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Corrective Action Plans

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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
Finding 9986 (2023-001)
Significant Deficiency 2023
Rannie Webster Foundation
NH
Internal Control / Segregation of Duties Cash Management HUD Housing Programs
Action taken in response to finding: A clerical support position was recently hired at the end of November, 2023 who will be responsible for handling all receipts and processing of deposits via remote deposit, which was also recently implemented so deposits can be done daily. This will segregate th...
Action taken in response to finding: A clerical support position was recently hired at the end of November, 2023 who will be responsible for handling all receipts and processing of deposits via remote deposit, which was also recently implemented so deposits can be done daily. This will segregate the cash handling from the recording of receipts once he is fully trained on the system. Bank reconciliation reviews will be completed monthly.
View Audit 13626
Mmm Roseland INC
TX
HUD Housing Programs Cash Management Reporting
Audit Finding 2023-001: Surplus cash should be funded to the residual receipts account within 60 days of year end. Management made a deposit on December 5, 2023 for $194,026 which was 5 days late and short due to the audit of the financial statements not being completed at the time. Response: In t...
Audit Finding 2023-001: Surplus cash should be funded to the residual receipts account within 60 days of year end. Management made a deposit on December 5, 2023 for $194,026 which was 5 days late and short due to the audit of the financial statements not being completed at the time. Response: In the future, management will calculate surplus cash prior to the audit. Additionally, management will make the additional required deposit as soon as possible.
View Audit 13623
Finding 9669 (2023-002)
Significant Deficiency 2023
Volunteers of America Colorado Branch
CO
Subrecipient Monitoring HUD Housing Programs Significant Deficiency
Finding Number: 2023-002 Condition: In a monitoring visit performed by U.S. Department of Housing and Urban Development (HUD), the grantor found that the supporting documentation submitted does not enable a third-party reviewer to make a clear determination that match requirements were met. Planned ...
Finding Number: 2023-002 Condition: In a monitoring visit performed by U.S. Department of Housing and Urban Development (HUD), the grantor found that the supporting documentation submitted does not enable a third-party reviewer to make a clear determination that match requirements were met. Planned Corrective Action: The Organization established a policy and procedure to calculate the match requirement, compare it with the required total, and proactively identify actions to address any shortages at the end of each month. The Organization also ensured that all matches were supported by documents in a format that third parties could verify. Contact person responsible for corrective action: Chiyoko Yokota, Chief Financial Officer & Angel Hurtado, VP of Programs Anticipated Completion Date: 1/31/2023
View Audit 13410
Finding 9667 (2023-001)
Significant Deficiency 2023
Volunteers of America Colorado Branch
CO
Subrecipient Monitoring Eligibility HUD Housing Programs
Finding Number: 2023-001 Condition: In a monitoring visit performed by HUD, the grantor found that rent reasonableness determination was not completed on five of the six files reviewed. In our testing we found that six of ten participants we tested did not have a rent reasonableness determination da...
Finding Number: 2023-001 Condition: In a monitoring visit performed by HUD, the grantor found that rent reasonableness determination was not completed on five of the six files reviewed. In our testing we found that six of ten participants we tested did not have a rent reasonableness determination dated prior to the grant funds being expended Planned Corrective Action: The Organization revised the program policy to compare the rent reasonableness of at least three similar units using the Rent Reasonableness Comparison worksheet before any lease-up and document the test with evidence that is reviewed and verified with a supervisor signature prior to execution of the lease. The Organization will repeat this process annually as long as the participant remains in the same unit. The Organization also hired an extra full-time program quality control staff to monitor the compliance with the procedures. Moreover, The Organization will have an internal audit by the finance department at the halfway point of the grant year. Contact person responsible for corrective action: Chiyoko Yokota, Chief Financial Officer & Angel Hurtado, VP of Programs Anticipated Completion Date: 1/31/2023
View Audit 13410
Finding 9658 (2023-002)
Material Weakness 2023
Williamston Housing Authority
NC
HUD Housing Programs Cash Management Material Weakness
Name of Contact Person: Michael Gaddy Executive Director Corrective Action: We have addressed all reported deficiencies noted in the 2023 physical inspection. Management will be more diligent in working with Ma...
Name of Contact Person: Michael Gaddy Executive Director Corrective Action: We have addressed all reported deficiencies noted in the 2023 physical inspection. Management will be more diligent in working with Maintenance to monitor the physical condition of all properties. Proposed Completion Date: Immediately
View Audit 13376
Fellowship Commons Whalley, Inc.
CT
Cash Management HUD Housing Programs
Upon discovery of the FY23 underfunding, a corrective deposit was made subsequent to year end. The monthly amount for FY24 was also corrected to return the project to compliance with deposit requirements.
Upon discovery of the FY23 underfunding, a corrective deposit was made subsequent to year end. The monthly amount for FY24 was also corrected to return the project to compliance with deposit requirements.
View Audit 13375
Heights Towers Services Company
TX
HUD Housing Programs Eligibility Reporting
Audit Finding 2023-001: For three tenants selected for testing during the audit, incorrect amounts of tenant income and expenses were used in the computation of tenant rent and HUD assistance. Response: Management has prepared recertifications for the tenants found to have inaccurate calculations d...
Audit Finding 2023-001: For three tenants selected for testing during the audit, incorrect amounts of tenant income and expenses were used in the computation of tenant rent and HUD assistance. Response: Management has prepared recertifications for the tenants found to have inaccurate calculations during the audit. Additionally, management will conduct a review of the tenant and HUD assistance for all move-in tenants and prepare recertifications in case of errors. Training and experience will also improve the accuracy of the staff handling tenant certifications. Responsible Party:Linda G. Holder, Vice President/COO/Agent, Houston Housing Management Corporation, 2211 Norfolk, Suite 614,Houston, TX 77098
View Audit 13353
Finding 9651 (2023-002)
Material Weakness 2023
Pono Homes, Inc.
MD
Questioned Costs Cash Management HUD Housing Programs
Recommendation: Training of staff should be performed to bring staff up to date with the implementation of all residual receipts’ compliance requirements. Action Taken: The Organization did not obtain approval to pay back the excess residual receipt amount. This led to the residual receipt account...
Recommendation: Training of staff should be performed to bring staff up to date with the implementation of all residual receipts’ compliance requirements. Action Taken: The Organization did not obtain approval to pay back the excess residual receipt amount. This led to the residual receipt account being greater than its compliance amount. The Organization will request approval to pay back excess residual receipts.
View Audit 13330 Questioned Costs: $1
Finding 9650 (2023-001)
Material Weakness 2023
Pono Homes, Inc.
MD
Questioned Costs HUD Housing Programs Reporting
Recommendation: In conjunction with Pono Homes, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, Pono Homes, Inc. should pay the invoice amount on a monthly basis.Action Taken: The audi...
Recommendation: In conjunction with Pono Homes, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, Pono Homes, Inc. should pay the invoice amount on a monthly basis.Action Taken: The auditors have worked with the auditee in conjunction with their local HUD field office to determine a course of action. All parties agreed with the recommendation to avoid unauthorized distributions.
View Audit 13330 Questioned Costs: $1
Finding 9648 (2023-001)
Material Weakness 2023
The Shire, Inc.
MD
Questioned Costs HUD Housing Programs Reporting
Recommendation: In conjunction with The Shire, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, The Shire, Inc. should pay the invoice amount on a monthly basis. Action Taken: The audi...
Recommendation: In conjunction with The Shire, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, The Shire, Inc. should pay the invoice amount on a monthly basis. Action Taken: The auditors have worked with the auditee in conjunction with their local HUD field office to determine a course of action. All parties agreed with the recommendation to avoid unauthorized distributions.
View Audit 13329 Questioned Costs: $1
Finding 9636 (2023-003)
Significant Deficiency 2023
Detroit Housing Commission
MI
HUD Housing Programs Eligibility Subrecipient Monitoring
Finding Number: 2023-003 Condition: Participant files selected for testing did not include complete information to support the participant's income to determine the level of benefits provided. Planned Corrective Action: The Housing Choice Voucher Program will work towards and maintain program compli...
Finding Number: 2023-003 Condition: Participant files selected for testing did not include complete information to support the participant's income to determine the level of benefits provided. Planned Corrective Action: The Housing Choice Voucher Program will work towards and maintain program compliance to ensure we are meeting all regulatory requirements. We will do this through staff hiring and restructuring. Ongoing in- house as well as Industry training to stay current and skilled on all program rules and updates as it pertains to the HCV Program with monthly and weekly reporting and monitoring. DHC understands the challenges outlined above and we have implemented measures to improve, redefine, address, and resolve all items according to HUD best practices. We will continue our ongoing efforts and have measurable goals with set dates and timelines. That will show marked improvement over the next 6-12 months in the following areas.  Reduction of Annual recertifications.  Increased utilization.  Increased PBV potential/new RFP.  PIC error corrective actions.  Increased landlord outreach/landlord Fairs.  Customer Service improvement/Call Center Staffing.  Continued industry training for all HCV Housing Specialist.  HCV Department RFP contract proposal. Contact person responsible for corrective action: Felicia Burris, HCV Interim Director. Anticipated Completion Date: 06/30/2024
View Audit 13310
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