Corrective Action Plans

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Finding 2025-003 Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles, E – Eligibility, and N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comments on Finding Auditee has not had time to evaluate Auditor’s finding. Corrective Act...
Finding 2025-003 Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles, E – Eligibility, and N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comments on Finding Auditee has not had time to evaluate Auditor’s finding. Corrective Action We will keep all required documentation in tenant files and establish processes and procedures to ensure compliance with the provisions in HUD Handbook 4350.3, HUD Handbook 4381.5, and the Regulatory Agreement. Anticipated Completion Date December 31, 2025
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to p...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended March 31, 2025. Responsible Party Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow our policies and procedures to ensure that our accounting records are kept accurate and complete, and a responsible official will review and sign off on the monthly financial statements. Anticipated Completion Date December 31, 2025
Planned corrective action: The Executive Director will draw down funds first prior to paying an invoice to a contractor for Capital Funds projects. This step has been added to the contracting checklist. In addition, the ED will only draw down one project at a time to eliminate confusion. There were ...
Planned corrective action: The Executive Director will draw down funds first prior to paying an invoice to a contractor for Capital Funds projects. This step has been added to the contracting checklist. In addition, the ED will only draw down one project at a time to eliminate confusion. There were 4 payments issued to a contractor at the time of the audit, but as of October 1, 2025, all draw downs will be done in accordance with the guidance provided in this finding.
2025-003 – Lack of Written Findings and Questioned Costs. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have b...
2025-003 – Lack of Written Findings and Questioned Costs. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have been developed, these policies have not yet been formally approved and adopted by the Village. As a result of this condition, the Village did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation. We recommend that the Village review and approve the draft policies as soon as practical, but no later than the end of fiscal year 2026. Corrective Action. The Village has prepared a policies and procedures manual for the federal grant programs, which will be approved by the Village Council before the end of fiscal year 2026. Responsible Person. Ross Wilson, Village Clerk/Treasurer. Anticipated Completion Date: February 2026.
2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were per...
2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were performed for vendors. As a result, there is no evidence that the Village verified whether these parties were suspended or debarred prior to entering covered transactions. Auditor Recommendation. We recommend that the Village retain evidence that SAM.gov exclusion checks are being completed for vendors to document that vendors are not suspended or debarred prior to entering covered transactions. Corrective Action. The Village will begin retaining documentation for its SAM.gov exclusion checks that it completes for vendors to verify whether these parties were suspended or debarred prior to entering covered transactions. Responsible Person. Ross Wilson, Village Clerk/Treasurer. Anticipated Completion Date: February 2026.
Finding 2025-007: Utility Allowance Housing Choice Voucher, 14.871 Material Weakness/Noncompliance Special Test and Provisions Repeat Finding 2024-005 I agree with this finding. MRI Happy Software completed their Utility Allowance Survey and was submitted to the GLRHA on September 4, 2025. These doc...
Finding 2025-007: Utility Allowance Housing Choice Voucher, 14.871 Material Weakness/Noncompliance Special Test and Provisions Repeat Finding 2024-005 I agree with this finding. MRI Happy Software completed their Utility Allowance Survey and was submitted to the GLRHA on September 4, 2025. These documents are currently under review. Estimated date of completion on or before December 31, 2025.
Finding 2025-006: HQS Quality Control Inspections Housing Choice Voucher, 14.871 Material Weakness/Noncompliance Special Test and Provisions Repeat Finding 2024-004 I agree with this finding. A system is now in place and the first round of HQS Inspections were already completed for the 2025-2026 aud...
Finding 2025-006: HQS Quality Control Inspections Housing Choice Voucher, 14.871 Material Weakness/Noncompliance Special Test and Provisions Repeat Finding 2024-004 I agree with this finding. A system is now in place and the first round of HQS Inspections were already completed for the 2025-2026 audit timeframe. - Completed
Finding 2025-005: HUD Depository Agreement Housing Choice Voucher Program 14.871 Material Weakness/Noncompliance – Special Tests and Provisions I agree with this finding. Due to unforeseen circumstances a new financial institute will sign a new GDA. Once this is complete documentation for HUD funds ...
Finding 2025-005: HUD Depository Agreement Housing Choice Voucher Program 14.871 Material Weakness/Noncompliance – Special Tests and Provisions I agree with this finding. Due to unforeseen circumstances a new financial institute will sign a new GDA. Once this is complete documentation for HUD funds to be deposited into the account will be completed and all other accounts will be closed. Estimated date of completion – December 31, 2025.
Finding 2025-004: Internal Control Structure Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2024-02 I agree with this finding. Continued steps will be taken to ensure no errors are made with extra effort and detail. – No esti...
Finding 2025-004: Internal Control Structure Housing Choice Voucher, 14.871 Material Weakness – Eligibility, Reporting and Special Tests and Provisions Repeat Finding 2024-02 I agree with this finding. Continued steps will be taken to ensure no errors are made with extra effort and detail. – No estimated date of completion
CORRECTIVE ACTION PLAN Finding 2025-001 – Reporting The District concurs with the finding 2025-001. Corrective Action: Moving forward, the District Treasurer will enter the monthly claims with the Food Service Director and will verify that the meal counts and the total claims are correct for both br...
CORRECTIVE ACTION PLAN Finding 2025-001 – Reporting The District concurs with the finding 2025-001. Corrective Action: Moving forward, the District Treasurer will enter the monthly claims with the Food Service Director and will verify that the meal counts and the total claims are correct for both breakfast and lunch. The anticipated completion date of the corrective action is September 29, 2025. Contact Person: Alicia D. Koster, Superintendent of Schools (518) 762-4611 akoster@johnstownschools.org
View Audit 370819 Questioned Costs: $1
Finding 2025-001: Material Weakness in Internal Control over Financial Reporting ● Condition: The Abbey did not consolidate subsidiaries in its financial statements. ● Criteria: Generally Accepted Accounting Principles (GAAP) require that all subsidiaries be consolidated into the parent Abbey's fina...
Finding 2025-001: Material Weakness in Internal Control over Financial Reporting ● Condition: The Abbey did not consolidate subsidiaries in its financial statements. ● Criteria: Generally Accepted Accounting Principles (GAAP) require that all subsidiaries be consolidated into the parent Abbey's financial statements. ● Cause: The Abbey lacked adequate internal controls to ensure all subsidiaries were identified and consolidated. ● Effect: The financial statements were materially misstated, as they did not include the financial position and results of operations of the subsidiary. Corrective Action Plan: ● Responsible Person: Right Reverend Gregory Boquet, O.S.B. ● Planned Action: We agree with the auditor’s finding that there is a material weakness in internal control over financial reporting due to the non-consolidation of subsidiaries. However, after careful consideration, management has decided not to implement the recommended procedures to consolidate the subsidiaries. ● Justification: Management believes that the current procedures are adequate, and that the non-consolidation of the subsidiaries does not materially affect the financial statements. The costs and resources required to implement the recommended procedures outweigh the benefits, given the subsidiaries’ minimal impact on the overall financial position and results of operations. We will continue to monitor the situation and reassess it if necessary. ● Anticipated Completion Date: Not applicable, as no changes will be made. Views of Responsible Officials: The Abbey disagrees with the finding. Management believes that the current procedures are adequate, and that the non-consolidation of the subsidiaries does not materially affect the financial statements. The Abbey will not implement the recommended procedures but will continue to monitor the situation and reassess if necessary.
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended February 28, 2025. Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Rental and Cooperative Housing (Section 221(d)(4)) Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will ensure that the accounts reconcile to source documents as part of our month-end closing process. Anticipated Completion Date August 31, 2025
Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. ...
Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. Anticipated Completion Date July 31, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completio...
Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completion Date July 1, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will contact HUD to discuss resolution of this matter within 30 days. Anticipated Completion Date September 30, 2025
Finding 2025-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will contact HUD to discuss resolution of this matter within 30 days. Anticipated Completion Date September 30, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will deposit $732 into the residual receipts account within 30-days. Anticipated Completion Date July 31, 2025
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will deposit $732 into the residual receipts account within 30-days. Anticipated Completion Date July 31, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and com...
Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and complete. Anticipated Completion Date September 30, 2025
Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made wi...
Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made without completed review of certified payrolls, staff acknowledges records kept did not provide adequate backup to verify these controls. Going forward, staff will not only be sure to keep copies of certified payrolls with related invoices, they will also maintain records that confirm invoices without certified payrolls did not include labor that is subject to Davis-Bacon wage requirements. These records will likely come in the form of detailed invoice cost breakdowns (showing absence of labor costs) or correspondence affirming no labor costs were included in the invoice. Contact person responsible for corrective action: Matthew Wallace Anticipated Completion Date: Immediately
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project complet...
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project completion to ensure that work was carried out in accordance with contract specifications had been implemented effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at both the beginning and end of the project are in the file. Staff has already set up either bi-weekly or monthly meetings (depending on project activity levels) to report on the status of ongoing projects. These meetings were intended to help staff keep current projects in line with the overall project budget (i.e. not obligating funds beyond what’s available). Using these same meetings to check project files for all necessary records will be an adjustment of negligible effort. In instances where there is a sizable gap between portions of a project (e.g. part of the project can’t be completed until spring) staff will consider closing out the completed portion of the project and completing a final inspection on the balance of the job at a later date. Contact person responsible for corrective action: Edwin Manninen, Matthew Wallace Anticipated Completion Date: Immediately
Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contac...
Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Finding Number: 2025-005 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corre...
Finding Number: 2025-005 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corrective Action: The Township will update the Grant Policy to include a requirement for dual review on all grant reporting. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Finding 2025-002 See response to finding 2025-001.
Finding 2025-002 See response to finding 2025-001.
View Audit 367580 Questioned Costs: $1
2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the sta...
2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the staff on the form, and process to review each application to ensure compliance with the approved policy. The following actions will be taken: 1. Develop a formal peer review form and process for reviewing sliding fee scale applications. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 11, 2025 2. Provide training to all billing staff for peer review process and forms. Implementation of the process after training. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 12, 2025 and September 1, 2025 3. Monitor for effectiveness. After completion of peer review, the two managers will review and provide feedback to each employee monthly. Billing staff will be responsible for completing reviews and feedback on process and form structure. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: September 18, 2025 4. Verify effectiveness. The CFO and Revenue Cycle Manager will conduct a random audit of the peer review forms and ensure compliance with the policy for slide applications and ensure the peer review forms are completed, signed and dated. Anticipated completion date: March 1, 2026 Contact person responsible for corrective action: Evan Condelario, CFO
In Finding 2025-001, it was reported that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing. In addition, one patient ...
In Finding 2025-001, it was reported that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing. In addition, one patient who qualified for a discount did not receive a discount. Management recognizes the importance of complying with federal sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, procedures will be established to ensure employees are trained to maintain the required documentation, including sliding fee applications, for sliding fee discounts provided. The Organization will establish procedures to ensure that selected patient records are reviewed by a supervisor on a periodic basis to ensure that the required documentation is properly maintained and that the patients receive the proper discount in accordance with the Organization’s policies.
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