Corrective Action Plans

Finding 485338 (2024-001)

Significant Deficiency 2024

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.

View Audit 317340

Finding 480389 (2024-001)

None 2024

West House Corporation

RI

HUD Housing Programs Internal Control / Segregation of Duties

Management has corrected the error.

View Audit 316621

Finding 480388 (2024-001)

None 2024

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

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

Finding 478293 (2024-003)

None 2024

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

Finding 478289 (2024-002)

None 2024

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

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

Finding 478281 (2024-002)

None 2024

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

Finding 403896 (2024-001)

Material Weakness 2024

Uncompahgre Combined Clinics Dba Uncompahgre Medical Center

CO

Internal Control / Segregation of Duties Subrecipient Monitoring

Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the...

Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization recognizes the deficiency of internal controls regarding determination, recording, and monitoring of the sliding fee process from application through adjustment. The Organization has acknowledged that along with our Finance Team being new to the position for all of 2023 along with the realization that our electronic medical record was making an automatic adjustment on the Federal Poverty Level. This automatic adjustment issue has been resolved. We also reviewed the monthly adjustments and have implemented a monthly oversight process to review adjustments made to patient accounts. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Tricia Lippert, Comptroller at 970-327-0537.

View Audit 310773

Finding 403361 (2024-001)

Significant Deficiency 2024

Ott's Branch Elderly Housing, Inc.

SC

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) tak...

Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation.

View Audit 310491 Questioned Costs: $1

Finding 403260 (2024-001)

Significant Deficiency 2024

Realife Cooperative of Bloomington

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 Cooperati...

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. Planned Completion Date: Not Applicable

View Audit 310433

Finding 395120 (2024-002)

None 2024

Church Street Estates Corp.

RI

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Management will correct the next voucher

View Audit 305045 Questioned Costs: $1

Finding 395119 (2024-001)

None 2024

Church Street Estates Corp.

RI

HUD Housing Programs Internal Control / Segregation of Duties

Management has corrected the errors

View Audit 305045

Finding 1218727 (2023-002)

Material Weakness 2023

Benton County

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles

The County has since implemented corrective actions to strengthen internal controls and ensure compliance moving forward, including: Providing targeted staff training on eligibility requirements, including self-attestation limitations. Implementing a secondary review process for eligibility determin...

The County has since implemented corrective actions to strengthen internal controls and ensure compliance moving forward, including: Providing targeted staff training on eligibility requirements, including self-attestation limitations. Implementing a secondary review process for eligibility determinations and payment calculations when clients self-certify income. Establishing ongoing monitoring procedures, including periodic file reviews. Benton County is committed to maintaining strong internal controls and ensuring compliance with all applicable federal and state requirements. These enhancements are designed to prevent recurrence and support consistent application of program guidelines.

View Audit 404788

Finding 1218280 (2023-008)

Material Weakness 2023

Lead Academy

AL

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, supporting documentation necessary to verify and document vendor payment was not available, resulting in the inability to obtain sufficient, appropriate audit evidence related to these amou...

Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, supporting documentation necessary to verify and document vendor payment was not available, resulting in the inability to obtain sufficient, appropriate audit evidence related to these amounts. During the testing of ESSER funds, there were 2 instances where the purchase order could not be located and one invoice that could not be located. Corrective Action: The school (LEAD Academy) contracted with New Schools for Alabama (NSFA) during 2023 to handle all their finance and accounting needs. By the end of 2023, the school also transitioned all payroll services to New Schools for Alabama. NSFA helped establish a purchase order procedure and worked with the school to make sure a purchase order or signed contract is in place prior to the purchase of goods and services. Additionally, approval on all invoices is required before NSFA processes them for payment, in order to verify that all goods and services have been received. Prior to 2024, proper procedures were not in place to maintain vendor files and accounts payable documentation. All financial records are now maintained digitally, with the original documents residing at the school. Additionally, NSFA worked with existing staff regarding proper documentation and filing of financial records and helped establish a new filing system. NSFA requires the school to indicate the source of funding for purchases, in order to know how to code the expenditure. We utilize monthly budget to actual reports to verify that expenditures are in line with the approved budget, ensuring that the correct coding has been used. We also ensure that only allowable expenditures are charged to federal funds, based on approved federal Egap applications and budgets.

View Audit 404529

Finding 1217894 (2023-006)

Material Weakness 2023

ARANSAS COUNTY NAVIGATION DISTRICT

TX

Reporting Internal Control / Segregation of Duties

Management acknowledges the need to strengthen system access controls and will review existing user roles and permissions, implement more restrictive controls over prior-period postings and establish periodic reviews of user access rights.

View Audit 403976

Finding 1217893 (2023-005)

Material Weakness 2023

ARANSAS COUNTY NAVIGATION DISTRICT

TX

Internal Control / Segregation of Duties

Management acknowledges the need to evaluate the current check signing and disbursement authorization structure and will consider incorporating governance-level participation and tiered approval thresholds to strengthen oversight.

View Audit 403976

Finding 1217892 (2023-004)

Material Weakness 2023

ARANSAS COUNTY NAVIGATION DISTRICT

TX

Reporting Internal Control / Segregation of Duties

Management acknowledges the need to strengthen internal controls over the calculation and reporting of TCDRS contributions. The District will implement enhanced review procedures to ensure consistency in the definition and application of eligible compensation and will improve reconciliation processe...

Management acknowledges the need to strengthen internal controls over the calculation and reporting of TCDRS contributions. The District will implement enhanced review procedures to ensure consistency in the definition and application of eligible compensation and will improve reconciliation processes between payroll records and TCDRS reporting.

View Audit 403976

Finding 1217890 (2023-002)

Material Weakness 2023

ARANSAS COUNTY NAVIGATION DISTRICT

TX

Procurement, Suspension & Debarment Subrecipient Monitoring Cash Management

Management acknowledges the need to strengthen internal controls surrounding the use of District credit cards. In 2024, the District implemented a requirement for the Harbor Master to review all credit card transactions prior to fulfillment of the combined credit card bill. Management is currently e...

Management acknowledges the need to strengthen internal controls surrounding the use of District credit cards. In 2024, the District implemented a requirement for the Harbor Master to review all credit card transactions prior to fulfillment of the combined credit card bill. Management is currently evaluating the form and function of a formalized credit card use agreement and related monitoring procedures.

View Audit 403976

Corrective Action Plans

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