Corrective Action Plans

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MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACCOUNT IS PROPERLY FUNDED IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. 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 $2,239. 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 $2,239. 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 Decmeber 20, 2024 in the amount of $129,509. 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 Decmeber 20, 2024 in the amount of $129,509. 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 30, 2025 in the amount of $22,052. 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 30, 2025 in the amount of $22,052. Management will ensure that the residual receipts account is properly funded in the future.
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT WILL PLACE THE FUNDS BACK IN THE RESTRICTED ACCOUNT.
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT WILL PLACE THE FUNDS BACK IN THE RESTRICTED ACCOUNT.
MANAGEMENT AGREES WITH THE FINDING. THE RESIDUAL RECEIPTS ACCOUNT DEFICIENCY WAS FUNDED MARCH 31, 2025 IN THE AMOUNT OF $36,461. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACOUNT IS PROPERLY FUNDED IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. THE RESIDUAL RECEIPTS ACCOUNT DEFICIENCY WAS FUNDED MARCH 31, 2025 IN THE AMOUNT OF $36,461. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACOUNT IS PROPERLY FUNDED IN THE FUTURE.
MANAGEMENT AGREEWS WITH THE FINDING. THE RESIDUAL RECEIPTS ACCOUNT DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $39,000. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACCOUNT IS PROPERLY FUNDED IN THE FUTURE.
MANAGEMENT AGREEWS WITH THE FINDING. THE RESIDUAL RECEIPTS ACCOUNT DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $39,000. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACCOUNT IS PROPERLY FUNDED IN THE FUTURE.
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.
MANAGEMENT AGREES WITH THE FINDING. THE RESIDUAL RECEIPTS ACCOUNT DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $50,836. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACCOUNTS IS PROPERTLY FUNDED IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. THE RESIDUAL RECEIPTS ACCOUNT DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $50,836. MANAGEMENT WILL ENSURE THAT THE RESIDUAL RECEIPTS ACCOUNTS IS PROPERTLY FUNDED IN THE FUTURE.
Section III Federal Award Findings and Questioned Costs Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care),) Grants for New and Expanded Services Under the Health Center Program, COVID-19 Grants for New and Expanded...
Section III Federal Award Findings and Questioned Costs Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care),) Grants for New and Expanded Services Under the Health Center Program, COVID-19 Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2025 002 – Special Tests Recommendation The Center should establish a system of internal controls to ensure that all slide fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken The Finance Department will take the following steps to enhance the slide fee discounts process: 1. Policy Revision: the health center will revise its Sliding Fee Discount Policy to ensure alignment with HRSA requirements, including accurate discount calculation methodologies, annual updates to the sliding fee scale, and proper utilization of NextGen system functionality to support implementation 2. Staff Training: the health center will provide comprehensive training to all relevant staff on the revised Sliding Fee Discount Policy and procedures. 3. Training will emphasize correct discount calculations, required documentation, and income verification processes. A recurring training program will be implemented to ensure ongoing compliance for both new hires and existing employees. 3. Retrospective Review: the health center will conduct a retrospective review of patient files for the current fiscal year to confirm that all sliding fee discounts are appropriately supported by required documentation. Any identified discrepancies will be corrected in a timely manner. 4. Ongoing Monitoring: the health center will establish monthly internal audits of sliding fee discount determinations to monitor compliance. Audit results will be documented and reviewed by management to ensure corrective actions are taken as needed. Responsible Party: Chief Financial Officer Target Completion Date: 04/30/2026 If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Javier Vallejo, CFO at (314)-482-0915. Sincerely yours, Javier Vallejo Chief Financial Officer
FINDING No. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that all required tenant eligibility steps are performed in accordance with HUD regulations, utilize the EIV system for income verification, inspect unit...
FINDING No. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure that all required tenant eligibility steps are performed in accordance with HUD regulations, utilize the EIV system for income verification, inspect units timely, and maintain all supporting documentation in the tenant files. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding this plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO
Oversight Agency for Audit, Piazza Apartments respectfully submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit peri...
Oversight Agency for Audit, Piazza Apartments respectfully submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: October 1, 2024, through September 30, 2025 The findings from the September 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should comply with state law and HUD regulations for refunding security deposits timely. Action Taken: Staff training has been provided and included in monthly reporting procedures.
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Chicago respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Cor...
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Chicago respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: July 1, 2024 through June 30, 2025 The finding for the June 30, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Project Based Rental Assistance Program, ALN 14.195 Recommendation: The Project should implement procedures to ensure that proper initial eligibility procedures are conducted for potential tenants and that tenant files are accurately maintained. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding this plan, please call Irene Phillips at 954- 835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Condition and context: The required monthly replacement reserves deposit amount increased from $842 to $885 during the year, but Living Centers No. 2 failed to increase the monthly deposit. Recommendation: Reemphasize current polici...
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Condition and context: The required monthly replacement reserves deposit amount increased from $842 to $885 during the year, but Living Centers No. 2 failed to increase the monthly deposit. Recommendation: Reemphasize current policies and procedures to ensure that the required monthly deposit is made in accordance with HUD requirements. Planned corrective action: Following turnover that resulted in accounting challenges, we hired a CFO to develop standard operating procedures and best practices to ensure we maintain operational excellence in non-profit accounting. We implemented strategies to address opportunities in training, best practices and oversight. Responsible officer: Terry Vaughn, Vice President of Operations and Sales. Estimated completion date: November 2025.
Findings #2025-001 and #2025-002 – Material Weakness and Other Noncompliance. Condition and context: Adjustments were required to properly state accrued interest payable and interest expense, depreciation and accumulated depreciation, maintenance expense and building equipment, tenant deposits held ...
Findings #2025-001 and #2025-002 – Material Weakness and Other Noncompliance. Condition and context: Adjustments were required to properly state accrued interest payable and interest expense, depreciation and accumulated depreciation, maintenance expense and building equipment, tenant deposits held in trust and tenant charges, salary expense and related payables, and accounts payable and related expense. These adjustments decreased the change in net assets by approximately $59,500. Additionally, an audit adjustment of approximately $24,350 was required to properly state cash and intercompany payables. Recommendation: Policies and procedures should be designed and implemented to ensure that transactions are appropriately recognized in the accounting records, supported by appropriately approved documentation and that accounts, including accruals, are timely reviewed and reconciled. Planned corrective action: Following turnover that resulted in accounting challenges, we hired a CFO to develop standard operating procedures and best practices to ensure we maintain operational excellence in non-profit accounting. We implemented strategies to address opportunities in training, best practices and oversight. Responsible officer: Terry Vaughn, Vice President of Operations and Sales. Estimated completion date: November 2025.
Recommendation: We recommend that the District review its internal controls and implement a procedure to ensure all reports required under the grant have a designated reviewer that is distinct from the individual responsible for preparing. Explanation of Disagreement with Audit Finding: There is no ...
Recommendation: We recommend that the District review its internal controls and implement a procedure to ensure all reports required under the grant have a designated reviewer that is distinct from the individual responsible for preparing. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The Business Manager and School Food Service Director met regarding the finding and agreed that the Food Service Director will continue to gather the required claim data and enter the appropriate data into DPIs required Excel template monthly. All supporting documentation as well as the Excel documents will be emailed to the Business Manager monthly. The Business Manager will verify the numbers in the Excel documents using the supporting documentation. If the Business Manager agrees with the numbers in the Excel files, they will be uploaded to DPI as is. If any discrepancies are discovered, the Food Service Director and the Business Manager will work together to ensure the correct data is sent to DPI. Name of Responsible Official: Tera Fritz, Business Manager Expected Completion Date: September 1, 2025
Management will ensure that any distributions of project assets are approved by HUD in advance. A formal written policy has been adopted that requires all proposed distributions to be submitted to HUD for prior written approval before any disbursement. The policy clearly defines roles, responsibilit...
Management will ensure that any distributions of project assets are approved by HUD in advance. A formal written policy has been adopted that requires all proposed distributions to be submitted to HUD for prior written approval before any disbursement. The policy clearly defines roles, responsibilities, and the approval workflow. No distributions are to be processed without documented evidence of HUD’s written approval. This verification is required before processing any transaction.
The Project will make catch-up deposits when operating cash is available. In addition, the following measures have been implemented: 􀁸 A monthly compliance checklist has been established to verify timely reserve for replacement deposits. 􀁸 The Housing Accountant is required to provide monthly confir...
The Project will make catch-up deposits when operating cash is available. In addition, the following measures have been implemented: 􀁸 A monthly compliance checklist has been established to verify timely reserve for replacement deposits. 􀁸 The Housing Accountant is required to provide monthly confirmation to the Executive Director that deposits have been made, with documentation. 􀁸 Cash flow forecasting is now conducted monthly to identify potential shortfalls in advance. This allows management to prioritize HUD-mandated deposits and, if necessary, seek HUD approval for a rent increase to improve financial stability. 􀁸 A financial policy was adopted to temporarily defer discretionary or non-essential expenditures when cash flow is tight, ensuring compliance with HUD obligations.
Condition: The Organization had cash balances that exceeded federally insured limits, and management did not monitor or maintain documentation of the financial institutions’ ratings Criteria: HUD guidelines require cash to be maintained in financial institutions that meet minimum GNMA ratings when b...
Condition: The Organization had cash balances that exceeded federally insured limits, and management did not monitor or maintain documentation of the financial institutions’ ratings Criteria: HUD guidelines require cash to be maintained in financial institutions that meet minimum GNMA ratings when balances exceed federally insured limits. Financial institution ratings are to be monitored by management on a quarterly basis, and documentation is to be maintained for at least three years as required by the HUD handbook 4350.1 Cause: The cause of this issue was the absence of established procedures requiring periodic review of cash balances exceeding federally insured limits and the lack of a documented process for monitoring and retaining financial institution rating information. Effect: There were no negative effects on the Organization. Action Plan: The Organization has maintained a strong partnership with our banking institution for several years, and this relationship continues to provide meaningful support to our residents and community. Management acknowledges that certain cash balances exceeded federally insured limits and that documentation of financial institution ratings was not consistently monitored or maintained. To address this, management will (1) evaluate opportunities to rebalance cash holdings to remain within insured limits where feasible, and (2) implement a formal process to review, document, and retain financial institution credit ratings on at least a quarterly basis. This process will be incorporated into the Organization’s ongoing treasury and risk-management procedures to ensure compliance going forward.
Criteria: HUD requires the Organization to maintain fidelity bond coverage of at least two months' cash collections Cause: Following completion of the 2025 Mark-to-Market process for HRCA Housing for Elderly Inc., we failed to update our fidelity bond coverage to reflect the revised requirements. Ac...
Criteria: HUD requires the Organization to maintain fidelity bond coverage of at least two months' cash collections Cause: Following completion of the 2025 Mark-to-Market process for HRCA Housing for Elderly Inc., we failed to update our fidelity bond coverage to reflect the revised requirements. Action Plan: Once the finding was identified, we immediately contacted our insurance broker and requested an increase to the fidelity bond coverage. The bond has since been raised to a $2M limit, and the updated policy became effective on 11/14/25. Going forward, the fiscal team will incorporate an annual verification of bond coverage into its routine monitoring procedures to ensure timely updates after significant organizational or regulatory changes. In addition, we are implementing an internal audit component to enhance our review of all HUD requirements. This added oversight will help mitigate future risk and ensure continued compliance with all applicable regulations.
Condition: The Organization had cash balances that exceeded federally insured limits, and management did not monitor or maintain documentation of the financial institutions’ ratings Criteria: HUD guidelines require cash to be maintained in financial institutions that meet minimum GNMA ratings when b...
Condition: The Organization had cash balances that exceeded federally insured limits, and management did not monitor or maintain documentation of the financial institutions’ ratings Criteria: HUD guidelines require cash to be maintained in financial institutions that meet minimum GNMA ratings when balances exceed federally insured limits. Financial institution ratings are to be monitored by management on a quarterly basis, and documentation is to be maintained for at least three years as required by the HUD handbook 4350.1 Cause: The cause of this issue was the absence of established procedures requiring periodic review of cash balances exceeding federally insured limits and the lack of a documented process for monitoring and retaining financial institution rating information. Effect: There were no negative effects on the Organization. Action Plan: The Organization has maintained a strong partnership with our banking institution for several years, and this relationship continues to provide meaningful support to our residents and community. Management acknowledges that certain cash balances exceeded federally insured limits and that documentation of financial institution ratings was not consistently monitored or maintained. To address this, management will (1) evaluate opportunities to rebalance cash holdings to remain within insured limits where feasible, and (2) implement a formal process to review, document, and retain financial institution credit ratings on at least a quarterly basis. This process will be incorporated into the Organization’s ongoing treasury and risk-management procedures to ensure compliance going forward.
HACP has implemented the following corrective actions: Continued oversight of two current inspectors to ensure compliance with HQS and federal regulations; Retention of a Compliance Coordinator to oversee inspection processes and documentation; implementation of improved documentation standards rela...
HACP has implemented the following corrective actions: Continued oversight of two current inspectors to ensure compliance with HQS and federal regulations; Retention of a Compliance Coordinator to oversee inspection processes and documentation; implementation of improved documentation standards related to inspections, re-inspections, and abatements; Regular file audits conducted by the ED or Deputy Director to verify timely rescheduling and enforcement of rent abatements.
Finding #2025-001: Comments on the Finding and Each Recommendation: The Corporation received a reimbursement from the reserve for replacements, as approved by HUD, for $17,400 for HVAC services based on a proposal during the year ended September 30, 2025; however the proposal was never accepted and ...
Finding #2025-001: Comments on the Finding and Each Recommendation: The Corporation received a reimbursement from the reserve for replacements, as approved by HUD, for $17,400 for HVAC services based on a proposal during the year ended September 30, 2025; however the proposal was never accepted and the scheduled repairs never incurred. At September 30, 2025, the $17,400 had not been deposited back into the reserve for replacements. Management should transfer $17,400 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. On November 6, 2025, management transferred $17,400 from the operating account to the reserve for replacements.
Identifying Number: 2025-001 Finding: The Organization calculated surplus cash of $31,225 as of September 30, 2020 and surplus cash of $39,082 as of September 30, 2021, which includes the undeposited amount from September 30, 2020. This amount was not deposited into a residual receipts fund account....
Identifying Number: 2025-001 Finding: The Organization calculated surplus cash of $31,225 as of September 30, 2020 and surplus cash of $39,082 as of September 30, 2021, which includes the undeposited amount from September 30, 2020. This amount was not deposited into a residual receipts fund account. The Organization calculated surplus cash of $149,237 as of September 30, 2022, which includes the undeposited amount from September 30, 2021. The Organization has not deposited this amount into a separate residual receipts fund account within 90 days of the fiscal year-end. Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management disagrees with the finding because surplus cash was caused by a release from the replacement reserve and a timing difference between the release of the reserve and the addition of building improvements. Building improvements and a related payable were recorded during the year ended September 30, 2023. As of September 30, 2025, the Organization did not have any surplus cash; therefore, management does not intend to make a deposit into a residual receipts account. The construction payable will be paid in full as funds become available. Management has had discussions with their lender and intends to contact HUD directly to resolve this finding. Due to the necessary involvement of third parties to complete the corrective action, the Organization cannot determine an anticipated completion date.
Identifying Number: 2025-001 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 m...
Identifying Number: 2025-001 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 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 most recently corresponded with the lender in August 2024. Management is currently waiting on HUD’s review for completion. Due to the necessary involvement of third parties to complete the corrective action, the Organization cannot determine an anticipated completion date.
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