Corrective Action Plans

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2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance ...
2024-002 ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 Eligibility - Missing Documentation Condition Found During the eligibility testing of the audit, the following deficiencies were identified – certain tenant files are not kept on file within the required compliance timeframe. We consider this finding to be a material weakness with the Eligibility Compliance Requirement. Corrective Action Plan Additional staff have been hired to ensure all tenant files are kept current. A monthly review will be performed by the AVP of Asset Management to ensure accuracy. Responsible Person for Corrective Action Plan The Associate Vice President of Asset Management. Implementation Date of Corrective Action Plan December 2025
2024-105 Lack of Payroll Review and Approval Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the ove...
2024-105 Lack of Payroll Review and Approval Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors’ approval of time recorded by employees. Corrective Action Planned: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employee's time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manger providing the final approval within ADP once all items are confirmed. This entire process is fully documented, with approvals recorded within the ADP by employees and supervisors and the shared file drive where HR and Finance initial off on the reviewed payroll items, ensuring a traceable record of the entire payroll approval process Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chie...
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025 Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
2024-101 Lack of 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 also lacks a clear review process related to the sliding fee scale...
2024-101 Lack of 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 also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: October 2025
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center...
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend that management hold additional training for front desk staff regarding the collection and verification of patient information for each patient. We also recommend enhancing your sliding fee status feature in your billing system to be completed for all patients to identify if the patient is insured, an application is pending, an application was received, an application was approved by finance for adjustment, and if an application was waived, to enable better tracking of the eligibility of each patient. We also recommend reviewing outstanding patient balances over 180 days to determine if follow up with a patient is required to collect the outstanding balance or to see if something has been collected by the front desk but not communicated to the finance team. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management agrees with the recommendations identified above. During April 2025, NHA started a project to review Self Pay balances with service dates prior to January 1, 2025 to follow up on why the balance is still outstanding. This would have caught the error identified above. In addition to this project, they have held additional trainings for front desk staff and will continue to do so and will continue to improve their methods of tracking patient eligibility. Name(s) of the contact person(s) responsible for corrective action: Doni Miller Planned completion date for corrective action plan: November 30, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Doni Miller, CEO at 419-720-7883.
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she...
Finding 2024-001 - Housing Choice Voucher Tenant Files - Eligibility- Rent Calculations Noncompliance & Significant Deficiency Section 8 Housing Choice Voucher Cluster - ALN 14.871 Corrective Plan: 1. Income Verification Vanette Greer (please state tenant in audit for privacy act) - Stated that she did not have one of her weekly check stubs due to being out with Covid. The Specialist processed the following: She totaled three (3) check stubs, then divided by 4 with one being at zero. She then annualized. Upon further review, it was determined that the YTD included an additional pay week (which she stated that she was out with Covid). An interim will be completed with a Retroactive Agreement offered. 2. Income Verification Lola Garrett (please state tenant in audit for privacy act) -A student credit was given but failed to acquire the necessary source document. No retro necessary. 3. Late Reexaminations (4). Four reexaminations were processed late due to insufficient information provided. The Executive Director approved the late reexams to preserve and grow the lease-up rate (at 86%} prior to HUD's declaration of insufficient funds (May 2025} for the remaining calendar year of 2025. 4. Inspections - We did have one inspection overlooked at an elderly site since 2020. The other tenants within the complex did receive inspections including SEMAP. We are now utilizing the PIC report going forward (instead of in-house system) to prevent such an oversight again. Person Responsible: Jeff Trahan, Executive Director Anticipated Completion Date: July 14, 2025 Note: It is the Auditee's position that such an oversight constitutes a "deficiency" (oversight flaw) rather than a Significant Deficiency leading to a Material Weakness in Internal Control.
Contact Person Jan Kamstra, Executive Director Corrective Action Plan The Authority will review its procedures over utility allowances to ensure a secondary review of the schedule is performed. Planned Completion Date for CAP Immediately
Contact Person Jan Kamstra, Executive Director Corrective Action Plan The Authority will review its procedures over utility allowances to ensure a secondary review of the schedule is performed. Planned Completion Date for CAP Immediately
Management has consulted with HUD's account executive regarding the use of the reserves as collateral for financing. As of this date, management is still waiting for HUD's response since they are analyzing the transaction. Banco Popular de Puerto Rico, the mortgage, will be notified about HUD final ...
Management has consulted with HUD's account executive regarding the use of the reserves as collateral for financing. As of this date, management is still waiting for HUD's response since they are analyzing the transaction. Banco Popular de Puerto Rico, the mortgage, will be notified about HUD final notification to ensure the correct collateral requirements are met. Evidence of resolution will be sent to HUD. The reposible person for the corrective action plan is Carmen G Rivera, Blanco's Vice President. The estimated completion date for the finding is June 30, 2025
Oversight Agency for Audit, Mermentau Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201 Coral Springs, Florid...
Oversight Agency for Audit, Mermentau Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201 Coral Springs, Florida 33067 Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 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. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should make sufficient monthly deposits to the escrow account in a timely manner. Action Taken: Escrows were underfunded due primarily to a high increase in insurance rates. Escrow balances will be reviewed on a regular basis to ensure adequate funding. If the audit Oversight Agency has questions regarding these plans, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO
Finding 574705 (2024-002)
Significant Deficiency 2024
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the service...
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the services of McCright & Associates LLC, a reputable HQS servicing company, to assist with rent reasonableness requirements. McCright now conducts all rent reasonableness comparables for all new units and staff confirm that a copy is stored in the participant file. Staff believe that with the implementation of these procedures appropriate steps have been taken to address this concern
Finding 574704 (2024-001)
Significant Deficiency 2024
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include d...
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with EIV requirements. Additionally, staff have been in contact with their software provider about system enhancements such as the software producing a warning/error if an employee attempts to process an EIV reexamination without updating the EIV date. Such enhancements would further help to ensure compliance with federal program requirements. Staff have also been attending training to ensure sufficient knowledge of program EIV requirements. Staff believe these efforts should address this concern.
Corrective Action Planned: The Authority will obtain depository agreements with all of their banks. Completion Date: December 31, 2025
Corrective Action Planned: The Authority will obtain depository agreements with all of their banks. Completion Date: December 31, 2025
Corrective Action Planned: The Authority will work on getting the Authority’s information in timely and working with their fee accountant to make sure the submission is in timely. Completion Date: December 31, 2025
Corrective Action Planned: The Authority will work on getting the Authority’s information in timely and working with their fee accountant to make sure the submission is in timely. Completion Date: December 31, 2025
Name of Auditee: Cascade Meadows Senior Apartments HUD Auditee identification number: 126EE064 Name of audit firm: Loveridge Hunt & Co, PLLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by: Name: Karen Long Position: Executive Director Telephone number: : 541.296.5462 Ext 1...
Name of Auditee: Cascade Meadows Senior Apartments HUD Auditee identification number: 126EE064 Name of audit firm: Loveridge Hunt & Co, PLLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by: Name: Karen Long Position: Executive Director Telephone number: : 541.296.5462 Ext 116 Finding 2024-001 - 1. Statement of Condition: During auditors’ tests of compliance over the program, they noted two tenant files that did not have appropriate documentation at the time of review of tenant files. Subsequent to field work, management was able to obtain the necessary documentation and share it with auditors to verify that income and deductions are properly calculated and documented. 2. Cause: EIV documentation was not available until 90 days after move in of a new household, and documentation was not saved with the tenant file. Property manager used bank statement to verify Social Security payment rather than using the most recent available third-party verification. Another tenant’s medical expense was not obtained timely due to having a paper receipt; management was able to receive a screen shot of the purchase of eyeglasses. 3. Actions Taken on the Finding: Moving forward only acceptable forms of verifications will be used. If using a screenshot, it will be followed up with tenant self-certification.
Management will ensure that HUD issues Form HUD-9250 for all withdrawal requests, including one that addresses the additional $4,458 that was withdrawn from replacement reserves account.
Management will ensure that HUD issues Form HUD-9250 for all withdrawal requests, including one that addresses the additional $4,458 that was withdrawn from replacement reserves account.
View Audit 364928 Questioned Costs: $1
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: The AHA Director of Assisted Housing and the Senior Housing Inspector are conducting monthly reviews of inspection reports to identify deficiencies and ensure inspections extensions are completed on time. This program management process will continue on an ongoing basis. Additionally, we have hired an additional inspector to help meet inspection deadlines and improve overall timeliness. Anticipated Completion Date: Ongoing
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: To strengthen our compliance oversight, we now have a total of two Compliance Managers on staff. We recently filled the previously vacant Compliance Manager position, which will enhance our capacity to monitor and ensure that annual recertifications are being processed every 12 months and support staff in adhering to HUD requirements and agency procedures. We have made progress in hiring and retaining staff, which is strengthening our operational capacity and will support the timely processing of annual recertifications in compliance with HUD requirements. Anticipated Completion Date: Ongoing
CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bo...
CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Compliance Requirement: Special Tests and Provisions – Residual Receipts Funds Supportive Housing for the Elderly (Section 202), Assistance Listing 14.157 Recommendation: Every effort should be made to comply with the residual receipts requirement to make deposits into the account within 60 days following the end of the fiscal year or request waivers by the due date. Planned Corrective Actions: Every effort will be made to deposit the required amount within the allotted 60 day period. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100. Sincerely, MBDM – Drake Senior Housing Corporation Elizabeth Goleski, CEO
CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: ...
CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Compliance Requirement: Special Tests and Provisions – Residual Receipts Funds Supportive Housing for the Elderly (Section 202), Assistance Listing 14.157 Recommendation: Every effort should be made to comply with the residual receipts requirement to make deposits into the account within 60 days following the end of the fiscal year or request waivers by the due date. Planned Corrective Actions: Every effort will be made to deposit the required amount within the allotted 60 day period. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100. Sincerely, MBDM – Epsilon Senior Housing Corporation Elizabeth Goleski, CEO
We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a process to verify that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit...
Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a process to verify that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will train individuals doing the calculations to ensure calculations are done and maintained in the files and implement processes to verify rent reasonableness calculations are done. Name of the contact person responsible for corrective action: Bob Kazmierski Planned completion date for corrective action plan: December 31, 2024
The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff ...
The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff primarily responsible for this function have left their positions in the last two years and have been replaced by staff new to the position. The Authority did increase quality control reviews due to the transition period. The finding does not identify a systemic issue rather it found various instances of noncompliance. Prior to the Audit the Authority scheduled a three-day onsite rent calculation training for all staff with Nan McKay inc that occurred the week of May 20, 2025. Finding 2024-001- Moving To Work Demonstration Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Authority will continue and enhance its training regimen for staff responsible for rent determination. Furthermore, the Authority has engaged the services of Edgemere Consulting. As part of this engagement Edgemere will conduct an independent quality control review of public housing and rental assistance files. From the information gathered from the file review Edgemere Consulting will develop specific training initiatives for the staff including enhanced quality control measures. Person Responsible: Bruna Campbell, Compliance officer Anticipated Completion Date: December 31, 2025 - Ongoing
View Audit 364699 Questioned Costs: $1
Finding 2024-004 See response to finding 2024-002.
Finding 2024-004 See response to finding 2024-002.
Finding #2024-001- 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 err...
Finding #2024-001- 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: Amy Barnes, Village Clerk/Treasurer, 608-523-4521, Email: clerk@blanchardvillewi.gov Anticipated Completion: Not Applicable
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