding 480347 (2023-001)
Significant Deficiency 2023
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.
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
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 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
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
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.
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.
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
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
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
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
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.
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
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
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
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
• 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.
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.
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.
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
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
2023-003 ALN 14.850 - Public & Indian Housing Program - 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 Projecte...
2023-003 ALN 14.850 - Public & Indian Housing Program - 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
2023-002 ALN 14.850 - Public & Indian Housing Program - Allowable Activities - Use of Operating Funds for Capital Improvements Management acknowledges the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correcti...
2023-002 ALN 14.850 - Public & Indian Housing Program - Allowable Activities - Use of Operating Funds for Capital Improvements 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 Questioned Costs: $1
To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 202...
To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Special Tests and Provisions - 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 We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients' needs and complies with all federal guidelines. Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will overseE3 the training. 3. The Revenue Cycle Manager_will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results. Timeline: 1. Procedure draft completion: Completed 2. Review and approval by senior management: July 24, 2024 3. Initial staff training session: July 25, 2024 4. Follow-up training sessions: As needed 5. Monthly compliance audits: Starting September 1, 2024
Finding Number: 2023-001 Finding Title: Eligibility – Source Documentation Program: 14.871 Section 8 Housing Choice Vouchers 14.879 Mainstream Vouchers Name of Contact Person Responsible for Corrective Action: Terri Smith, Director Metro HRA Corrective Action Planned: HRA staff has developed a check...
Finding Number: 2023-001 Finding Title: Eligibility – Source Documentation Program: 14.871 Section 8 Housing Choice Vouchers 14.879 Mainstream Vouchers Name of Contact Person Responsible for Corrective Action: Terri Smith, Director Metro HRA Corrective Action Planned: HRA staff has developed a checklist form and update procedures for all staff to ensure signatures and forms are not missing in case files, this includes but is not limited to criminal background checks performed, citizenship forms, members of the household forms, and debts owed forms. The checklist will be completed for each case and stored in each participant file as part of the quality control process. The quality control process that was implemented in June 2023 had not been in place for a full year when the 2023 audit was completed. All files are being checked at Annual Recertification. Once this has been in place for a full year, all files will have been checked for the appropriate forms and signatures. Anticipated Completion Date: This process will be in place effective July 2024.
Finding 479420 (2023-001)
Significant Deficiency 2023
Special Tests and Provisions: HPP staff will follow written policy and procedures for ensuring all clients have a rent reasonableness form with new move ins and annual recertifications. The Director of Housing Programs will initial each document submitted for a new move in or an annual recertificati...
Special Tests and Provisions: HPP staff will follow written policy and procedures for ensuring all clients have a rent reasonableness form with new move ins and annual recertifications. The Director of Housing Programs will initial each document submitted for a new move in or an annual recertification to ensure all necessary documents are in each client file. Person Responsible for Corrective Action: Director of Housing Heather Ryan Figueroa Anticipated Date of Completion: June 7, 2024
No action needed. Required deposit of $1,971 was deposited into the residual reserve account on March 4, 2024.
No action needed. Required deposit of $1,971 was deposited into the residual reserve account on March 4, 2024.
View Audit 315935 Questioned Costs: $1
Finding, Reference Number: 2023-001 Federal Agency: Department of Agriculture (USDA) Description of Finding: Criteria: 7 CFR Section 250.1 9(a) identifies requirements related to record keeping for this major program. It is important to note the Food Bank appeared to maintain the appropriate suppo...
Finding, Reference Number: 2023-001 Federal Agency: Department of Agriculture (USDA) Description of Finding: Criteria: 7 CFR Section 250.1 9(a) identifies requirements related to record keeping for this major program. It is important to note the Food Bank appeared to maintain the appropriate supporting documents and required components, this finding relates to one component regarding the lack of a signoff not lack of documentation. Condition: During audit testing, we noted the following; the invoices created as a result of USDA orders being made were not consistently signed off on by the recipient agency representative upon pick up or delivery of the commodities. Statement of Concurrence or Nonconcurrence: The Food Bank agrees with this finding. Corrective Action: The Food Bank places a strong emphasis on ensuring accountability in the pickup process for agencies by requiring them to sign invoices upon receiving their orders. This practice is crucial for maintaining accurate records and verifying the receipt of products and other items. To strengthen this procedure, we will be reinforcing with our staff the absolute requirement for agencies to sign for their orders at the time of pickup. As of July 8, 2024 we will implement a new procedure mandating dual sign-offs on all orders by both the agency representative and a Food Bank staff member. Our Programs team will also conduct educational marketing raising awareness among the agencies about the importance of signing their invoices. These steps will not only enhance our operational efficiency but also uphold our commitment to transparency and accountability in distributing food resources to those in need. Name of Contact Person: Nicholas Pisani, Chief Operating Officer; phone number 518-786-3691 ext. 241; email NickP@Regionalfoodbank.net Projected completion date: July 8, 2024
Finding 2023-002: Special Tests and Provisions The Corporation has three properties secured by CDBG loans. The properties are known as Mid-City, AppleTree Housing, Inc. (“ATH”), and Center West. The Corporation was unable to support that at least fifty-one percent (51%) of the tenants at the ATH pro...
Finding 2023-002: Special Tests and Provisions The Corporation has three properties secured by CDBG loans. The properties are known as Mid-City, AppleTree Housing, Inc. (“ATH”), and Center West. The Corporation was unable to support that at least fifty-one percent (51%) of the tenants at the ATH property were leased to and occupied by low or very low-income persons as determined by the Federal “Section 8” Income Standards with completed tenant certifications and recertifications. At ATH, 6 of 6 occupied unit’s certifications were not completed during the year ended June 30, 2023. This was an initial finding during the year ended June 30, 2020. Planned Corrective Action: It is the goal of the Corporation to maintain compliance with regulatory requirements. Where hardships are encountered the Corporation remains in ongoing communication with respective regulatory agencies to promote transparency and mitigate risk of loss in fundings or default. Mark Deitcher, CFO, is responsible for the corrective action plan. If the U.S Department of Housing and Urban Development has questions regarding this plan, please call Mark Deitcher at 1-215-557-8414.
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