Corrective Action Plans

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2025-001 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documenta...
2025-001 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing
2025-001 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documenta...
2025-001 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing
2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documenta...
2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing
2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documenta...
2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing
2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documenta...
2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing
2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documenta...
2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing
Jeff Cottingham, Management agent, and Diane Theesfeld, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Jeff Cottingham, Management agent, and Diane Theesfeld, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Client Response: Since the identification of this in August 2025, our Clinical Manager has reviewed and audited every slide fee patient's information on a monthly basis. Additionally, the individual who has applied the majority of the incorrect discounts is no longer with the organization. Since thi...
Client Response: Since the identification of this in August 2025, our Clinical Manager has reviewed and audited every slide fee patient's information on a monthly basis. Additionally, the individual who has applied the majority of the incorrect discounts is no longer with the organization. Since this was also a finding from last year's audit, FY'23-24, as outlined in 2024-4 (pg.28), moving forward, our CFO will be handling the creation of the Slide Fee scale and will work with management and the Consultants to automate the system so errors rarely occur.
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the...
Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The board of directors will continue to closely monitor the financial operations of the Project. Name(s) of the contact person(s) responsible for corrective action: Mary Gilberts, Management Agent Planned completion date for corrective action plan: June 2026
Condition: Expenditure repots for the IDEA Cluster was not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the dued dates. Management response: Management will take th...
Condition: Expenditure repots for the IDEA Cluster was not filed in a timely manner. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the dued dates. Management response: Management will take the necessary steps to file all quarterly expenditure reports on time in the future. Anticipated date of completion: June 30, 2026.
Finding Number: 2025-001 Condition: Withdrawals totaling $13,846 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Mana...
Finding Number: 2025-001 Condition: Withdrawals totaling $13,846 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management has deposited the underfunded amount of $13,846 to the replacement reserve account on July 10, 2025. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: July 10, 2025
Finding Number: 2025-001 Condition: The Organization accrued for and expensed an invoice for professional service fees incurred by another project. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls to e...
Finding Number: 2025-001 Condition: The Organization accrued for and expensed an invoice for professional service fees incurred by another project. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls to ensure the invoice approval process is adequate for professional fees to ensure expenses are charged to the project that incurred the cost. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: June 30, 2025
Finding Number: 2025-002 Condition: During testing of tenant files, it was noted that the EIV report was missing for one tenant. Planned Corrective Action: Management has acknowledged the noncompliance and related internal control deficiency over compliance and will implement proper procedures and c...
Finding Number: 2025-002 Condition: During testing of tenant files, it was noted that the EIV report was missing for one tenant. Planned Corrective Action: Management has acknowledged the noncompliance and related internal control deficiency over compliance and will implement proper procedures and controls to ensure EIV is properly utilized. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: June 30, 2026
Finding Number: 2025-001 Condition: The Organization paid for expenses and an invoice for professional service fees incurred by another project. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over co...
Finding Number: 2025-001 Condition: The Organization paid for expenses and an invoice for professional service fees incurred by another project. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management received reimbursement from the other project on September 8, 2025. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: September 8, 2025
Finding Number: 2025-001 Condition: Withdrawals totaling $8,603 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Manag...
Finding Number: 2025-001 Condition: Withdrawals totaling $8,603 were made from the replacement reserve without HUD authorization. Planned Corrective Action: Management has acknowledged noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management has deposited the underfunded amount of $8,603 to the replacement reserve account on September 3, 2025. Contact person responsible for corrective action: Tyler Luce Anticipated Completion Date: September 3, 2025
Management shall establish and maintain procedures within its federal grants policy to ensure compliance with all applicable federal reporting requirements, including the timely, accurate, and complete submission of required reports.
Management shall establish and maintain procedures within its federal grants policy to ensure compliance with all applicable federal reporting requirements, including the timely, accurate, and complete submission of required reports.
Recommendation: We recommend that the District implement procedures and controls to ensure that only eligible students are included on the MARSS listing. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The ...
Recommendation: We recommend that the District implement procedures and controls to ensure that only eligible students are included on the MARSS listing. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure that only eligible students are included on the MARSS listing. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
Recommendation: We recommend that the District implement procedures and controls to ensure the journal entries are accurate before posting. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will ...
Recommendation: We recommend that the District implement procedures and controls to ensure the journal entries are accurate before posting. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on implementing procedures and controls to ensure all journal entries are reviewed and accurate before posting. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
Recommendation: We recommend that the District implement procedures and controls to ensure that all paper applications are being reviewed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will c...
Recommendation: We recommend that the District implement procedures and controls to ensure that all paper applications are being reviewed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure that all paper applications are being reviewed. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.
We agree with the auditor's comments, and the following actions will be taken to ensure official written documentation is obtained for a student enrolled in another school or in an educational program before removing the student from the graduation cohort: 1. Annual training to school office staff a...
We agree with the auditor's comments, and the following actions will be taken to ensure official written documentation is obtained for a student enrolled in another school or in an educational program before removing the student from the graduation cohort: 1. Annual training to school office staff at the August enrollment and attendance meeting provided by the Attendance Accounting Analyst. 2. Additional reminder training was provided to all school office staff on December 4, 2025 and December 5, 2025. 3. The policies and procedures related to the training are on a shared drive to be accessed at any time. Please reach out to us with any questions.
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Center's reserve account is fully funded per the requirements of the loan resoluti...
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Center's reserve account is fully funded per the requirements of the loan resolution security agreement. However, there is no documented secondary monitoring of the reserve balance as compared to the required minimum reserve balance. Responsible Individuals: Crystal Richter, Interim CFO Corrective Action Plan: Hired an Accountant July 2025. Management will ensure there are multiple people involved and overseeing the reserve balance and documentation will be retained review and approval over the reserve balance. Anticipated Completion Date: December 2025
Management's Response/Planned Corrective Action: The Organization's Director overseeing these programs will provide training to staff on policies. The Organization has recently implemented internal chart audits to aid in verifying compliance with funder regulations and identifying any deficiency in ...
Management's Response/Planned Corrective Action: The Organization's Director overseeing these programs will provide training to staff on policies. The Organization has recently implemented internal chart audits to aid in verifying compliance with funder regulations and identifying any deficiency in supporting document retention and will continue this practice going forward.
2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurr...
2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurred before the Federal award was made that were authorized by the Federal awarding agency or pass-through entity. All financial obligations incurred under the Federal award must be liquidated within the required time period. Costs incurred outside the approved period of performance are unallowable and constitute questioned costs. Client’s Response: During the grant cycle, the Organization submitted for an extension but did not receive confirmation of said extension. During the current fiscal year, the Organization has implemented additional controls to ensure that all grant funding is expended within the timeframe allotted. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444
Contact Person – Superintendent, Dr. Erich Heise Corrective Action Plan – Will establish policy to ensure payrolls are submitted a week after the week of work is performed. Completion Date – Ongoing
Contact Person – Superintendent, Dr. Erich Heise Corrective Action Plan – Will establish policy to ensure payrolls are submitted a week after the week of work is performed. Completion Date – Ongoing
HHC has reviewed our process for reporting appropriate charges for each CPT code on bills to all third-party payors and found that in isolated cases, the EPIC system was reporting the Sliding Fee Discount Fee on the bill and not the charge from our Fee Schedule for selected CPT codes. HC will collab...
HHC has reviewed our process for reporting appropriate charges for each CPT code on bills to all third-party payors and found that in isolated cases, the EPIC system was reporting the Sliding Fee Discount Fee on the bill and not the charge from our Fee Schedule for selected CPT codes. HC will collaborate with our EPIC partner- UPMC- to identify why the bills are not appropriately reflecting the CPT code fees from our Fee Schedule instead of the Sliding Fee Discount Fee. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements. HHC has reviewed our Sliding Fee Discount Policy and determined that there are areas that require revision. There should not be any patients that are given a sliding fee discount based on their self-declaration of income and then continue to receive care without the provision of income verification. HHC is in the process of a total review of our Sliding Fee Discount Policy/Process/Application and will make appropriate adjustments to ensure compliance with the HRSA Sliding Fee Discount Requirements. HHC will replace our One-Time Sliding Fee process with a more compliant approach that will involve: Self-Declaration of Income, whereby the patient will provide us with the income and family size without the required supporting documentation and the appropriate sliding fee will be applied for that visit only, and all future visits will be considered a full fee patient until the patient provides the appropriate support for income and family size; All patients will be requested to provide their income and family size. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements. HHC has reviewed the claim in question and has no explanation as to why the income reported for a patient was different than the supporting income documents provided by the patient. HHC recognizes that this occurred in only one of forty patient samples. HHC will ensure that all employees that are involved with the Sliding Fee Discount program are re-trained on the importance of accurately reporting the patient’s income based on the supporting documentation provided by the patient. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements.
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