Corrective Action Plans

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Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residua...
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residual receipts deposit is made within 90 days of fiscal year end. Management response: Agree. Management made the required residual receipts deposit on January 8, 2025.
View Audit 365221 Questioned Costs: $1
Audit Finding 2025-002: The regulatory agreement stipulates that all withdrawals from the Reserve for Replacement Account be supported by invoices and payments as proof of amounts expended. An invoice of $1,707 was duplicated while calculating the funds to be withdrawn from the Reserve for Replacem...
Audit Finding 2025-002: The regulatory agreement stipulates that all withdrawals from the Reserve for Replacement Account be supported by invoices and payments as proof of amounts expended. An invoice of $1,707 was duplicated while calculating the funds to be withdrawn from the Reserve for Replacement account . Response: Management agrees with the finding and has refunded $1,707 to the Reserve for Replacement Account on August 12, 2025.
Audit Finding 2025-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. Several withdrawals totaling $108,111 for emergency repairs and improvements, to cover payroll, pay audit fees and for ...
Audit Finding 2025-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. Several withdrawals totaling $108,111 for emergency repairs and improvements, to cover payroll, pay audit fees and for other operating expenses were made from the Reserve for Replacement account without prior approval from the lender. Response: Management agrees with the finding, was aware of the requirement for prior approval and on April 30, 2025, and has obtained retroactive approval from the lender for the withdrawal of 108,111.
Audit Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months. -Response: Management believed that including this expenditure in its request for withdrawal of funds from the reserv...
Audit Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months. -Response: Management believed that including this expenditure in its request for withdrawal of funds from the reserve for replacement account was sufficient. Management also promptly replaced the funds taken temporarily from the residual receipts account, once they received the funds from the reserve for replacement account controlled by the lender. In the future, management will make sure to obtain prior approval from HUD before making any withdrawals from the residual receipts account.
Audit Finding 2025-001: During our testing of reserve for replacement account transactions, it was discovered that the Project had made deposits of an insufficient amount each month for 22 months through September 2024. -Response: The reserve for replacement account is controlled by the lender and ...
Audit Finding 2025-001: During our testing of reserve for replacement account transactions, it was discovered that the Project had made deposits of an insufficient amount each month for 22 months through September 2024. -Response: The reserve for replacement account is controlled by the lender and when the lender discovered the deficiency during the year ended May 31, 2025 a lumpsum amount was drafted from the Project's monthly payment to cover the shortfall. In future, Management will inform the lender of changes to the monthly required deposit to the reserve for replacement account made by HUD.
Finding No. 2025-001 Residual receipts deposit We agree. Condition: The residual cash surplus of $49,570 for the fiscal year ended March 31, 2024, was deposited into the Residual Receipts account approximately 12 months after the fiscal year-end, exceeding the 90-day HUD requirement. Cause: The dela...
Finding No. 2025-001 Residual receipts deposit We agree. Condition: The residual cash surplus of $49,570 for the fiscal year ended March 31, 2024, was deposited into the Residual Receipts account approximately 12 months after the fiscal year-end, exceeding the 90-day HUD requirement. Cause: The delay was due to a discrepancy in the Employer Identification Number (EIN) on file with the financial institution, which prevented the timely opening of the required account. Planned Corrective Actions: A formal review will be conducted within 30 days after the fiscal year-end to assess surplus cash status and initiate the deposit process. All communications and actions related to the residual receipt deposit will be documented and retained for audit purposes.
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, an...
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, and if there is a balance that cannot be repaid, a payment plan will be established. Working with fee accountants during this process monthly will ensure there are no balances remaining at year end.
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 reg...
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 regarding required reference year for financial data used in preparing HUD Form 52723. o Each year prior to submission of HUD form 52723, the Authority will review all relevant PIH notices regarding calculation of the Public Housing Operating Subsidy, will adhere to the most current requirements, and will update its internal control documents and procedures to ensure consistency with current HUD guidance. Specifically, formula income, audit costs, and PILOT will be based on the Financial Data Schedule defined by HUD.
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance cover...
2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance coverage is reviewed annually and adjusted as necessary to meet HUD requirements. Explanation of disagreement with audit finding: Management is in agreement with the finding. Prior to affiliating with Silverstone Living, the Foundation had a separate endorsement included in their Property Coverage policy that included increased crime coverage to comply with HUD requirements. After transferring coverage to Silverstone Living’s policies, the increased crime coverage did not get transferred over to keep the Foundation in compliance. Action taken in response to finding: The Foundation is actively working with its insurance provider to increase coverage to the required level. The revised policy is expected to be in place by July 31, 2025. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 31, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Janet Langlois at 603-589-4111.
U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed bel...
U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs – Major Federal Programs U.S. Department of Housing and Urban Development 2025-001 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: CLA recommends that management ensures the regulatory agreement is being followed by all parties involved, unless otherwise instructed by a HUD representative. Any communication regarding changes to the regulatory agreement should come directly from HUD. Explanation of disagreement with audit finding: Management is in agreement with the finding. They received miscommunication from Lument. Since the Foundation goes through Lument for HUD requests and approvals, management thought the communication they received from Lument was approved by HUD. As a result, management was under the impression that the residual receipts account was fully funded, and the deposit of surplus cash was not required. Action taken in response to finding: On July 18, 2025, management submitted a formal request to HUD to suspend deposits to the residual receipts fund. On July 21, 2025, HUD approved a suspension of deposits to the reserve as long as a balance of $640,856.81 is maintained. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 21, 2025.
The Organization should keep track of the monthly payments required as set by the annual form HUD-9250.
The Organization should keep track of the monthly payments required as set by the annual form HUD-9250.
The $4,945.78 has been transferred back into the reserve for replacement account. To ensure this will not happen again the Assistant Controller will review the Reserve for Replacement Request before sending to HUD.
The $4,945.78 has been transferred back into the reserve for replacement account. To ensure this will not happen again the Assistant Controller will review the Reserve for Replacement Request before sending to HUD.
View Audit 363992 Questioned Costs: $1
Finding 572937 (2025-002)
Significant Deficiency 2025
Deposits required by HUD were not made during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project enforce procedures that ensure deposits are made timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned i...
Deposits required by HUD were not made during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project enforce procedures that ensure deposits are made timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has made the missing deposit as of March 31, 2025. Name of the contact person responsible for corrective action: Laurie Rudman, Senior Vice President, CFO Planned completion date for corrective action plan: March 31, 2025
View Audit 363778 Questioned Costs: $1
Finding 572935 (2025-001)
Significant Deficiency 2025
The Project had not timely reviewed the bank reconciliations for July 2024. Recommendation: CLA Recommends the Project review bank reconciliations timely and formerly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to fin...
The Project had not timely reviewed the bank reconciliations for July 2024. Recommendation: CLA Recommends the Project review bank reconciliations timely and formerly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has retroactively reviewed all bank reconciliations that were not reviewed by the former management team as of March 31, 2025. Name of the contact person responsible for corrective action: Laurie Rudman, Senior Vice President, CFO Planned completion date for corrective action plan: March 31, 2025
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Freeport, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 A...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Freeport, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: March 31, 2025. The finding from the March 31, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number 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 AUDIT - FINDING 2025-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 The Project overpaid management fees to the management company. Recommendation: The management company should reimburse the Project for the $755 overpayment. Action Taken: The Project agrees with the finding. The management company will repay the overpaid management fee as soon as possible. If the Department of Housing and Urban Development has questions regarding this plan, please call Les Russo at 847-424-5601.
View Audit 363740 Questioned Costs: $1
Name of auditee: Friendship Manor Housing Development Fund Company, Inc. Project No.: 01411252 TIN: 20-8665840 Name of audit firm: EFPR Group, CPA, PLLC Period covered by audit: March 31, 2025 CAP prepared by: Andrea D. Mays President of the Managing Agent ADM Management Group, Inc. (716) 892-1799 C...
Name of auditee: Friendship Manor Housing Development Fund Company, Inc. Project No.: 01411252 TIN: 20-8665840 Name of audit firm: EFPR Group, CPA, PLLC Period covered by audit: March 31, 2025 CAP prepared by: Andrea D. Mays President of the Managing Agent ADM Management Group, Inc. (716) 892-1799 Current Findings on the Schedule of Findings and Questioned Costs and Recommendations (1) Finding 2025-001 Management will use the $42,926 of funds withdrawn from the reserves for replacements to payoff the loan acquired for the vehicle as originally intended.
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. The advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware...
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. The advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware that such an advance was not permitted to be made. Kane Financial Services was also unaware. The plan to correct it includes the following action steps: • Seeking approval from HUD for the $2.7M advance. • If the advance is not approved, then the repayment will occur by the organizations over an 18-month period beginning in October 2025. It is understood that such advances will not be made going forward without prior HUD approval. The contact information for oversight of the plan is: Susan Shain Executive Vice President of Finance, Kane Financial Services Email: Sshain@kanefs.com Phone: 561-223-4161 Sincerely, Susan Shain Executive Vice President of Finance Kane Financial Services
View Audit 363196 Questioned Costs: $1
Recommendation Management should establish additional procedures and monitor compliance with those procedures to ensure proper dissemination of EIV information in accordance with guidelines specified by HUD. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with th...
Recommendation Management should establish additional procedures and monitor compliance with those procedures to ensure proper dissemination of EIV information in accordance with guidelines specified by HUD. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and recommendation and will remind staff of the proper procedures for dissemination of EIV information.
Recommendation Management should enhance and strengthen procedures to ensure tenant income certifications are completed within 90 days of the tenant being entered into the HUD TRACS system. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and reco...
Recommendation Management should enhance and strengthen procedures to ensure tenant income certifications are completed within 90 days of the tenant being entered into the HUD TRACS system. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and recommendation and will ensure timely income verifications going forward.
Recommendation Management should establish additional procedures and monitor compliance with those procedures to ensure proper dissemination of EIV information in accordance with guidelines specified by HUD. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with th...
Recommendation Management should establish additional procedures and monitor compliance with those procedures to ensure proper dissemination of EIV information in accordance with guidelines specified by HUD. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and recommendation and will remind staff of the proper procedures for dissemination of EIV information.
Statement of condition 2025-001: During the year ended March 31, 2025, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included the same invoice as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate withdraw...
Statement of condition 2025-001: During the year ended March 31, 2025, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included the same invoice as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate withdrawal. Comments on the finding and each recommendation: Management should transfer $14,376 from the operating cash account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. On May 29, 2025, management transferred $14,376 from the operating cash account to the reserve for replacements account.
View Audit 362933 Questioned Costs: $1
Statement of Condition 2025-001 (Assistance Listing 14.157): The Property received a score of 49 on a physical inspection of the Property performed on June 17, 2024 by a representative of HUD. By reference, the NSPIRE inspection is included as a statement of condition. Recommendation: Management ...
Statement of Condition 2025-001 (Assistance Listing 14.157): The Property received a score of 49 on a physical inspection of the Property performed on June 17, 2024 by a representative of HUD. By reference, the NSPIRE inspection is included as a statement of condition. Recommendation: Management should ensure all necessary repairs have been made. Management should continue to conduct routine unit and general property inspections and deficiencies should be corrected in a timely manner. Management Response: Agree. Management has responded to HUD regarding this inspection report and has addressed all health and safety issues. On May 16, 2025, a new physical inspection was completed at the Property and received a passing score of 87.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Greeley II, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110, Minneapolis, MN 55426;...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Greeley II, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110, Minneapolis, MN 55426; Audit Period: March 31, 2025; The finding from the March 31, 2025 schedule of findings and questioned costs is discussed below. The finding is 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 AUDIT - DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT - FINDING 2025-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 For one of the tenant files tested, the Project did not include a move-out inspection report. Recommendation: Project personnel should be reminded that including proper documentation in the tenant files is an important step in tenant management. A move-out inspection form should be completed and included in the tenant file when a tenant vacates. Action Taken: The Project agrees with the finding. Project personnel have been reminded to be aware of the importance of including all necessary documenation in the tenant file. A copy of the move-out inspection report was obtained and placed in the file in May 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Ling Han at 651-757-3038.
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