Corrective Action Plans

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Corrective Action Plan: Management is in the process of working with HHS to renew the Provisional Rate agreements. The anticipation is that the agreement will be completed by the end of 2025. Anticipated Completion Date: December 31, 2025
Corrective Action Plan: Management is in the process of working with HHS to renew the Provisional Rate agreements. The anticipation is that the agreement will be completed by the end of 2025. Anticipated Completion Date: December 31, 2025
View Audit 369691 Questioned Costs: $1
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25
Corrective Action Plan - ACH payment not supported. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The PHA will review the ACH payment and obtain supporting documentation. Anticipated completion date - Within the next fiscal year.
Corrective Action Plan - ACH payment not supported. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The PHA will review the ACH payment and obtain supporting documentation. Anticipated completion date - Within the next fiscal year.
View Audit 369677 Questioned Costs: $1
FINDING 2024-001 – Reporting; Significant Deficiency in Internal Control Over Compliance and Noncompliance Condition and context: Supporting documentation for the quarterly financial reports required by the grant did not include documentation of a review process or filing could not be verified for t...
FINDING 2024-001 – Reporting; Significant Deficiency in Internal Control Over Compliance and Noncompliance Condition and context: Supporting documentation for the quarterly financial reports required by the grant did not include documentation of a review process or filing could not be verified for timely submission. We noted for two of the three reports selected; submission support was not retained by the client. The grantor confirmed submission of all required reports however, the date of submission could not be verified. As such, both reports were determined to have been submitted late. Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all quarterly reports. Calendar reminders will be added to the task list for the compiler of the report information as well as the reviewer/signer of the report. These reminders will be implemented in the work calendars of the employees responsible at the onset of the grant. Reports required by the grant must be submitted timely and must have two levels of documented review. The bookkeeper and project manager will compile the information needed for the grant. The project manager and executive director will review and sign off on the grant report prior to each reporting date. Additionally, report backup and proof of timely submission will be retained by the bookkeeper and project manager. Contact Persons: Phil Champlin – Executive Director Mary Pat Davoren – Bookkeeper
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a man...
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-010: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City H...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-010: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City Health Center, Inc. has already started the process to file the reports with HRSA to resolve this request
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-008: • Heart City Health Center, Inc. will improve its understanding on matching principles on federal grant programs to ensure proper compliance with future grants • Heart City Healt...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-008: • Heart City Health Center, Inc. will improve its understanding on matching principles on federal grant programs to ensure proper compliance with future grants • Heart City Health Center, Inc. started the discussion with HRSA on this funding and will continue to work with them on this funding
View Audit 369664 Questioned Costs: $1
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-007: • Heart City Health Center, Inc. will continue to improvement knowledge and understanding of grant requirements as / if new funding is received to avoid allocating unallowed expe...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-007: • Heart City Health Center, Inc. will continue to improvement knowledge and understanding of grant requirements as / if new funding is received to avoid allocating unallowed expenses to the grant reimbursement • Heart City Health Center, Inc. started the discussion with HRSA on this funding and will continue to work with them on this funding
View Audit 369664 Questioned Costs: $1
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-005: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-005: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then or in the incorrect grant period
View Audit 369664 Questioned Costs: $1
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-004: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-004: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then or in the incorrect grant period
View Audit 369664 Questioned Costs: $1
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-003: • Heart City Health Center, Inc. continues to focus on the preparation and review process around cost allocation to the multiple different funding sources to ensure no future dup...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-003: • Heart City Health Center, Inc. continues to focus on the preparation and review process around cost allocation to the multiple different funding sources to ensure no future duplication
View Audit 369664 Questioned Costs: $1
Lincoln County Clerk and Lincoln County Treasurer will review the fiscal report prepared by the third party administrator prior to its submission to the U.S. Treasury.
Lincoln County Clerk and Lincoln County Treasurer will review the fiscal report prepared by the third party administrator prior to its submission to the U.S. Treasury.
The Center has subsequently engaged with a third-party organization to help review the Center's monthly vouchers submitted for reimbursement to help ensure proper and timely vouchering.
The Center has subsequently engaged with a third-party organization to help review the Center's monthly vouchers submitted for reimbursement to help ensure proper and timely vouchering.
The Center is implementing reconciliations of the grant expenditures to the general ledger.
The Center is implementing reconciliations of the grant expenditures to the general ledger.
The Center has implemented time and effort reports in the subsequent year to properly substantiate each employee's time and effort spent on each grant.
The Center has implemented time and effort reports in the subsequent year to properly substantiate each employee's time and effort spent on each grant.
View Audit 369652 Questioned Costs: $1
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Cash Disbursements Recommendation: We recommend that the Commission review its policies and procedures in place to ensure that only allowable activities are associated with the usage of program funding allocations. Explanation of disagreement with...
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Cash Disbursements Recommendation: We recommend that the Commission review its policies and procedures in place to ensure that only allowable activities are associated with the usage of program funding allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The unallowable cash disbursement of $35.43 was promptly removed from the HCVP program and reallocated to the appropriate account. Additional cash disbursement samples were provided to the auditor for further testing to ensure compliance. Staff received training in allowable and unallowable administrative costs under the HCVP guidelines. To strengthen internal controls and prevent recurrence, a second-level review of accounting codes is now required for disbursements. Name(s) of the contact person(s) responsible for corrective action: Bei Hua, Chief Financial Officer Planned completion date for corrective action plan: October 2025 and ongoing If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Crystal Gorham at 443-518-7818 and Bei Hua at 443 518-7802 .
View Audit 369641 Questioned Costs: $1
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – HQS Enforcement Recommendation: We recommend the Commission review their abatement procedures to ensure any unit that has not met the HQS standards is properly abated in cases of inspection deficiencies associated with landlord fault, and to revie...
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – HQS Enforcement Recommendation: We recommend the Commission review their abatement procedures to ensure any unit that has not met the HQS standards is properly abated in cases of inspection deficiencies associated with landlord fault, and to review their procedures to enforce family obligations in cases of inspection deficiencies associated with tenant fault. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review the inspection report weekly, to send out abatement letters, warning letters, and/or proposed termination letters to ensure compliance with HQS inspections. HCHC staff updated the internal process to ensure that inspection abatement letters are being sent to all parties, and when the deficiencies are tenant-related, the families are sent a warning letter and/or termination letter for non-compliance. Name(s) of the contact person(s) responsible for corrective action: Crystal Gorham, Director of Rental Assistance Planned completion date for corrective action plan: November 2025, and ongoing
View Audit 369641 Questioned Costs: $1
U.S. Department of Housing and Urban Development 2024-001 Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Eligibility Recommendation: We recommend that the Commission review its procedures for collecting and recording third party income support and data, and to ensure that HAP calculations are ...
U.S. Department of Housing and Urban Development 2024-001 Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Eligibility Recommendation: We recommend that the Commission review its procedures for collecting and recording third party income support and data, and to ensure that HAP calculations are performed accurately. The Commission should ensure that staff involved in collection and recording of income support and data, and in performing related calculations, are properly informed of procedural changes and are provided with sufficient training. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HCHC staff have reviewed the HUD hierarchy of collecting documents and reviewed the Administrative Plan to ensure that all third-party income support and data are calculated correctly when determining household income. HCHC staff had a mandatory training to ensure that regulations, policies, and procedures are being followed. Name(s) of the contact person(s) responsible for corrective action: Crystal Gorham, Director of Rental Assistance Planned completion date for corrective action plan: April 2025
View Audit 369641 Questioned Costs: $1
Veterans Place of Washington Boulevard, Inc. submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Herbein + Company, Foster Plaza 10, 680 Andersen Drive, Suite 205, Pittsburgh, PA 15220 Audit period: Year ended Dec...
Veterans Place of Washington Boulevard, Inc. submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Herbein + Company, Foster Plaza 10, 680 Andersen Drive, Suite 205, Pittsburgh, PA 15220 Audit period: Year ended December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. Section III - Federal Award Findings and Questioned Costs 2024-001 MISSING DOCUMENTATION AND DUPLICATE INVOICE SUBMISSION - MATERIAL WEAKNESS Federal Program Economic Development Initiative, Community Project Funding and Miscellaneous Grants - ALN 14.251 Criteria In order to be allowable under federal awards, costs must meet general criteria, which includes adequate documentation. Under OMB guidance, Public Law (Pub. L) No. 116-117, Payments Integrity Information Act of 2019, and Executive Order 13520 on reducing improper payments, federal agencies are required to take actions to prevent improper payments, review federal awards for such payments, and as applicable, recover improper payments, including any duplicate payment. Condition While performing tests over activities allowed or unallowed and allowable costs/cost principles, we noted documentation for one invoice charged to the grant could not be located. As a result, we were unable to determine that the cost was allowable per the terms of the grant award. We also noted that a second invoice charged to the grant was submitted for reimbursement twice. Cause This is a new grant in the current year to cover the portion of the cost for a new building. While management submitted invoices to the Department of Housing and Urban Development for review and approval prior to reimbursement, they did not maintain a record of the costs submitted for each reimbursement request by either listing the invoices and amounts charged or other means. Effect The Organization was unable to provide documentation for one of the invoices charged to the program, and a second invoice was charged to the program twice. Questioned Costs $54,461 Context The grant was for a portion of construction costs with the difference coming from donations or other assets of Veterans Place of Washington Boulevard, Inc. In order to receive reimbursement for expenses, the Organization was required to submit invoices to the Department of Housing and Urban Development (HUD) for approval prior to uploading the invoices for reimbursement. The expenses in question were approved by HUD prior to requesting or receiving reimbursement. Furthermore, there were approximately $96,000 of construction costs that were incurred but not reimbursed by HUD that appear to meet the terms and conditions of the grant. Repeat Finding No Recommendation We recommend that detailed documentation of the costs submitted for reimbursement are maintained in a separate file so that costs charged to the program are easily identified. Management Response In the situation concerning our inability to identify invoices associated with a requested reimbursement, costs for a particular area were submitted for review and approval by HUD and the costs were not clearly attributed to one singular invoice but reflected as portions of the total invoice submitted by one vendor. In the future, when requesting reimbursement, costs will be more clearly indicated to a specific invoice and identified so they can be more easily tracked. In the case of a duplicate invoice, we typically checked against our records of paid invoices and in this case, our belief was that it was paid but not marked as submitted for reimbursement. In the future, invoices will be verified against both our record of paid invoices as well as a separate record of reimbursed invoices.
View Audit 369640 Questioned Costs: $1
Management agrees with the finding and in the summer of 2024, contracted with a third party accounting company to provide services.
Management agrees with the finding and in the summer of 2024, contracted with a third party accounting company to provide services.
View Audit 369638 Questioned Costs: $1
Management agrees with the finding and in the summer of 2024, contracted with an accounting company to provide services.
Management agrees with the finding and in the summer of 2024, contracted with an accounting company to provide services.
2024-003. Special Tests and Provisions United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: There were instances in which comparable rents for the area were not documented and maintained in tenant files. Recommendation: The Organization should im...
2024-003. Special Tests and Provisions United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: There were instances in which comparable rents for the area were not documented and maintained in tenant files. Recommendation: The Organization should implement procedures for supervisory review of documentation and approval for all tenant files to ensure reasonable rent charged is demonstrated. Corrective Action: The Organization will ensure written documentation is maintained in tenant files, to support that the grant funds to pay rent were used for reasonable rent in relation to comparable rent in the area. Responsible Contact Person(s): Louis Bamonte, Director of Finance Brighter Tomorrows, Inc., - P.O. Box 706 – Shirley, New York 11967 Anticipated Completion Date: December 31, 2025.
2024-001. Allowable Costs/Cost Principles United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 United States Department of Justice, Passed through New York State, Office of Victims Services Crime Victim Assistance ALN: 16.575 Condition: The Organization did...
2024-001. Allowable Costs/Cost Principles United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 United States Department of Justice, Passed through New York State, Office of Victims Services Crime Victim Assistance ALN: 16.575 Condition: The Organization did not have written policies referencing the Uniform Guidance requirements. Recommendation: The Organization should update their policies and procedures manual to ensure compliance with the procurement requirements at 2 CFR 200.317-327, and the impact of 24 CFR 578.103(c). Corrective Action: The Organization will update the written policies and procedures to comply with the Uniform Guidance requirements. Responsible Contact Person(s): Louis Bamonte, Director of Finance Brighter Tomorrows, Inc., - P.O. Box 706 – Shirley, New York 11967 Anticipated Completion Date: December 31, 2025.
An error was identified in the Excel spreadsheet (Model) used to allocate technology costs to projects where Coleridge is obligated to provide Administrative Data Research Facility (ADRF) services. The effect of this error was costs were under-allocated to projects. Corrective Action Plan: 1. The er...
An error was identified in the Excel spreadsheet (Model) used to allocate technology costs to projects where Coleridge is obligated to provide Administrative Data Research Facility (ADRF) services. The effect of this error was costs were under-allocated to projects. Corrective Action Plan: 1. The error in the Model has been corrected. 2. Control checks will be built into the Model to highlight when calculations are not working, or outputs fall outside expected ranges. 3. On a monthly basis, the Controller will review the Model and sign off in writing that the allocations are correct. No invoices will be released until the review and sign-off has been completed. 4. On an annual basis, an internal audit will be performed on the Model to validate that calculations are working as intended. The audit will be conducted by a member of the Finance department who is not a user of the Model. Any issues identified during the audit will be documented. The Controller will take action to remediate all issues and certify in writing when this work has been completed. No invoices will be released until the certification has been completed.
View Audit 369626 Questioned Costs: $1
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