Corrective Action Plans

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Views of Responsible Officials and Planned CorrectivUnited States Department of Housing and Urban Development Plaza Esperanza, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025: Name of Audit Firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place ...
Views of Responsible Officials and Planned CorrectivUnited States Department of Housing and Urban Development Plaza Esperanza, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025: Name of Audit Firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place Suite 109 Lincoln, RI 02865 Audit period covered: 7/1/2024-6/30/2025 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. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: Section 202 Project Rental Assistance—Assistance Listing # 14.157 Recommendation: The Corporation should design and implement internal controls to ensure that all security deposits are transferred in the required time period. Management should also conduct a monthly inspection of the security deposit listing. Action Taken: Management is in agreement with the auditor’s findings. Management has instructed all accounting personnel to review all matters related to tenant compliance. If the United States Department of Housing and Urban Development has questions regarding this plan, please call Frank Shea at (401) 296-3761.
Corrective Action Plan Delinquent replacement reserve deposits of $34,425 for fiscal years 2024-2025 were made on August 22, 2025. The remaining delinquent replacement reserve and paint reserve deposits will be made as soon possible. Also, a recurring payable will be created to ensure future deposit...
Corrective Action Plan Delinquent replacement reserve deposits of $34,425 for fiscal years 2024-2025 were made on August 22, 2025. The remaining delinquent replacement reserve and paint reserve deposits will be made as soon possible. Also, a recurring payable will be created to ensure future deposits are made timely. Anticipated Completion Date December 31, 2025 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL 62353 (217) 773-3325
Corrective Action Plan Delinquent replacement reserve deposits of $26,385 for fiscal years 2024-2025 were made on August 8, 2025. The remaining replacement reserve and paint reserve deposits will be made as soon as funds are available. Also, a recurring payable will be created to ensure future depos...
Corrective Action Plan Delinquent replacement reserve deposits of $26,385 for fiscal years 2024-2025 were made on August 8, 2025. The remaining replacement reserve and paint reserve deposits will be made as soon as funds are available. Also, a recurring payable will be created to ensure future deposits are made timely. Anticipated Completion Date June 30, 2026 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL 62353 (217) 773-3325
Corrective Action Plan Delinquent replacement reserve deposits of $31,456 for fiscal years 2023-2024 were made by August 22, 2025. The remaining delinquent deposits will be made as soon as funds are available. Delinquent paint reserve deposits of $3,000 for fiscal years 2024-2025 were made on June 1...
Corrective Action Plan Delinquent replacement reserve deposits of $31,456 for fiscal years 2023-2024 were made by August 22, 2025. The remaining delinquent deposits will be made as soon as funds are available. Delinquent paint reserve deposits of $3,000 for fiscal years 2024-2025 were made on June 18, 2025. The remaining delinquent deposits will be made as soon as funds are available. A recurring payable will be created to ensure future deposits are made timely. Anticipated Completion Date June 30, 2026 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL 62353 (217) 773-3325
Corrective Action Plan The Finance Director will create a calendar task to ensure that future surplus cash deposits are made timely. Anticipated Completion Date September 30, 2025 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL 62353 (217) 773-3325
Corrective Action Plan The Finance Director will create a calendar task to ensure that future surplus cash deposits are made timely. Anticipated Completion Date September 30, 2025 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL 62353 (217) 773-3325
Corrective Action Plan The delinquent deposits for fiscal year 2025 were made on 8/22/2025. A recurring payable will be created to ensure future deposits are made timely. Anticipated Completion Date August 22, 2025 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL ...
Corrective Action Plan The delinquent deposits for fiscal year 2025 were made on 8/22/2025. A recurring payable will be created to ensure future deposits are made timely. Anticipated Completion Date August 22, 2025 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL 62353 (217) 773-3325
Management will review its finance infrastructure and the related cost/benefit of hiring additional staff with the required expertise.
Management will review its finance infrastructure and the related cost/benefit of hiring additional staff with the required expertise.
Cognizant or Oversight Agency for Audit, Warren Village, Inc. respectfully submits the following corrective action plan for the year ended March 31 , 2025. Audit period: Ended March 31 , 2025 The findings from the 3/31/2025 schedule of findings and questioned costs are summarized below. The find ing...
Cognizant or Oversight Agency for Audit, Warren Village, Inc. respectfully submits the following corrective action plan for the year ended March 31 , 2025. Audit period: Ended March 31 , 2025 The findings from the 3/31/2025 schedule of findings and questioned costs are summarized below. The find ings are numbered consistently with the numbers assigned in the schedule. Financial Statement Audit Findings Material Weakness 2025-001: Adjusting Journal Entries Recommendation: Auditors recommend the Organization improve communication with the Partnership and the Partnership auditor to ensure all related Partnership transactions are recorded timely, accurately and within the appropriate period. Action Taken: Management will engage the Partnership auditor earlier in more thorough communication around audited financial statement details and reconciling entries in future years, beginning with the 2025 calendar year audit commencing March 2026. Management was challenged by the one-time, varying construction project and LIHTC partner deliverables, complex legal entity pieces, and shortage of review and financial integration time between audits. Responsible Party: Vice President of Strategy, Finance & Operations Anticipated Date of Completion: June 2026 Responsible Contact: Amy Fleming, 303-320-5050 or email afleming@warrenvillage.org . Federal Award Findings and Questioned Costs Elig ibility, Significant Deficiency 2025-002: U.S. Department of Housing and Urban Development - Section 8 - Housing Assistance Payments Program Assistance Listing No.14.195 Recommendation: Auditors recommend that the Organization confer with Property Management staff to examine selected tenant files from the transition of property management companies through the recertification period of all tenants up to July and August 2025 to ensure appropriate evidence is contained within all tenant files to support complete tenant certification and eligibility. Action Taken: We have discussed with property management a review of all tenant files fromJune 2024 to August 2025 and requested a third-party compliance company or equivalent experience be engaged. Corrections will be made where feasible along with ongoing process improvements, including the implementation of a new internal Housing Director position to provide greater oversight of files and property management accountability. The Housing Director was hired July 21, 2025, with a target date set of December 31, 2025, for completed file review. Responsible Party: Housing Director, Vice President of Strategy, Finance & Operations and Property Management (Rocky Mountain Communities) Anticipated Date of Completion: January 2026 Responsible Contact: Amy Fleming, 303-320-5050 or email afleming@warrenvillage.org If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Amy Fleming, Vice President of Strategy, Finance & Operations at 303-320-5050 or email at afleming@warrenvillage.org.
Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the securi...
Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the security deposit cash account to the former tenant. Action(s) taken or planned on the finding: The management agent refunded $407 to the former tenant on August 25, 2025.
View Audit 368134 Questioned Costs: $1
Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent will ...
Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent will reimburse $3,118 to the Corporation.
View Audit 368133 Questioned Costs: $1
2025-002. HUD Project loan made to other HUD Programs Corrective action planned: Trinidad Housing Authority is searching for other Accounting Services for the Housing Authority. We are currently working on a payment plan with payroll for Corazon Square and have started processing payments to Low Ren...
2025-002. HUD Project loan made to other HUD Programs Corrective action planned: Trinidad Housing Authority is searching for other Accounting Services for the Housing Authority. We are currently working on a payment plan with payroll for Corazon Square and have started processing payments to Low Rent. As we are moving forward in our search for accounting services, we will continue to pay equal amounts monthly to Low Rent. Contact person: Kathee Gutierrez Adams, Interim Executive Director. Anticipated completion date: Our goal is to be completely in compliance by end of fiscal year March 31, 2026.
HACM Management will sign all Capital Fund vouchers going forward.
HACM Management will sign all Capital Fund vouchers going forward.
The current Occupancy Specialist is developing a training and implementation plan to ensure that rent reasonableness calculations are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenan...
The current Occupancy Specialist is developing a training and implementation plan to ensure that rent reasonableness calculations are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of rent reasonableness calculations and other required paperwork is included in the tenant files.
The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant ...
The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of income from tenants and other required paperwork is included in the tenant files.
The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.
The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.
View Audit 366550 Questioned Costs: $1
Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the f...
Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the full amount was deposited, the delay constituted noncompliance with HUD's timing rules. To address this, management will implement procedures to ensure surplus cash deposits are made within 60 days based on unaudited computations, track and schedule deposits in advance, formally request HUD approval if deferrals are necessary, and maintain documentation of all related communications and approvals for compliance purposes. Actions Taken or Planned on the Findings: This was paid on check # 9841 Working on an implementation program for the future. Completion Date: August 25, 2025 Finding Resolution Status: In-Process Contact Person: Controller: Don Trigg Accountant: Charley Hinkle
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should incr...
FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was increased from $1,182,615 to $1 ,282,815 effective 6/1/2025 with annual insurance renewals to be above the minimum required threshold. The new process implemented will now assess the budgeted potential organizational revenue growth prospectively in the current fiscal year and any calculation increase required will be made prior to the end of the current fiscal year before the insurance renewal for the next fiscal year to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Completion date for corrective action plan: 06/01/2025 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Edward Forfa, Executive Director at 413-445-4056 ext. 160.
FINDING NUMBER 2025-001 Reporting views of responsible officials: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Auditors' summary of auditee's comments on the findings and recommendati...
FINDING NUMBER 2025-001 Reporting views of responsible officials: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Auditors' summary of auditee's comments on the findings and recommendations: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Response indicator: Agree. Response: The Company will work with the financial institutions to ensure that HUD’s requirements are followed. Completion date: September 30, 2025
Finding: We found one (1) instance where adequate documentation was not maintained to ensure the appropriate amount was charged to a patient based on the sliding fee policy in place. Upon further analysis, there were a total of four (4) instances where appropriate documentation was not maintained re...
Finding: We found one (1) instance where adequate documentation was not maintained to ensure the appropriate amount was charged to a patient based on the sliding fee policy in place. Upon further analysis, there were a total of four (4) instances where appropriate documentation was not maintained relating to fiscal year 2025. Uniform Guidance requires the Organization to be in compliance with special tests and provisions. This includes maintaining appropriate documentation of the application and fee determination for every patient utilizing the sliding fee discount. This is a repeat of finding 2024-003 from the prior year. One error was identified during our testing. Expanded procedures identified that the population impacted were four individuals. The amount of questioned costs cannot be determined. A sample of 40 individuals were selected and tested for compliance with the Organization's sliding fee policy. One (1) known compliance error was found during testing of the 40 individuals. Upon analyzing the entire population, it was determined that a total of four (4) files were not in compliance. The Organization was not in compliance with the requirements of the federal program due to a scanner malfunction where the application and supporting documentation were not adequately scanned, resulting in a corrupt file. Cause: Management has indicated that the scanner malfunction lead to the noncompliance. Upon the realization of the scanner issue, it was replaced and an analysis was performed for any other patient files that may have been corrupted. Management review of the entire population identified a total of (4) four files that were corrupt relating to fiscal year 2025. Corrective Response: Management is in agreement with the above analysis by the auditors. The issue was discovered and corrected with an update to the server and an update to the process to ensure that all scans are reviewed prior to the destruction of the original documents. This was fully resolved prior to the fiscal year end. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: CFO/Revenue Cycle Director/Director of Clinical Ops/Vice President of IT
The replacement reserve account was underfunded in the amount of $1,120 during the year ended May 31, 2025. Management will deposit the required amount into the replacement reserve and confirm all future required deposit increases are implemented.
The replacement reserve account was underfunded in the amount of $1,120 during the year ended May 31, 2025. Management will deposit the required amount into the replacement reserve and confirm all future required deposit increases are implemented.
View Audit 365848 Questioned Costs: $1
Total annual withdrawals made from the general operating reserve were in excess of 20% of prior year’s ending balance. Management will obtain approval from HUD for withdrawals made from the general operating reserve during the year ended May 31, 2025 in the amount of $24,741.
Total annual withdrawals made from the general operating reserve were in excess of 20% of prior year’s ending balance. Management will obtain approval from HUD for withdrawals made from the general operating reserve during the year ended May 31, 2025 in the amount of $24,741.
View Audit 365848 Questioned Costs: $1
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforc...
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforcement, including rent abatement. Further internal procedures implemented to ensure additional contractor oversight and postrepair audits to ensure that failed HQS inspections are remedied properly and timely. Responsible Party: Andrea Fink, Housing Programs & Services Manager Timeline: Full implementation of the CAP by 9/15/2025 This Corrective Action Plan has been reviewed and approved by: -;t((t ih= Rob L. Fredericks (Aug 20. 2025 10:00:43 PDT) Rob L. Fredericks Executive Director/CEO
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of ...
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of March 31, 2025, the physical inspection is closed. Action(s) taken or planned on the finding: Management has responded to HUD in regard to this inspection report and has addressed all exigent health and safety issues.
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