Corrective Action Plans

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CORRECTIVE ACTION PLAN Finding 2024-001 Name of Contact Person – Tammy Krei, Director of Housing & Neighborhood Development Corrective Action Effective immediately, the Housing & Neighborhood Development (HND) Department will establish controls and procedures to allow for proper reporting and submis...
CORRECTIVE ACTION PLAN Finding 2024-001 Name of Contact Person – Tammy Krei, Director of Housing & Neighborhood Development Corrective Action Effective immediately, the Housing & Neighborhood Development (HND) Department will establish controls and procedures to allow for proper reporting and submission of the required CDBG Annual Formula Grants PR28 Performance and Evaluation (PER) Financial Summary Report. Proposed Completion Date: October 2024
8/26/2024 Sun Life Family Health Center, Inc. Responsible Party: Samantha Reinhard, Director of Community Outreach, sam.reinhard@slfhc.org Audit Period Ending: May 31, 2024 Finding #2024-002 Statement of Condition - Patients did not receive the proper sliding fee adjustments under the Organization’s...
8/26/2024 Sun Life Family Health Center, Inc. Responsible Party: Samantha Reinhard, Director of Community Outreach, sam.reinhard@slfhc.org Audit Period Ending: May 31, 2024 Finding #2024-002 Statement of Condition - Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Management Plan - The Organization concurs with the finding and management has implemented procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. The Director of Community Outreach will ensure review of all new sliding fee applications monthly to ensure data input accuracy. The Director of Revenue Cycle will conduct quarterly audits of sliding fee claims to ensure the adjustments are applied correctly by the billing department. Plan has been implemented during fiscal year 2025.
CORRECTIVE ACTION PLAN September 30, 2024 United States Department of Housing and Urban Development Mercer County Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Maher Duessel, CPA...
CORRECTIVE ACTION PLAN September 30, 2024 United States Department of Housing and Urban Development Mercer County Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Maher Duessel, CPA's 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: July 1, 2023 - June 30, 2024 The finding from the June 30, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS— FEDERAL AWARD PROGRAMS AUDITS Finding 2024-001 Section 8 Project-Based Cluster: Project Based Rental Assistance ALN # 14.195 Recommendation: The Company should follow the internal controls in place to ensure the accuracy of the application information entered into the tenant management system in order to ensure correct placement on the waiting list. Action taken: Management agrees with the finding, and as noted, has taken action to address the issue. Additional steps to prevent the issue from reoccurring are as follows: The Receptionist im-puts the applicant information in the system as well date and time stamps the application. When given to the Leasing Agent, she will revery the dates in the system match the application. Two-person verification before the application is filed away.
View Audit 324143 Questioned Costs: $1
Statement of condition #2024-001: During the year ended June 30, 2024, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included two of the same invoices as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate ...
Statement of condition #2024-001: During the year ended June 30, 2024, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included two of the same invoices as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate withdrawal. Comment on Finding and Recommendation: Management should transfer $4,613 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management deposited $4,613 into the reserve for replacements fund on September 18, 2024.
View Audit 324026 Questioned Costs: $1
Name of auditee: Moreno Valley Senior Housing, Inc. HUD auditee identification number: 143-EE037-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Anne Sackrison Position: Chief Executive Officer Telephone number: 586...
Name of auditee: Moreno Valley Senior Housing, Inc. HUD auditee identification number: 143-EE037-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Anne Sackrison Position: Chief Executive Officer Telephone number: 586-753-9052 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding #2024-001: Effective December 1, 2023, the required monthly deposit to the reserve for replacements is $8,215; however, the Corporation did not make the monthly deposits when two months of the replacement reserve deposits were returned by the bank. As of June 30, 2024, the reserve for replacements is underfunded by $16,430. Comments on the Finding and Each Recommendation: Management should transfer $16,430 from the operating account in order to bring the reserve for replacements current. Action(s) taken or planned on the finding: Agreed. Management made a deposit to the reserve for replacement on July 29, 2024 for $16,430.
View Audit 324006 Questioned Costs: $1
Comments on the Finding and Each Recommendation: The Corporation did not make the total required reserve for replacement deposits during the year ended June 30, 2024. Additionally, the required monthly deposits for the period from August 1, 2022 through June 30, 2023 were not made in the amounts spe...
Comments on the Finding and Each Recommendation: The Corporation did not make the total required reserve for replacement deposits during the year ended June 30, 2024. Additionally, the required monthly deposits for the period from August 1, 2022 through June 30, 2023 were not made in the amounts specified by HUD which resulted in the reserve for replacements account being underfunded by $623 as of June 30, 2024. The management agent should transfer funds of $623 from the operating account in order to bring the reserve for replacements account to current, and confirm with HUD monthly reserve for replacements deposits requirements at least annually. Action(s) taken or planned on the finding Management agrees with the recommendation. Management transferred $623 from the operating account to the reserve for replacements account on September 25, 2024. No further action is required.
View Audit 323965 Questioned Costs: $1
Comments on the Finding and Each Recommendation: The Corporation's required deposit into the residual receipts account of $41,019 per the June 30, 2023 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Management should make all...
Comments on the Finding and Each Recommendation: The Corporation's required deposit into the residual receipts account of $41,019 per the June 30, 2023 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Management should make all required residual receipts deposits per the annual Computation of Surplus Cash, Distributions and Residual Receipts within 90 days after the fiscal year end. Action(s) taken or planned on the finding Management agrees with the recommendation. Management deposited $41,019 into the residual receipts fund on October 30, 2023. No further action is required.
View Audit 323965 Questioned Costs: $1
Comments on the Finding and Each Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2024, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical ...
Comments on the Finding and Each Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2024, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical default on the Flexible Subsidy Loan. Management should continue communicating with HUD in order to obtain approval for the deferment request for the Section 201 Flexible Subsidy Loan. Action(s) taken or planned on the finding Management agrees with the recommendation. Management has submitted a request for deferment of the Flexible Subsidy Loan. Management is awaiting HUD approval of the deferment request.
Name of auditee: Abbeville County Council on Aging Housing Committee HUD auditee identification number: 054-11077 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Deborah Nunn Position: Treasurer Telephone number: (336)...
Name of auditee: Abbeville County Council on Aging Housing Committee HUD auditee identification number: 054-11077 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Deborah Nunn Position: Treasurer Telephone number: (336) 808-1276 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition #2024-001 (CFDA No. 14.155): Comments on the Finding and Each Recommendation: During the year ended June 30, 2024, the Corporation paid entity expenses of $1,088 out of operating activities. The Corporation should consider surplus cash restrictions and ensure terms of the Regulatory Agreement are followed. The management agent should request $1,088 from the residual receipts account. Action(s) taken or planned on the finding: Agree. Management agrees with the finding and concurs with auditor's recommendation. The management agent will request funds from the residual receipts account.
View Audit 323964 Questioned Costs: $1
Condition: The School District does not currently have a control in place whereby a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in an incorrect reporting of the number of free and reduced priced meals, which could result in the Sch...
Condition: The School District does not currently have a control in place whereby a review of the meal counts entered into the Michigan Nutrition Data (MiND) system takes place, which could result in an incorrect reporting of the number of free and reduced priced meals, which could result in the School District being reimbursed an incorrect amount by the Michigan Department of Education. Planned Corrective Action: The Business Office has implemented a formalized internal control procedure for the Food Service Department to adhere, alongside performing a thorough review of the monthly claims reimbursement submission. The formalized internal control procedure will accompany the supporting documentation submitted to the Business Office monthly (Attachment A). The procedure involves a review of inputted meal counts, prior to the claim submission. The Food Service Department Administrator responsible for meal claim input will provide corroboration of input accuracy, as documented by signoff from a secondary reviewer. In addition, the Business Office has prepared a Meal Claim Check Tool spreadsheet to utilize, on a monthly basis, as another layer of validation. The Meal Claim Check Tool spreadsheet allows the Business Office to input meal count figures from the Food Service POS system report and compare against the figures from the claims submission report. Any discrepancy identified would be immediately addressed with the Food Service Department and would require an amended claim submission. Contact person responsible for corrective action: Danielle Jacobs, Director of Business Services Anticipated Completion Date: 08/01/2024
View Audit 323903 Questioned Costs: $1
Finding 501793 (2024-002)
Significant Deficiency 2024
Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063,84.268 Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements and is formally implemented. Explanation of disagreement with audit f...
Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063,84.268 Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements and is formally implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Augsburg University will update its Written Information Security Program to: • Include a risk management section describing how Augsburg is identifying, assessing, and communicating risks. • Identify the use of multi-factor authentication for individuals accessing sensitive information across systems. • Define the procedures to in place to securely dispose of sensitive information. • Document procedures to monitor and log activity of authorized users and detect unauthorized activity. • Document the process for performing annual penetration tests and annual vulnerability assessments. Names of the contact persons responsible for corrective action: Scott Krajewski Planned completion date for corrective action plan: May 31, 2025
Finding 501787 (2024-001)
Significant Deficiency 2024
Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreeme...
Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student Financial Services is working with the Registrar and IT to review the current reporting system. Adjustments will be made to reporting process to ensure accurate and timely reporting of students’ enrollment status to NSLDS. Names of the contact persons responsible for corrective action: Amanda Burgess Planned completion date for corrective action plan: May 31, 2025
The Chief School Business Official (CSBO) will pay closer attention to detail to avoid this type of error in the future by double checking his/her entry into the ISBE Expenditure Reporting program. See full Corrective Action Plan included in the audit report.
The Chief School Business Official (CSBO) will pay closer attention to detail to avoid this type of error in the future by double checking his/her entry into the ISBE Expenditure Reporting program. See full Corrective Action Plan included in the audit report.
View Audit 323867 Questioned Costs: $1
The Chief School Business Official (CSBO) will pay closer attention to detail to avoid this type of error in the future by double checking his/her entry into the ISBE Expenditure Reporting program. See full Corrective Action Plan included in the audit report.
The Chief School Business Official (CSBO) will pay closer attention to detail to avoid this type of error in the future by double checking his/her entry into the ISBE Expenditure Reporting program. See full Corrective Action Plan included in the audit report.
View Audit 323867 Questioned Costs: $1
2024-001 Replacement Reserve Deposits 14.571 Supportive Housing for the Elderly Responsible Official Ellen Mason, Executive Director Plan Detail During December 2023, the Organization formerly requested an increase in rents from HUD in order for the rents to be more consistent with approved rents in...
2024-001 Replacement Reserve Deposits 14.571 Supportive Housing for the Elderly Responsible Official Ellen Mason, Executive Director Plan Detail During December 2023, the Organization formerly requested an increase in rents from HUD in order for the rents to be more consistent with approved rents in the area, as well as increase the rents based on the Project’s budget. This increase in rental income will help the Organization fund its annual budget and required deposits to the replacement reserve. Anticipated Completion Date: October 2024.
Finding #2024-002 – Material Weakness and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Family Planning Services, Assistance Listing #93.217, Contract Number: FPHPA006521-02-00, Contract Year: 04/01/23 – 03/31/24. Condition and context: The find...
Finding #2024-002 – Material Weakness and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Family Planning Services, Assistance Listing #93.217, Contract Number: FPHPA006521-02-00, Contract Year: 04/01/23 – 03/31/24. Condition and context: The finding reported as finding #2024-001 includes adjustments for the year ended March 31, 2024 to increase federal expenditures by $220,388. Recommendation: See finding #2024-001. Planned corrective action: WHFPT will strengthen its policies and procedures by documenting the subrecipient reconciliation process in greater detail and will add a requirement for additional reviews. Responsible officer: Kathie Nixon, CEO. Estimated completion date: October 31, 2024
Assistance Listing No.: 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects - Section 207/223f Corrective Action Plan: In response to the findings regarding unsigned documents, we confirm that we have made multiple attempts to have tenant sign the HUD r...
Assistance Listing No.: 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects - Section 207/223f Corrective Action Plan: In response to the findings regarding unsigned documents, we confirm that we have made multiple attempts to have tenant sign the HUD required documents such as the Recertification Verification, Asset Verification, Enterprise Income Verification (EIV) and Notice and Consent for the Release of the Tenant's Information (HUD 9887 Form). Unfortunately, we have been unable to secure the tenant’s signature due to her current medical situation. The tenant has been in and out of the hospital, which has limited her availability for in_x0002_person meetings. Additionally, the tenant has difficulty walking, which has further complicated the process of arranging a convenient time to sign the necessary paperwork. To prevent similar occurrences in the future, we will continue our efforts to have a robust monitoring and review process and improve our coordination with the tenants. We will explore alternative methods to ensure the HUD documentation is completed as required. Completion Date: Immediately Contact Person: Angie Pearson, Site Manager
View Audit 323747 Questioned Costs: $1
Finding 501689 (2024-001)
Significant Deficiency 2024
Student Financial Assistance – Assistance Listing No. 84.063, 84.268 Recommendation: CLA recommends that the College update their procedures to identify changes in breaks for purposes of R2T4 calculations. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Student Financial Assistance – Assistance Listing No. 84.063, 84.268 Recommendation: CLA recommends that the College update their procedures to identify changes in breaks for purposes of R2T4 calculations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Corrective action was taken immediately. R2T4 calculations for 2024-25 include a five-day break for fall semester (Thanksgiving Break November 27 – December 1). Name(s) of the contact person(s) responsible for corrective action: Jenae Schmidt Planned completion date for corrective action plan: September 1, 2024 If the Department of Education has questions regarding this plan, please call Jenae Schmidt at 651-696-6214.
View Audit 323740 Questioned Costs: $1
Inaccurate and Untimely Return of Title IV Funds (R2T4): Planned Corrective Action: The Financial Aid Department corrected the current year errors by completing the R2T4s for the students identified. In addition to those corrections, a full file review was done to ensure that no other students were...
Inaccurate and Untimely Return of Title IV Funds (R2T4): Planned Corrective Action: The Financial Aid Department corrected the current year errors by completing the R2T4s for the students identified. In addition to those corrections, a full file review was done to ensure that no other students were missed. To prevent the recurrence of this issue going forward, the Financial Aid Office will pull a 0 credit hour report at the end of each module to ensure that all unofficial withdrawals are followed up on and that all R2T4s are filed in a timely manner. Persons Responsible for Corrective Action Plan: Veronica L. Hamblin, Director of Accounting Anticipated Date of Completion: The corrections for the 2023-2024 Academic year have already been completed, and the new process will be implemented by October 18, 2024 following the completion of the August online module.
#2024-002 – Material Weakness – Eligibility Coronavirus State and Local Fiscal Recovery Funds, ALN #21.027 Recommendation We recommend verifying each applicant’s enrollment status with all universities prior to disbursement of scholarship funding. View of responsible officials and planned corrective...
#2024-002 – Material Weakness – Eligibility Coronavirus State and Local Fiscal Recovery Funds, ALN #21.027 Recommendation We recommend verifying each applicant’s enrollment status with all universities prior to disbursement of scholarship funding. View of responsible officials and planned corrective action The Foundation receives information directly from PASSHE universities to verify enrollment status of applicants. Universities submit information to the Foundation on an electronic form, which includes Student Name, Student ID, Scholarship Amount, Student Enrollment Status, etc. Authorized officials enter their approval by changing “Pending Review” to either “Scholarship Eligible” or “Not Eligible” on the form and keying in the scholarship amount the student is eligible for based on their verified enrollment status, for example: $1,000 for a part time student or $2,000 for a full-time student. For 4 of the 40 applicants sampled during the audit, a PASSHE university created an inconsistency on the form, having not completed or updated the enrollment status column to be consistent with the final amount they verified approved for payment. The key control, i.e. the University’s entry and approval of the eligible amount, prevented any errors from occurring. The Foundation verified the enrollment status for the four applicants identified in the audit, noting that the scholarships were properly disbursed. Going forward the Foundation has updated its verification process with the universities to ensure proper classification of the applicant’s enrollment status is verified in accordance with the eligibility requirements of the grant.
#2024-001 – Material Weakness – Operating Deficiency – Classification of expenses Coronavirus State and Local Fiscal Recovery Funds, ALN #21.027 Recommendation We recommend that administrative expenses be recorded in accordance to the natural classification of the underlying expense, but be allocate...
#2024-001 – Material Weakness – Operating Deficiency – Classification of expenses Coronavirus State and Local Fiscal Recovery Funds, ALN #21.027 Recommendation We recommend that administrative expenses be recorded in accordance to the natural classification of the underlying expense, but be allocated to the grant award by reclassifying the expense to the correct class within the accounting system. View of responsible officials and planned corrective action Management acknowledges deficiencies in the process of recording administrative expenses. The Foundation records expenses in their natural classification at the time of initial recognition. In the current period, management later reclassified certain expenses (e.g. Payroll) from natural class to functional class (e.g. program expenses) to address an accounting recommendation made by the auditor during the prior audit. Upon identifying the error, management restored the impacted expenses to their natural classifications. The adjustment had no effect on net assets or total expenses and did not impact any disbursement of federal grant funds. The Foundation will continue to record expenses by natural classification at point of entry and will not make any subsequent reclassifications to the underlying expense.
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT WILL ENSURE THAT HUD'S APPROVAL IS OBTAINED IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT WILL ENSURE THAT HUD'S APPROVAL IS OBTAINED IN THE FUTURE.
View Audit 323673 Questioned Costs: $1
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT HAS SUBMITTED THE FORMS FOR HUD'S APPROVAL
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT HAS SUBMITTED THE FORMS FOR HUD'S APPROVAL
View Audit 323620 Questioned Costs: $1
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT HAS SUBMITTED THE FORMS FOR HUD'S APPROVAL.
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT HAS SUBMITTED THE FORMS FOR HUD'S APPROVAL.
View Audit 323619 Questioned Costs: $1
FINDING 2024‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Internal Control over Compliance Recommendation: The University should design and implement a robust review process of all R2T4 calculations for official and unofficial withdrawals. This will ...
FINDING 2024‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Internal Control over Compliance Recommendation: The University should design and implement a robust review process of all R2T4 calculations for official and unofficial withdrawals. This will help ensure the accuracy of the calculation before the return of funding. Response: There is no disagreement with this audit finding. Action taken in response to finding: To ensure the accuracy of R2T4 calculations, the Student Financial Services Office will take the following actions: • Implementation of R2T4 Module: Starting with the 2024-2025 academic year, the Financial Aid Office will utilize the Banner-delivered R2T4 module to perform calculations, ensuring more accurate and consistent data management. • Multi-Step Review Process: A multi-step review process has been implemented by Student Financial Services staff to ensure thorough verification of all R2T4 calculations and timely returns of funds. • Enhanced Training: Staff are pursuing additional training on R2T4 regulations and procedures to further strengthen their expertise and reduce the risk of future discrepancies. These actions are in process currently, and expected to be fully implemented and corrected by October 2024 to ensure that R2T4 calculations are prepared and reviewed for accuracy for the 2024-2025 award year. Enhanced training will continue on a go forward basis. Contact Person(s): Louisa Diana, Director of Compliance; Sarah Everitt, Dean of Student Financial Services;
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