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Corrective Action Plans

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I.c. Corporation T/a Seton Manor
VA
Special Tests & Provisions HUD Housing Programs Internal Control / Segregation of Duties
Management will take steps to remind the on-site property manager of the requirement and to ensure refunds are completed within the 30-day period.
Management will take steps to remind the on-site property manager of the requirement and to ensure refunds are completed within the 30-day period.
View Audit 319754
Finding 496969 (2024-003)
Significant Deficiency 2024
Northland Health Partners Community Health Center
ND
Significant Deficiency Internal Control / Segregation of Duties
Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of...
Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.
View Audit 319712
Elder Care Two, Inc.
RI
Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties
Management has corrected the error.
Management has corrected the error.
View Audit 319211 Questioned Costs: $1
Elder Care Two, Inc.
RI
HUD Housing Programs Internal Control / Segregation of Duties
Management has corrected the error.
Management has corrected the error.
View Audit 319211
Elder Care One, Inc.
RI
Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties
Management has corrected the error.
Management has corrected the error.
View Audit 319208 Questioned Costs: $1
Finding 485748 (2024-001)
Significant Deficiency 2024
Lockport Housing Authority
NY
Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs
Auditee Response: The Authority will not pay any invoices until the proper documentation of Davis Bacon wages being paid is received from the contractor. The Authority will then be ensured that future payments have the proper certified payroll.
Auditee Response: The Authority will not pay any invoices until the proper documentation of Davis Bacon wages being paid is received from the contractor. The Authority will then be ensured that future payments have the proper certified payroll.
View Audit 318581
Finding 485658 (2024-004)
Material Weakness 2024
Four Rivers Special Education District
IL
Internal Control / Segregation of Duties
CONDITION: The District's accounting function is controlled by a limited number of individuals resulting in the inadequate segregation of duties. RECOMMENDATION: The District should segregate duties where possible. The board should be aware of this problem and closely review and approve all financia...
CONDITION: The District's accounting function is controlled by a limited number of individuals resulting in the inadequate segregation of duties. RECOMMENDATION: The District should segregate duties where possible. The board should be aware of this problem and closely review and approve all financial related information. ACTION TAKEN: The District concus with the recommendation. The District has reviewed and continues to review its financial policies and procedures to better segregate duties where possible. The Director continually reminds the board of their responsibility in regards to reviewing and approving financial items and asking questions. It is not cost feasible to hire additional personnel. ANTICIPATED DATE OF COMPLETION: Ongoing.
View Audit 318470
Finding 485611 (2024-002)
Significant Deficiency 2024
Fulton County Community Unit School District No. 3
IL
Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management
Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.
Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.
View Audit 318383
Lincoln Christian University
IL
Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...
2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.
View Audit 318153
Lincoln Christian University
IL
Material Weakness Reporting Internal Control / Segregation of Duties
2024-001 Material Adjustments and Financial Statement Preparation Recommendation: We recommend that the University establish internal procedures to adjust all account balances at year-end and evaluate their internal staff capacity. Explanation of disagreement with audit finding: There is no disagr...
2024-001 Material Adjustments and Financial Statement Preparation Recommendation: We recommend that the University establish internal procedures to adjust all account balances at year-end and evaluate their internal staff capacity. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This was the final year in which Lincoln Christian University provided degree-earning education. These material entries and assistance with financial statement preparation are not expected in future years. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2025
View Audit 318153
Valley Family Health Care, Inc.
ID
Special Tests & Provisions Internal Control / Segregation of Duties
VALLEY FAMILY HEALTH CARE, INC. (VFHC) BELIEVES THE SIGNIFICANT DEFICIENCIES NOTED IN THE SCHEDULE OF FINDINGS AND QUESTIONED COSTS WERE A COMBINATION OF INSUFFICIENT USER TRAINING ISSUES, SYSTEM (EPIC) ISSUES AND INADEQUATE REVIEW AND INTERNAL AUDITING. TO ADDRESS THE SYSTEM ISSUES, WE HAVE REQ...
VALLEY FAMILY HEALTH CARE, INC. (VFHC) BELIEVES THE SIGNIFICANT DEFICIENCIES NOTED IN THE SCHEDULE OF FINDINGS AND QUESTIONED COSTS WERE A COMBINATION OF INSUFFICIENT USER TRAINING ISSUES, SYSTEM (EPIC) ISSUES AND INADEQUATE REVIEW AND INTERNAL AUDITING. TO ADDRESS THE SYSTEM ISSUES, WE HAVE REQUESTED VERIFICATION FROM OUR 3RD PARTY BILLING SYSTEM ON HOW THE EFFECTIVE AND EXPIRATION DATES ENTERED IN THE SYSTEM FOR THE FEDERAL POVERTY LEVEL (FPL) DATA IMPACT THE CALCULATION. IN ADDITION, IN DECEMBER OF 2023, VFHC IMPLEMENTED A NEW FEE SCHEDULE THAT INCREASED THE NUMBER OF SLIDING FEE DISCOUNTS THAT COULD BE AUTOMATICALLY CALCULATED BY THE SYSTEM, TO REMOVE THE OPPORTUNITY FOR USER ERROR. TO ADDRESS USER ERRORS, WE REINSTATED OUR FRONT OFFICE MANAGER POSITION RESPONSIBLE FOR TRAINING FRONT DESK STAFF WHO ASSIST PATIENTS WITH THE COMPLETION OF THE SLIDING FEE DISCOUNT APPLICATION. THE HANDBOOK AND TRAINING MATERIALS HAVE BEEN ENHANCED. IN ADDITION, WE ARE CREATING LOGIC IN THE EPIC SYSTEM TO IDENTIFY MISSING OR INCONSISTENT INFORMATION AND DIRECT THESE ISSUES TO A WORK QUE THAT WILL BE REVIEWED BY STAFF. WE ARE IMPLEMENTING AN INTERNAL AUDIT PROCESS OF THE SLIDING FEE DISCOUNTS. THE FRONT OFFICE MANAGER OR DESIGNEE WILL AUDIT A STATISTICALLY MEANINGFUL RANDOM SAMPLE OF NEW SLIDING FEE DISCOUNT APPLICATIONS FOR COMPLETENESS AND ACCURACY. IN ADDITION, WE WILL AUDIT A STATISTICALLY MEANINGFUL NUMBER OF PATIENT ACCOUNTS WHERE A SLIDING FEE DISCOUNT WAS TAKEN TO ENSURE THE ACCURACY OF THE CALCULATION. WE REVIEWED EACH OF THE AUDIT EXCEPTIONS AND DETERMINED THAT IN TWO OF THE FIVE INSTANCES; WE GAVE A LARGER DISCOUNT THAN THE PATIENT QUALIFIED FOR. WE WILL NOT MAKE ACCOUNT ADJUSTMENTS TO COLLECT. IN ONE INSTANCE, WE GAVE A SMALLER DISCOUNT BY $45.50 AND THE BILLING TEAM IS CORRECTING THIS ACCOUNT TO ISSUE A REFUND FOR THE ADDITIONAL DISCOUNT. IN ONE INSTANCE, NO SLIDING FEE DISCOUNT WAS GIVEN AND THE VERIFICATION RETAINED IN THE SYSTEM INDICATED THAT THIS WAS CORRECT. HOWEVER, IT IS POSSIBLE THAT HAD STAFF REQUESTED ADDITIONAL INCOME VERIFICATION; THE PATIENT MAY HAVE HAD A DIFFERENT FPL ASSIGNED. IN ONE INSTANCE, IT APPEARS THE APPROPRIATE SLIDE FEE DISCOUNT WAS APPLIED BUT THE SUPPORTING DOCUMENTATION WAS NOT RETAINED IN THE PATIENT CHART. VFHC TAKES THESE ISSUES VERY SERIOUSLY AND WILL BEGIN CORRECTIVE ACTIONS IMMEDIATELY. PROPOSED COMPLETION DATE: WE ANTICIPATE THESE ACTIONS TO BE COMPLETED BY THE END OF THE 3RD QUARTER.
View Audit 318111
Finding 485338 (2024-001)
Significant Deficiency 2024
Berkshire Retirement Home INC
MA
HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties
Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to e...
Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management 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 immediately increased from $1,135,927 to $1,182,615 to be above the minimum required threshold of $1,164,177 when identified. The new process implemented will assess potential organizational revenue growth ahead of insurance renewal to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Planned completion date for corrective action plan: 8/12/2024
View Audit 318084
Finding 485330 (2024-001)
Material Weakness 2024
Fetter Health Care Network, Inc.
SC
Special Tests & Provisions Internal Control / Segregation of Duties
In Finding 2024-001, it was reported that the Organization did not obtain and properly document all necessary elements required by the Organization’s sliding fee policy, resulting in sliding fee discounts that were not properly calculated for certain sliding fee patients. Management recognizes th...
In Finding 2024-001, it was reported that the Organization did not obtain and properly document all necessary elements required by the Organization’s sliding fee policy, resulting in sliding fee discounts that were not properly calculated for certain sliding fee patients. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee discount policy. In response to Finding 2024-001, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the Organization’s sliding fee policy.
View Audit 318078
Finding 485172 (2024-002)
Significant Deficiency 2024
Regis University
CO
Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.
View Audit 317977
Finding 485144 (2024-001)
Significant Deficiency 2024
East Central Kansas Economic Opportunity Corporation
KS
HUD Housing Programs Allowable Costs / Cost Principles Eligibility
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...
August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation
View Audit 317959
Finding 481217 (2023-001)
Material Weakness 2024
Community Workshop Residentials, INC G / Fha Project No. 072-Hd057
IL
Internal Control / Segregation of Duties HUD Housing Programs
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.
View Audit 317340
West House Corporation
RI
HUD Housing Programs Internal Control / Segregation of Duties
Management has corrected the error.
Management has corrected the error.
View Audit 316621
V. N. Housing Corporation
RI
HUD Housing Programs Internal Control / Segregation of Duties
Finding 2024-001: No verification of social security number (1 of 2 files); no evidence of prior applicant disposition on wait list (1 of 2 files); no EIV form (1 of 2 files). Management has corrected the errors. Responsible party: Diane Mogayzel, accounting supervisor, 401-739-0100
Finding 2024-001: No verification of social security number (1 of 2 files); no evidence of prior applicant disposition on wait list (1 of 2 files); no EIV form (1 of 2 files). Management has corrected the errors. Responsible party: Diane Mogayzel, accounting supervisor, 401-739-0100
View Audit 316620
Finding 479549 (2024-001)
Significant Deficiency 2024
Village Cooperative of Hutchinson
MN
Reporting Internal Control / Segregation of Duties
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Coopera...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles.
View Audit 316099
Epsom Elderly Housing, Inc.
NH
HUD Housing Programs Internal Control / Segregation of Duties
Plan: A procedure has been implemented to ensure that at least two people in the agency have EIV Coordinator level access. This guarantees that someone within the agency always has the ability to grant or remove staff permissions and to run EIV reports in compliance with HUD requirements. The final...
Plan: A procedure has been implemented to ensure that at least two people in the agency have EIV Coordinator level access. This guarantees that someone within the agency always has the ability to grant or remove staff permissions and to run EIV reports in compliance with HUD requirements. The final permission settings for the second coordinator are currently being verified and tested. Anticipated Completion Date: 07/31/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
View Audit 314973
Finding 478290 (2024-004)
Significant Deficiency 2024
Epsom Elderly Housing, Inc.
NH
HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
View Audit 314973
Epsom Elderly Housing, Inc.
NH
Eligibility HUD Housing Programs Internal Control / Segregation of Duties
Plan: A procedure will be implemented and documented to ensure that all tenant income and expenses are reviewed by a second individual to ensure accuracy. Anticipated Completion Date: 09/30/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
Plan: A procedure will be implemented and documented to ensure that all tenant income and expenses are reviewed by a second individual to ensure accuracy. Anticipated Completion Date: 09/30/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
View Audit 314973
Finding 478285 (2024-004)
Significant Deficiency 2024
Belmont Elderly Housing, Inc.
NH
HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...
Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
View Audit 314972
Belmont Elderly Housing, Inc.
NH
HUD Housing Programs Internal Control / Segregation of Duties
Plan: A procedure has been implemented to ensure that at least two people in the agency have EIV Coordinator level access. This guarantees that someone within the agency always has the ability to grant or remove staff permissions and to run EIV reports in compliance with HUD requirements. The final...
Plan: A procedure has been implemented to ensure that at least two people in the agency have EIV Coordinator level access. This guarantees that someone within the agency always has the ability to grant or remove staff permissions and to run EIV reports in compliance with HUD requirements. The final permission settings for the second coordinator are currently being verified and tested. Anticipated Completion Date: 07/31/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
View Audit 314972
Finding 477896 (2024-001)
Significant Deficiency 2024
Clinica Campesina Family Health Services
CO
Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.
View Audit 314530
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