Corrective Action Plans

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The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant ...
The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of income from tenants and other required paperwork is included in the tenant files.
The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.
The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.
View Audit 366550 Questioned Costs: $1
Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the f...
Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the full amount was deposited, the delay constituted noncompliance with HUD's timing rules. To address this, management will implement procedures to ensure surplus cash deposits are made within 60 days based on unaudited computations, track and schedule deposits in advance, formally request HUD approval if deferrals are necessary, and maintain documentation of all related communications and approvals for compliance purposes. Actions Taken or Planned on the Findings: This was paid on check # 9841 Working on an implementation program for the future. Completion Date: August 25, 2025 Finding Resolution Status: In-Process Contact Person: Controller: Don Trigg Accountant: Charley Hinkle
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should incr...
FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was increased from $1,182,615 to $1 ,282,815 effective 6/1/2025 with annual insurance renewals to be above the minimum required threshold. The new process implemented will now assess the budgeted potential organizational revenue growth prospectively in the current fiscal year and any calculation increase required will be made prior to the end of the current fiscal year before the insurance renewal for the next fiscal year to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Completion date for corrective action plan: 06/01/2025 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Edward Forfa, Executive Director at 413-445-4056 ext. 160.
FINDING NUMBER 2025-001 Reporting views of responsible officials: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Auditors' summary of auditee's comments on the findings and recommendati...
FINDING NUMBER 2025-001 Reporting views of responsible officials: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Auditors' summary of auditee's comments on the findings and recommendations: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Response indicator: Agree. Response: The Company will work with the financial institutions to ensure that HUD’s requirements are followed. Completion date: September 30, 2025
Finding: We found one (1) instance where adequate documentation was not maintained to ensure the appropriate amount was charged to a patient based on the sliding fee policy in place. Upon further analysis, there were a total of four (4) instances where appropriate documentation was not maintained re...
Finding: We found one (1) instance where adequate documentation was not maintained to ensure the appropriate amount was charged to a patient based on the sliding fee policy in place. Upon further analysis, there were a total of four (4) instances where appropriate documentation was not maintained relating to fiscal year 2025. Uniform Guidance requires the Organization to be in compliance with special tests and provisions. This includes maintaining appropriate documentation of the application and fee determination for every patient utilizing the sliding fee discount. This is a repeat of finding 2024-003 from the prior year. One error was identified during our testing. Expanded procedures identified that the population impacted were four individuals. The amount of questioned costs cannot be determined. A sample of 40 individuals were selected and tested for compliance with the Organization's sliding fee policy. One (1) known compliance error was found during testing of the 40 individuals. Upon analyzing the entire population, it was determined that a total of four (4) files were not in compliance. The Organization was not in compliance with the requirements of the federal program due to a scanner malfunction where the application and supporting documentation were not adequately scanned, resulting in a corrupt file. Cause: Management has indicated that the scanner malfunction lead to the noncompliance. Upon the realization of the scanner issue, it was replaced and an analysis was performed for any other patient files that may have been corrupted. Management review of the entire population identified a total of (4) four files that were corrupt relating to fiscal year 2025. Corrective Response: Management is in agreement with the above analysis by the auditors. The issue was discovered and corrected with an update to the server and an update to the process to ensure that all scans are reviewed prior to the destruction of the original documents. This was fully resolved prior to the fiscal year end. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: CFO/Revenue Cycle Director/Director of Clinical Ops/Vice President of IT
The replacement reserve account was underfunded in the amount of $1,120 during the year ended May 31, 2025. Management will deposit the required amount into the replacement reserve and confirm all future required deposit increases are implemented.
The replacement reserve account was underfunded in the amount of $1,120 during the year ended May 31, 2025. Management will deposit the required amount into the replacement reserve and confirm all future required deposit increases are implemented.
View Audit 365848 Questioned Costs: $1
Total annual withdrawals made from the general operating reserve were in excess of 20% of prior year’s ending balance. Management will obtain approval from HUD for withdrawals made from the general operating reserve during the year ended May 31, 2025 in the amount of $24,741.
Total annual withdrawals made from the general operating reserve were in excess of 20% of prior year’s ending balance. Management will obtain approval from HUD for withdrawals made from the general operating reserve during the year ended May 31, 2025 in the amount of $24,741.
View Audit 365848 Questioned Costs: $1
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforc...
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforcement, including rent abatement. Further internal procedures implemented to ensure additional contractor oversight and postrepair audits to ensure that failed HQS inspections are remedied properly and timely. Responsible Party: Andrea Fink, Housing Programs & Services Manager Timeline: Full implementation of the CAP by 9/15/2025 This Corrective Action Plan has been reviewed and approved by: -;t((t ih= Rob L. Fredericks (Aug 20. 2025 10:00:43 PDT) Rob L. Fredericks Executive Director/CEO
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of ...
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of March 31, 2025, the physical inspection is closed. Action(s) taken or planned on the finding: Management has responded to HUD in regard to this inspection report and has addressed all exigent health and safety issues.
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - 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 GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residua...
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residual receipts deposit is made within 90 days of fiscal year end. Management response: Agree. Management made the required residual receipts deposit on January 8, 2025.
View Audit 365221 Questioned Costs: $1
Audit Finding 2025-002: The regulatory agreement stipulates that all withdrawals from the Reserve for Replacement Account be supported by invoices and payments as proof of amounts expended. An invoice of $1,707 was duplicated while calculating the funds to be withdrawn from the Reserve for Replacem...
Audit Finding 2025-002: The regulatory agreement stipulates that all withdrawals from the Reserve for Replacement Account be supported by invoices and payments as proof of amounts expended. An invoice of $1,707 was duplicated while calculating the funds to be withdrawn from the Reserve for Replacement account . Response: Management agrees with the finding and has refunded $1,707 to the Reserve for Replacement Account on August 12, 2025.
Audit Finding 2025-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. Several withdrawals totaling $108,111 for emergency repairs and improvements, to cover payroll, pay audit fees and for ...
Audit Finding 2025-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. Several withdrawals totaling $108,111 for emergency repairs and improvements, to cover payroll, pay audit fees and for other operating expenses were made from the Reserve for Replacement account without prior approval from the lender. Response: Management agrees with the finding, was aware of the requirement for prior approval and on April 30, 2025, and has obtained retroactive approval from the lender for the withdrawal of 108,111.
Audit Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months. -Response: Management believed that including this expenditure in its request for withdrawal of funds from the reserv...
Audit Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months. -Response: Management believed that including this expenditure in its request for withdrawal of funds from the reserve for replacement account was sufficient. Management also promptly replaced the funds taken temporarily from the residual receipts account, once they received the funds from the reserve for replacement account controlled by the lender. In the future, management will make sure to obtain prior approval from HUD before making any withdrawals from the residual receipts account.
Audit Finding 2025-001: During our testing of reserve for replacement account transactions, it was discovered that the Project had made deposits of an insufficient amount each month for 22 months through September 2024. -Response: The reserve for replacement account is controlled by the lender and ...
Audit Finding 2025-001: During our testing of reserve for replacement account transactions, it was discovered that the Project had made deposits of an insufficient amount each month for 22 months through September 2024. -Response: The reserve for replacement account is controlled by the lender and when the lender discovered the deficiency during the year ended May 31, 2025 a lumpsum amount was drafted from the Project's monthly payment to cover the shortfall. In future, Management will inform the lender of changes to the monthly required deposit to the reserve for replacement account made by HUD.
Finding No. 2025-001 Residual receipts deposit We agree. Condition: The residual cash surplus of $49,570 for the fiscal year ended March 31, 2024, was deposited into the Residual Receipts account approximately 12 months after the fiscal year-end, exceeding the 90-day HUD requirement. Cause: The dela...
Finding No. 2025-001 Residual receipts deposit We agree. Condition: The residual cash surplus of $49,570 for the fiscal year ended March 31, 2024, was deposited into the Residual Receipts account approximately 12 months after the fiscal year-end, exceeding the 90-day HUD requirement. Cause: The delay was due to a discrepancy in the Employer Identification Number (EIN) on file with the financial institution, which prevented the timely opening of the required account. Planned Corrective Actions: A formal review will be conducted within 30 days after the fiscal year-end to assess surplus cash status and initiate the deposit process. All communications and actions related to the residual receipt deposit will be documented and retained for audit purposes.
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, an...
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, and if there is a balance that cannot be repaid, a payment plan will be established. Working with fee accountants during this process monthly will ensure there are no balances remaining at year end.
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 reg...
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 regarding required reference year for financial data used in preparing HUD Form 52723. o Each year prior to submission of HUD form 52723, the Authority will review all relevant PIH notices regarding calculation of the Public Housing Operating Subsidy, will adhere to the most current requirements, and will update its internal control documents and procedures to ensure consistency with current HUD guidance. Specifically, formula income, audit costs, and PILOT will be based on the Financial Data Schedule defined by HUD.
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance cover...
2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance coverage is reviewed annually and adjusted as necessary to meet HUD requirements. Explanation of disagreement with audit finding: Management is in agreement with the finding. Prior to affiliating with Silverstone Living, the Foundation had a separate endorsement included in their Property Coverage policy that included increased crime coverage to comply with HUD requirements. After transferring coverage to Silverstone Living’s policies, the increased crime coverage did not get transferred over to keep the Foundation in compliance. Action taken in response to finding: The Foundation is actively working with its insurance provider to increase coverage to the required level. The revised policy is expected to be in place by July 31, 2025. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 31, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Janet Langlois at 603-589-4111.
U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed bel...
U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs – Major Federal Programs U.S. Department of Housing and Urban Development 2025-001 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: CLA recommends that management ensures the regulatory agreement is being followed by all parties involved, unless otherwise instructed by a HUD representative. Any communication regarding changes to the regulatory agreement should come directly from HUD. Explanation of disagreement with audit finding: Management is in agreement with the finding. They received miscommunication from Lument. Since the Foundation goes through Lument for HUD requests and approvals, management thought the communication they received from Lument was approved by HUD. As a result, management was under the impression that the residual receipts account was fully funded, and the deposit of surplus cash was not required. Action taken in response to finding: On July 18, 2025, management submitted a formal request to HUD to suspend deposits to the residual receipts fund. On July 21, 2025, HUD approved a suspension of deposits to the reserve as long as a balance of $640,856.81 is maintained. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 21, 2025.
The Organization should keep track of the monthly payments required as set by the annual form HUD-9250.
The Organization should keep track of the monthly payments required as set by the annual form HUD-9250.
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