Corrective Action Plans

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Federal Award Findings and Questioned Costs Item 2025-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor com...
Federal Award Findings and Questioned Costs Item 2025-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that move out inspections are performed timely, security deposits are returned timely and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to return security deposits in a timely manner but was slightly delayed in issuing the security deposit refund for this unit. Management reviewed with the teams to ensure rent refunds would be processed within 30 days.
Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor com...
Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that EIVs are performed timely, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete EIVs and recertifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2025. In 2026 property management will be outsourced to third party management company to address outstanding compliance issues.
Federal Award Findings and Questioned Costs Item 2025-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities Program Federal Assistance Listing Number: 14.181 Recommendation: Management should review the HUD...
Federal Award Findings and Questioned Costs Item 2025-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities Program Federal Assistance Listing Number: 14.181 Recommendation: Management should review the HUD-52670 and HUD-52670-A every month to ensure that it contains the correct tenants and amounts requested. Action Taken: REACH has policies in place to ensure that HAP funds received are only for current tenants. Due to staffing issues there was a delay in updating the HAP contract. All excess funds received will be returned to HUD.
Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities Program Federal Assistance Listing Number: 14.181 Recommendation: Management should establish proc...
Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities Program Federal Assistance Listing Number: 14.181 Recommendation: Management should establish procedures and monitor compliance with those procedures to insure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete certifications and EIVs in a timely manner but due to staffing shortages at the property continued to have issues with timely completion of income certifications in 2025. In 2026 property management will be outsourced to a third party management company to address outstanding compliance issues.
Federal Award Findings and Questioned Costs Item 2025-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Federal Assistance Listing Number: 14.157 Recommendation: Management should address all deficienci...
Federal Award Findings and Questioned Costs Item 2025-002 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Federal Assistance Listing Number: 14.157 Recommendation: Management should address all deficiencies identified in the NSPIRE Physical Inspection in a timely manner to ensure compliance with HUD regulations. Action Taken: REACH has policies in place to address deficiencies identified in the NSPIRE Physical Inspections but due to staffing shortages was having issues addressing them in a timely manner. REACH has cleared all deficiencies and submitted all requested materials to HUD and is awaiting the close-out confirmation letter.
Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures a...
Federal Award Findings and Questioned Costs Item 2025-001 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for the Elderly (Section 202) Federal Assistance Listing Number: 14.157 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to complete EIVs and recertifications in a timely manner but due to staffing shortages and tenant noncompliance issues the property continued to have issues with timely completion of income certifications in 2025. In 2026 property management will be outsourced to third party management company to address outstanding compliance issues.
2025-031 Adoption Assistance 93.659 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and child abuse and neglect registry checks, and that this documentation is readily available for audit. We also reco...
2025-031 Adoption Assistance 93.659 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and child abuse and neglect registry checks, and that this documentation is readily available for audit. We also recommend the Department enhance the renewal letter to include the reaffirmation of the original subsidy agreement date by the participant. Action taken in response to finding: For the finding related to signed adoption subsidy agreements, the Department has already implemented corrective actions to improve its process of maintaining signed adoption subsidy agreements. We built the capacity to upload electronic documents into iFamilyNet in July 2022, and we now ensure that all prospectively signed agreements are uploaded into the child’s iFamilyNet record. In addition, since July 2023, during the Title IV-E eligibility determination process, the eligibility specialist verifies that the signed adoption subsidy agreement has been uploaded. The Department will also explore the auditor’s recommendation to enhance the renewal letter to include the reaffirmation of the original subsidy agreement date by the participant to see if it is technically feasible. Although the Department was unable to produce a copy of a signed subsidy agreement, the Department has controls to oversee that a subsidy agreement was executed prior to legalization of the adoption through a built-in workflow process in our i-FamilyNet system. For the other 39 sample cases, the dates of the signatures by the Department and the pre-adoptive parents recorded in iFamilyNet matched the signature dates on the copies of the original signed agreements. Hence, the Department asserts the dates entered were accurate. We unfortunately could not produce the document to demonstrate that to the auditors. For the finding relating to out-of-state child welfare checks, the Department has already implemented corrective actions to improve its process of documenting requests of out-of-state child welfare checks. In February 2023, the Department integrated the out-of-state child welfare check into the Background Record Check (BRC) section of the foster home licensing process where it can be documented and included as part of the assessment. The Department also added a value to our “contact purpose” drop down menu within the dictation screen in iFamilyNet to capture structured data that an out-of-state child welfare check was made. Name(s) of the contact person(s) responsible for corrective action: Sharon Silvia, Assistant Commissioner of Permanency COMMONWEALTH OF MASSACHUSETTS CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Planned completion date for corrective action plan: Signed Subsidy Agreements: • July 2022 – capacity to upload electronic documents into iFamilyNet (complete) • July 2023 – eligibility specialist verifies that the signed adoption subsidy agreement has been uploaded (complete) • July 2026 – assess technical feasibility of enhancing the renewal letter Out-of-State Child Welfare Checks: • February 2023 – integrated out-of-state child welfare checks into BRC section and added value to contact purpose drop down (complete)
Provided training to staff on HUD EIV requirements and documentation standards. Updated the tenant file checklist to include a mandatory EIV report verification step:  Conducted an internal audit of all tenant files to identify any additional missing or late EIV reports.  Implement a quarterly com...
Provided training to staff on HUD EIV requirements and documentation standards. Updated the tenant file checklist to include a mandatory EIV report verification step:  Conducted an internal audit of all tenant files to identify any additional missing or late EIV reports.  Implement a quarterly compliance review process to ensure ongoing adherence to EIV requirements.
CORRECTIVE ACTION PLAN FOR AUDIT FINDING 2025-001 The Organization agrees with the finding. The Organization has agreed to start performing physical inspections again, as required by HUD. Contact: Kalisha France, Regional Property Manager Completion Date: March 5, 2026
CORRECTIVE ACTION PLAN FOR AUDIT FINDING 2025-001 The Organization agrees with the finding. The Organization has agreed to start performing physical inspections again, as required by HUD. Contact: Kalisha France, Regional Property Manager Completion Date: March 5, 2026
Condition: The Organization obtained a short term line of credit without formal approval from HUD from Park National Bank in 2024 with access to credit up to $15 million, which exceeds the limits in section 20b(iii) of the HUD agreement. Planned Corrective Action: On February 21, 2024, Change Health...
Condition: The Organization obtained a short term line of credit without formal approval from HUD from Park National Bank in 2024 with access to credit up to $15 million, which exceeds the limits in section 20b(iii) of the HUD agreement. Planned Corrective Action: On February 21, 2024, Change Healthcare / Optum sustained a cyber-attack and completely shut down claim’s submission processes for Knox Community Hospital. With over 3 weeks of not releasing insurance claims that amounted to over $40M, this impacted the cashflow greatly on the organization. The CFO at that time made the decision to seek a Line of Credit with Park National Bank for $15M to fund operations. Due to the urgency and short timeline, formal approval was not obtained from HUD. A detailed event log was maintained around the cyber-attack and provided to our Board and HUD representative. In the future, all regulatory agreements’ requirements will be reviewed by the CFO and in time there are new agreements or modifications made to existing agreements to ensure compliance with each agreement. HUD has since issued a letter approving KCH’s $15M Line of Credit. Contact person responsible for corrective action: Danielle O’Brien, CFO Anticipated Completion Date: 4/30/2026
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-003: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring al...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-003: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all tenant’s assets are verified at the time of recertification and documentation is maintained in the tenants’ file. Also, the tenant file related to the finding is recertified to determine if the proper tenant rent and HUD assistance payment were accurately calculated for the year ended December 31, 2025. ACTION TAKEN The Project will be continuing to train staff on the HUD Handbook requirements for the tenant files.
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT (CONTINUED) Department of Housing and Urban Development Finding 2025-002: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT (CONTINUED) Department of Housing and Urban Development Finding 2025-002: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all tenants’ paperwork is thoroughly reviewed and accurately used in the calculation of the tenant’s required monthly rent and HUD’s tenant assistance payments. ACTION TAKEN The Project billed HUD for the $540 of tenant assistance and will be reimbursing the tenant for the additional rent of $540. The Project will be billing the tenant for the $99 and reimbursing HUD for the additional tenant assistance of $99.
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring al...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all current staff are trained on HUD Handbook requirements for tenant files, including the EIV Existing Tenant Search report. ACTION TAKEN The Project will be continuing to train staff on the HUD Handbook requirements for tenant files.
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-003: Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 RECOMMENDATION The auditor recommends ensuri...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-003: Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 RECOMMENDATION The auditor recommends ensuring all disbursements are thoroughly reviewed prior to authorizing the expense to be paid. ACTION TAKEN The Project will be reimbursed by the other project for the expense paid on its behalf.
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT (CONTINUED) Department of Housing and Urban Development Finding 2025-002: Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 RECOMMENDATION The auditor recom...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT (CONTINUED) Department of Housing and Urban Development Finding 2025-002: Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 RECOMMENDATION The auditor recommends ensuring all tenant’s paperwork is thoroughly reviewed and accurately used in the calculation of the tenant’s required monthly rent and HUD’s tenant assistance payments. ACTION TAKEN The Project will be billing the tenant for the $312 and reimbursing HUD for the additional tenant assistance payments of $312 due to the Project.
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-001: Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 RECOMMENDATION The auditor recommends implem...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2025-001: Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 RECOMMENDATION The auditor recommends implementing greater oversight over HUD tenant compliance and proper employee training on HUD move out procedures. ACTION TAKEN The Project will monitor tenant move outs to ensure security deposits are refunded within the thirty-day period specified by HUD and review the HUD move out procedures with their employees.
We will regularly perform surplus calculation and comply with the required funding of the residual receipts account and will fund the shortfall immediately.
We will regularly perform surplus calculation and comply with the required funding of the residual receipts account and will fund the shortfall immediately.
Mortgage Insurance for Refinance of Existing Multifamily Homes – Assistance Listing No. 14.155 Recommendation: Abundant Life of Perrysburg should design and implement controls to prevent non-compliance with HUD requirements surrounding surplus cash deposits such as recalculating surplus cash at the ...
Mortgage Insurance for Refinance of Existing Multifamily Homes – Assistance Listing No. 14.155 Recommendation: Abundant Life of Perrysburg should design and implement controls to prevent non-compliance with HUD requirements surrounding surplus cash deposits such as recalculating surplus cash at the end of the year after all transactions have been posted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement more frequent surplus cash computations to avoid late deposits when required. Name(s) of the contact person(s) responsible for corrective action: Jennifer Polter, Property Manager Planned completion date for corrective action plan: July 31, 2026
The Town of Spruce Pine will strengthen internal controls over the identification, tracking, and reporting of federal and state awards. Management will maintain a comprehensive, centralized listing of all known and potential federal and state awards throughout the fiscal year, including assistance l...
The Town of Spruce Pine will strengthen internal controls over the identification, tracking, and reporting of federal and state awards. Management will maintain a comprehensive, centralized listing of all known and potential federal and state awards throughout the fiscal year, including assistance listing numbers, award amounts, and pass‑through information. Grant expenditures and receivables will be reconciled to the general ledger on a monthly basis. Prior to submission to the auditors, the SEFSA be independently reviewed for completeness, accuracy, and compliance with federal and state requirements.
Oversight Agency for Audit, Evangeline Council Housing for the Elderly, Inc. 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 Sp...
Oversight Agency for Audit, Evangeline Council Housing for the Elderly, Inc. 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 finding from the September 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: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: Management should implement procedures to ensure that the correct amount is deposited into the replacement reserve account each month. An approved form HUD-9250 should be obtained to remove the excess funds, or a reduced deposit should be made for one month. Action Taken: The verification of the correct funding amounts is now confirmed against the approved form HUD-9250 on a monthly basis. This step has been added to the month-end close process. If the Oversight Agency for Audit has questions regarding this plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO
Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedu...
Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedures, improve documentation consistency, and provide additional staff training. These corrective actions will help ensure ongoing compliance and accuracy in eligibility determinations. Personnel Responsible for Implementation: Meredith Elguira Position of Responsible Personnel: Community Development Director Expected Date of Implementation: April 30, 2026
Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization was fortunate to have sufficient cash on hand in order to continue to provide the highestquality of care to its residents during the COVID-19 pandemic, primarily as a result of federal and state st...
Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization was fortunate to have sufficient cash on hand in order to continue to provide the highestquality of care to its residents during the COVID-19 pandemic, primarily as a result of federal and state stimulus funds, which were restricted in usage, received during 2020 and 2021. The Organization made it a priority to ensure that its staff continued to be compensated throughout the pandemic. Accordingly, the Organization kept cash on hand in order to meet the needs of the residents cared for daily and the dedicated staff who serve them. The Organization was not expecting a surplus cash situation at December 31, 2020 or June 30, 2021. Had the Organization not received stimulus funds through programs such as the Provider Relief Fund and Paycheck Protection Program, the Organization would not have had surplus cash at both December 31, 2020 and June 30, 2021. The required deposit due to the residual receipt account for the year ended December 31, 2020 was made on May 31, 2022. The Organization is currently in the process of discussing repayment terms for the deposit due for the period June 30, 2021 with its asset manager which includes discussions for the repayment of $1.6M in frontline costs that were funded by the Parent Organization back to the Parent. Proposed Completion Date: No later than December 31, 2026
Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization is a community based non-profit and considers supporting local businesses, including a bank, a worthwhile business practice. The Organization is currently in the process of reviewing its banking re...
Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization is a community based non-profit and considers supporting local businesses, including a bank, a worthwhile business practice. The Organization is currently in the process of reviewing its banking relationships, and looking at other scenarios which would involve transferring funds to another institution. Proposed Completion Date: No later than December 31, 2026.
FINDING NUMBER 2025-003 Reporting views of responsible officials: The Company has already submitted the audit package into HUD’s REAC system and the Company will timely file the audit with HUD in the future. Auditors' summary of auditee's comments on the findings and recommendations: The Company has...
FINDING NUMBER 2025-003 Reporting views of responsible officials: The Company has already submitted the audit package into HUD’s REAC system and the Company will timely file the audit with HUD in the future. Auditors' summary of auditee's comments on the findings and recommendations: The Company has already submitted the audit package into HUD’s REAC System and the Company will timely file the audit package with HUD and REAC in the future. Response indicator: Agree. Response: The Company has already submitted the audit package to the Federal Audit Clearinghouse and the Company will timely file the audit package with the Federal Audit Clearinghouse in the future. Completion date: October 2, 2025 Contact person: Bonnie Calvert
FINDING NUMBER 2025-002 Reporting views of responsible officials: The Company will monitor cash balances or monitor the bank ratings. Concur or do not concur with the finding: Concur with the finding Auditors' summary of auditee's comments on the findings and recommendations: The Company should moni...
FINDING NUMBER 2025-002 Reporting views of responsible officials: The Company will monitor cash balances or monitor the bank ratings. Concur or do not concur with the finding: Concur with the finding Auditors' summary of auditee's comments on the findings and recommendations: The Company should monitor the investments held by these financial institutions to ensure that HUD’s requirements are met. Response indicator: Agree. Response: The Company should monitor the investments held by these financial institutions to ensure that HUD’s requirements are met. Completion date: December 31, 2026 Contact person: Bonnie Calvert
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