Corrective Action Plans

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Finding #2025-001- Segregation of Duties Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional error...
Finding #2025-001- Segregation of Duties Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or can both make and conceal an error, whether such error is intentional or unintentional. Cause: Limited number of personnel. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities because of the lack of segregation of duties. Recommendation: We recommend that the Village consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with the finding but do not believe it is cost-effective to increase the office staff in an attempt to bring about a more effective segregation of duties. Contact Person: Katherine Drake, Village Clerk/Treasurer, 608-523-4521, clerk@blanchardvillewi.gov Anticipated Completion: Not Applicable
2025-101 Lack of Effective Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization’s current review process related to the sliding fee scale t...
2025-101 Lack of Effective Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization’s current review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner does not always detect all errors. We also noted: • Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. • Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. Corrective Action Planned: The Organization has hired a new Chief Financial Officer and a new Revenue Cycle Manager. Sliding fee discount program training has been incorporated into onboarding for all new front desk employees. The billing department is adding a Patient Accounts Specialist who will monitor and review individual sliding fee determinations for accuracy and completeness and will conduct ongoing training with front desk staff as needed. Additionally, management will perform quarterly random sample testing of sliding fee determinations to verify that household size, income documentation, and discount tier were applied in accordance with the Organization's sliding fee discount policy. With respect to the school district agreement and the bus program, management will contact HRSA to request written guidance or a waiver confirming that the sliding fee discount schedule is not required to be applied to these programs. Management will also amend the Organization's sliding fee discount policies and procedures accordingly and will remove the word "disaster" from references to the bus program, as the program is not limited to disaster-related services. Person Responsible for Corrective Action: Tonya Nicholson, Chief Financial Officer Anticipated Completion Date: October 2026
CORRECTIVE ACTION PLAN September 10, 2025 U.S. DEPT. OF AGRICULTURE Pierce City School District R-VI respectfully submits the following corrective action plan for the year ended June 30, 2025. Contact information for the individual responsible for the corrective action: Matthew Street, Superintenden...
CORRECTIVE ACTION PLAN September 10, 2025 U.S. DEPT. OF AGRICULTURE Pierce City School District R-VI respectfully submits the following corrective action plan for the year ended June 30, 2025. Contact information for the individual responsible for the corrective action: Matthew Street, Superintendent Pierce City School District R-VI 300 N Myrtle Street Pierce City, MO 65723 (417) 476-2555 Independent Public Accounting Firm: The CPA Group, PC, 217 4th Street, Monett, MO 65708 Audit Period: Year ended June 30, 2025 The findings from the June 30, 2025, 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 2025-001 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, Matthew Street, Superintendent Pierce City School District R-VI
CORRECTIVE ACTION PLAN August 12, 2025 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, 2025. Contact information for the individual responsible for the co...
CORRECTIVE ACTION PLAN August 12, 2025 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, 2025. Contact information for the individual responsible for the corrective action: Dr. Tosha Tilford, Superintendent Southwest R-V School District 529 Pineville Road 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, 2025 The findings from the June 30, 2025, 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 2025-001 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, Dr. Tosha Tilford, Superintendent Southwest R-V School District
Criteria The compliance supplement states “Owners shall establish and maintain a replacement reserve to aid in funding extraordinary maintenance and repair and replacement of capital items. The replacement reserve funds must be deposited in a federally insured depository in an interest-bearing accou...
Criteria The compliance supplement states “Owners shall establish and maintain a replacement reserve to aid in funding extraordinary maintenance and repair and replacement of capital items. The replacement reserve funds must be deposited in a federally insured depository in an interest-bearing account. All earnings including interest on the reserve must be added to the reserve. An amount as required by HUD will be deposited monthly in the reserve fund (Regulatory Agreement, item 5 (a)). All disbursements from the reserve must be approved by HUD (24 CFR section 891.405).” Condition The monthly required deposit into the replacement reserve account was increased from $428 to $513 effective September 1, 2025. The deposits into the replacement reserve account were not increased as approved by HUD resulting in deficiency of $340. Cause The management agents did not implement the HUD approved required monthly increase in the replacement reserve deposits. Effect or potential effect The Organization is not in compliance with the requirements set forth by HUD related to its reserve for replacement account. Questioned Costs None Identification as a repeat finding Repeat finding Recommendation We recommend that the Organization deposit the deficient funds of $340 for the year ended December 31, 2025 as well as any deficiencies for the year ending December 31, 2026. Person Responsible for Implementation: Brian Watson, Chief Accounting Officer. Telephone (816) 463-0112 ext. 3016, Email bwatson@luinc.org Anticipated Completion Date: Late July or early August, 2026
Finding Reference: 2025-004 Description of Finding: The Authority was unable to provide documentation to show income had been verified during reexamination for 3 tenants out of a sample of 40 tenants. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Actio...
Finding Reference: 2025-004 Description of Finding: The Authority was unable to provide documentation to show income had been verified during reexamination for 3 tenants out of a sample of 40 tenants. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: Staff will attend annual file compliance training and upcoming rent calculation training to reinforce documentation requirements and ensure accurate income determinations going forward. We have also updated our file checklists, staff are reviewing all tenant files and we have an internal file review process, as noted in Finding 2025-002, to help ensure staff obtain and maintain all required third-party documentation for income reexaminations Name of Contact Person: Curtis Lokey, Director of Finance, 423-752-4893, clokey@chahousing.org
Finding Reference: 2025-003 Description of Finding: Contract rent adjustments were not applied to the calculation of rent for 4 tenants out of a sample of 40. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: Due to staffing challenges, some contra...
Finding Reference: 2025-003 Description of Finding: Contract rent adjustments were not applied to the calculation of rent for 4 tenants out of a sample of 40. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: Due to staffing challenges, some contract rent adjustments were implemented later than they should have been. We have since implemented a process to ensure contract rent adjustments are reviewed and applied timely. This process includes internal review procedures, and staff will receive annual training to reinforce contract rent requirements and help ensure adjustments are processed accurately and on time going forward.
Finding Reference: 2025-002 Description of Finding: The Authority was unable to provide all documents required to be maintained to determine eligibility. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: We have updated our file checklists to bette...
Finding Reference: 2025-002 Description of Finding: The Authority was unable to provide all documents required to be maintained to determine eligibility. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: We have updated our file checklists to better ensure that staff collect all required supporting documentation needed to determine eligibility during each reexamination. Staff received training on the new checklist format in late 2025 and have begun using the updated checklists. We are also reviewing all participant files to verify they are complete and compliant. In addition, we have an internal file review process that includes quality control reviews of a percentage of files at each site to help ensure required documentation is present and program requirements are being met. Staff will also attend annual file compliance training to reinforce documentation requirements and support continued compliance going forward.
Finding Reference: 2025-001 Description of Finding: The Authority did not perform timely repairs on 18 units in accordance with housing quality inspection requirements. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: We currently have a process t...
Finding Reference: 2025-001 Description of Finding: The Authority did not perform timely repairs on 18 units in accordance with housing quality inspection requirements. Statement of Concurrence or Nonconcurrence: The Authority agrees with the finding. Corrective Action: We currently have a process to respond to all life-threatening and health and safety inspection deficiencies in a timely manner. To improve the process for all other inspection deficiencies, we are working on a way to use technology to automatically import inspection findings into our system instead of manually entering each work order. This will reduce the time it takes to create work orders, allowing repairs to be completed more quickly. The system will also provide documentation of completed repairs, helping ensure records are maintained.
Condition: Controls were not designed or implemented effectively to ensure: 1. Mortgage and escrow payments were made in accordance with the due dates and amounts specified in the executed mortgage note agreement. 2. Earnings are retained in the replacement reserve account 3. The Organization comple...
Condition: Controls were not designed or implemented effectively to ensure: 1. Mortgage and escrow payments were made in accordance with the due dates and amounts specified in the executed mortgage note agreement. 2. Earnings are retained in the replacement reserve account 3. The Organization completes the required financial reports in accordance with the applicable accounting basis, supported by underlying records representing the activity for the period reported. Planned Corrective Action: Management will design and implement internal controls to ensure compliance with mortgage escrow payments, reserve account funding, and quarterly financial reporting requirements, including a process to ensure that documentation of reviews is retained. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2026
Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the budget submissions in question to ensure timely submission on a go-forw...
Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the budget submissions in question to ensure timely submission on a go-forward basis. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2026
The Organization agrees with the finding. The Organization discussed with HUD how to become current on replacement reserve amounts owed and made the payments. This finding has been closed. Contact: Shelley Evankovich, Management Agent Actual Completion Date: April 3, 2026
The Organization agrees with the finding. The Organization discussed with HUD how to become current on replacement reserve amounts owed and made the payments. This finding has been closed. Contact: Shelley Evankovich, Management Agent Actual Completion Date: April 3, 2026
Name of Auditee: Watertown Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2025 CAP Prepared by: Shawn VanBrocklin, Assistant Executive Director Phone: (315) 782-1251 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Findi...
Name of Auditee: Watertown Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2025 CAP Prepared by: Shawn VanBrocklin, Assistant Executive Director Phone: (315) 782-1251 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2025-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendations, please see below for action taken. (b) Action taken - The Authority will monitor all relevant dates and reporting timelines to ensure compliance with reporting guidelines. (c) Planned implementation date of corrective action - Completed by December 31, 2026.
Management Response/Corrective Action Plan: The School Nutrition Department has implemented strengthened procedures by adding a separate count of meals served in the accounting department. These measures are intended to improve the accuracy claims submitted.
Management Response/Corrective Action Plan: The School Nutrition Department has implemented strengthened procedures by adding a separate count of meals served in the accounting department. These measures are intended to improve the accuracy claims submitted.
Signatures on Checks CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will make sure that all checks have the proper signatures that are required Official Responsible for Ens...
Signatures on Checks CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will make sure that all checks have the proper signatures that are required Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: The planned completion date is December 31, 2026. Plan to Monitor Completion of CAP: The Board will be monitoring this corrective action plan and believes the Executive Director will remedy this finding.
Control Finding over Special Provisions CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will implement a checklist for documentation required to be obtained regarding specia...
Control Finding over Special Provisions CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will implement a checklist for documentation required to be obtained regarding special provisions compliance. They will also implement a formal review process of tenant files. Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: The planned completion date is December 31, 2026. Plan to Monitor Completion of CAP: The Board will be monitoring this corrective action plan and believes the Executive Director will remedy this finding.
Rent Reasonableness CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will include rent reasonableness documentation in all required tenant files. Official Responsible for Ens...
Rent Reasonableness CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will include rent reasonableness documentation in all required tenant files. Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: The planned completion date is December 31, 2026. Plan to Monitor Completion of CAP: The Board will be monitoring this corrective action plan and believes the Executive Director will remedy this finding.
1. Tracking Deficiencies The Housing Authority will use its ERP system, Yardi, for tracking all failed inspections. The system will have record of all relevant inspection-related information, and inspection staff will update the log on the same day that deficiencies are identified and as corrections...
1. Tracking Deficiencies The Housing Authority will use its ERP system, Yardi, for tracking all failed inspections. The system will have record of all relevant inspection-related information, and inspection staff will update the log on the same day that deficiencies are identified and as corrections and follow-up inspections are completed. Management will review the log regularly to monitor outstanding deficiencies, ensure timely corrective action, and verify compliance with required deadlines. 2. Notification Procedures For a 24-hour correctable deficiency resulting in a failed inspection, the tenant and landlord (if present) will be notified at the time of inspection, and both will receive follow up notice via email or phone immediately thereafter. Where notification is made via phone, a note will be made on the inspection booklet recording the time and details of the conversation. A letter summarizing the conversation will be sent to tenant and/or landlord as applicable. For deficiencies with longer correction times (e.g. 30 days), notification will be sent to the tenant and landlord within 5 business days of the inspection. Notification will include relevant information, including the deficiency identified, the required timeframe for correction, the party responsible for correcting the violation, and potential consequences for failure to complete the required repairs or corrections. Management will periodically review documentation to ensure notifications are completed timely and in accordance with Housing Authority policy and HUD requirements. 3. Management Oversight Management will monitor all open deficiencies to ensure that required notices are issued within required timeframes, corrections are completed and verified timely, and appropriate follow-up actions are taken when repairs or corrections are not completed as required. If deficiencies are not corrected within the required timeframe, the Housing Authority will take appropriate enforcement action in accordance with program requirements and applicable regulations, including HAP abatement and termination of tenant assistance, if required. In addition, failure by staff to complete required inspection and follow-up responsibilities will be reported to executive management for corrective action to ensure continued compliance and accountability. 4. Verification of Corrections All remediation of deficiencies must be verified before the deficiency is considered corrected and closed. Verification may include: Reinspection conducted by Housing Authority staff, with dates of correction documented; Remote video inspection, if it is feasible to discern whether the deficiency was adequately cured; or Photographs clearly documenting completed repairs or corrections 5. Staff Training Inspection and program staff will receive training on: HUD inspection requirements; Identification of life-threatening and 24-hour deficiencies; Required correction and verification timelines; and Documentation and recordkeeping procedures.
Management will submit the budget and a corrective action plan to HUD regarding the budget.
Management will submit the budget and a corrective action plan to HUD regarding the budget.
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current ...
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2025-002: The Corporation paid entity costs of $7,680 from operating cash. Comments on the Finding and Each Recommendation: The Sponsor should reimburse the Corporation $7,680 or management should request HUD approval for funds to be reimbursed from the reserve for replacement. Action(s) taken or planned on the finding: Management requested reimbursement from the reserve for replacement. HUD approval was received on February 25, 2026.
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current ...
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2025-001: As of December 31, 2025, deposits to the reserve for replacements account of $27,908 had not been made. Comments on the Finding and Each Recommendation: Management should make a deposit to the reserve for replacements for $27,908 for the delinquent deposits. In future periods, management should fund the reserve for replacements on an annual basis as required by the regulatory agreement. Action(s) taken or planned on the finding: Management made the delinquent deposit on March 11, 2026.
CORRECTIVE ACTION PLAN Name and Number of the Project: Cliff View Village II, Inc. No. 112-EE040 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2025 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regar...
CORRECTIVE ACTION PLAN Name and Number of the Project: Cliff View Village II, Inc. No. 112-EE040 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2025 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING 1: Section 202 Capital Advance, CFDA 14:157 CORRECTIVE ACTION COMPLETED: During March 2026 the Company deposited the delinquent payment of $120 into the residual receipts account for excess rent. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Becca Riebesell, Vice President, Asset Living.
Management concurs with the findings. Management is in the process of implementing formal procedures to strengthen oversight of HUD regulatory requirements, including the timely execution of replacement reserve deposits. These procedures will include clearly assigning responsibility, incorporating t...
Management concurs with the findings. Management is in the process of implementing formal procedures to strengthen oversight of HUD regulatory requirements, including the timely execution of replacement reserve deposits. These procedures will include clearly assigning responsibility, incorporating the requirement into a month-end compliance checklist, and documenting management review. Management expects these procedures to be implemented promptly and believes they will ensure compliance with HUD requirements going forward. Name of Responsible Person: Peyton Vang, Director of Finance Name of Contact: John Reilly Anticipated Completion Date: Corrective action was implemented effective July 2025
Management concurs with the findings. Management is in the process of implementing formal procedures to strengthen oversight of HUD regulatory requirements, including the preparation, review, and timely execution of surplus cash calculations and related residual receipts deposits. These procedures w...
Management concurs with the findings. Management is in the process of implementing formal procedures to strengthen oversight of HUD regulatory requirements, including the preparation, review, and timely execution of surplus cash calculations and related residual receipts deposits. These procedures will include clearly assigning responsibility, incorporating the requirement into a year‑end compliance checklist, and documenting management review. Name of Responsible Person: Peyton Vang, Director of Finance Name of Contact: John Reilly Anticipated Completion Date: August 2026
Response: Management concurs with the findings. Although the Organization does not currently use an interestbearing account for project funds, due to the ongoing operation of the program and continuous activity within the project funds account, any interest earned in such an account would be negligi...
Response: Management concurs with the findings. Although the Organization does not currently use an interestbearing account for project funds, due to the ongoing operation of the program and continuous activity within the project funds account, any interest earned in such an account would be negligible. Management is in the process of evaluating this recommendation to determine the appropriate course of action. Name of Responsible Person: Peyton Vang, Director of Finance Name of Contact: John Reilly Anticipated Completion Date: September 2026
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