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Corrective Action Plans

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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 Questioned Costs 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 Questioned Costs Special Tests & Provisions
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
Questioned Costs 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
Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking
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 Questioned Costs 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
Questioned Costs 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
Church Street Estates Corp.
RI
Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties
Management will correct the next voucher
Management will correct the next voucher
View Audit 305045 Questioned Costs: $1
Church Street Estates Corp.
RI
HUD Housing Programs Internal Control / Segregation of Duties
Management has corrected the errors
Management has corrected the errors
View Audit 305045
Finding 1236779 (2023-014)
Material Weakness 2023
US Helping Us, People Into Living, Inc.
DC
Subrecipient Monitoring Eligibility Reporting
o Develop a formal audit and compliance reporting calendar. o Identify all federal reporting deadlines and required submissions. o Assign responsibility for monitoring reporting deadlines. o Conduct periodic status meetings with finance staff and auditors. o Monitor audit progress regularly to ident...
o Develop a formal audit and compliance reporting calendar. o Identify all federal reporting deadlines and required submissions. o Assign responsibility for monitoring reporting deadlines. o Conduct periodic status meetings with finance staff and auditors. o Monitor audit progress regularly to identify and address delays. o Establish internal deadlines in advance of federal reporting due dates.
View Audit 412274
Finding 1236575 (2023-002)
Material Weakness 2023
COVATION CENTER INC
PA
Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles
Incomplete Documentation – Material Weakness Condition: During testing of the Center's activities, one (1) of the nine (9) disbursements selected for testing did not have an application checklist that was reviewed and approved prior to awarding and disbursement of funds. Corrective Action Planned: T...
Incomplete Documentation – Material Weakness Condition: During testing of the Center's activities, one (1) of the nine (9) disbursements selected for testing did not have an application checklist that was reviewed and approved prior to awarding and disbursement of funds. Corrective Action Planned: The Center will implement a standardized pre-disbursement checklist for all award applications, requiring that the checklist be fully completed, reviewed, and signed by an authorized reviewer before any funds are awarded or disbursed. No disbursement will be processed without a completed checklist on file. This step will be incorporated into the Center's written internal control procedures. Name(s) of Contact Person(s) Responsible for Corrective Action: Kendy Alvarez, Grant Program Manager; Stephanie Desaulniers, Executive Director Anticipated Completion Date: December 31, 2026
View Audit 412125
Finding 1236574 (2023-001)
Material Weakness 2023
COVATION CENTER INC
PA
Internal Control / Segregation of Duties Subrecipient Monitoring
Segregation of Duties – Material Weakness Condition: The responsibility for performance of certain accounting duties, principally as related to review and approval of the award application and eligibility criteria, was vested in a limited number of employees wherein there was also a familial relatio...
Segregation of Duties – Material Weakness Condition: The responsibility for performance of certain accounting duties, principally as related to review and approval of the award application and eligibility criteria, was vested in a limited number of employees wherein there was also a familial relationship amongst individuals overseeing the program, such that there was an overall lack of segregation of duties. Corrective Action Planned: Effective August 1, 2026, Covation Center completed a planned leadership transition: the Center's founder, who was previously involved in program oversight alongside a family member, has fully departed the organization and holds no ongoing role, formal or advisory, in the review or approval of CDBG program awards. Going forward, review and approval of grant applications and eligibility determinations will require sign-off from at least two unrelated individuals, with the Board of Directors (or a designated Board committee) providing independent oversight of program activity. The Center will formally document this approval workflow as part of its written program procedures (see response to Finding 2023-003). Name(s) of Contact Person(s) Responsible for Corrective Action: Stephanie Desaulniers, Executive Director; Covation Center Board of Directors Anticipated Completion Date: Implemented August 1, 2026; formal documentation of the workflow to be completed by December 31, 2026.
View Audit 412125
Finding 1230047 (2023-001)
Material Weakness 2023
Monterey County Business Council
CA
Cash Management Reporting Significant Deficiency
Finding Reference: 2023-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over rep...
Finding Reference: 2023-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of the Treasury, the Organization is required to submit the single audit to the Federal Audit Clearinghouse within 30 days of the issuance of the audit report or nine months after the end of the Organization’s fiscal year. During our reporting period we noted that the audit was not completed and filed timely. Cause: The Organization met the requirements for a single audit for the first time during the year ended December 31, 2023. Due to a lack of expertise in federal grant reporting requirements, the Organization overlooked the requirement to perform a single audit and file with the clearinghouse in a timely manner Corrective Action: In June 2025, Monterey County Business Council employed a CFO Consultant with 30+ years’ experience in finance and accounting who has performed a deep dive into the accounting framework. The Consultant has been engaged to assist the Organization in completing financial and single audits for the years ended December 31, 2022, 2023, and 2024. It is expected that the Organization will be caught up with federal clearinghouse filings by the end of 2025 or early 2026 at the latest. Under the consultant’s guidance, the Organization has made progress in financial reporting and will be filing the 2023 audit by September 30, 2026. Audits for subsequent years will be audited thereafter. Name of Responsible Person: Chris Steinbruner, CPA Questioned Cost: None Chris Steinbruner, CPA MCBC Board Member (831)-222-6111
View Audit 411327
Finding 1229674 (2023-012)
Material Weakness 2023
Municipality of Anchorage, Alaska
AK
Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.512
Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun strengthening year-end financial reporting and audit planning through formal close schedules, defined responsibilities, milestone...
Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun strengthening year-end financial reporting and audit planning through formal close schedules, defined responsibilities, milestone tracking, enhanced interdepartmental coordination, and increased management oversight to support the timely completion of future Federal Single Audits. Management will evaluate the effectiveness of these improvements through completion of a full audit cycle. Anticipated Completion Date June 30, 2027
View Audit 410871
Finding 1229593 (2023-009)
Material Weakness 2023
Municipality of Anchorage, Alaska
AK
Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303
Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing an enterprise-wide corrective action strategy to strengthen grant administration and reporting processes. Corrective actions include developing...
Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing an enterprise-wide corrective action strategy to strengthen grant administration and reporting processes. Corrective actions include developing standardized policies and procedures, formalizing documentation and supervisory review requirements, improving subrecipient monitoring, strengthening cross-departmental coordination, and incorporating these processes into formal year-end close and audit planning activities. Management will evaluate the effectiveness of these controls through completion of a full audit cycle. Anticipated Completion Date March 31, 2027
View Audit 410871
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