Corrective Action Plans

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Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanat...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been created along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. This revised process will be put in place on October 1, 2025.
View Audit 368617 Questioned Costs: $1
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ...
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ensure all employees' salary schedules are updated when we process the system-wide update. We will have an additional person to review and sign the new salary schedules before the first payroll is processed in the new fiscal year.
Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and ...
Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that the five transactions tested that did not have documentation of appropriate approval occurred prior to August 2024, the remediation date of Finding 2023-002. Completion Date: Matter was remediated in August 2024
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-004: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: The Company opened a residual receipt account and plans to deposit $3,633. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
View Audit 368559 Questioned Costs: $1
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-003: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: HUD approved the suspension of monthly deposits to the replacement reserve account for 2024 due to the account being overfunded in prior years. The Company has requested from HUD to approve a withdrawal of $14,400 to reimburse the property for deposits made during the approved suspension of payments. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
View Audit 368559 Questioned Costs: $1
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-001: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: An adjusting audit entry was made to reduce the property management fees. Management will monitor the expenses to ensure in compliance with the HUD approved Form 9839. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
View Audit 368559 Questioned Costs: $1
Finding 1156121 (2024-002)
Material Weakness 2024
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mikala Wodarek, Social Services Supervisor Corrective Action Planned: Clay County Social Services ack...
Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mikala Wodarek, Social Services Supervisor Corrective Action Planned: Clay County Social Services acknowledges the audit finding that in 2 of the 40 METS Medical Assistance eligibility case files reviewed, required documentation was either missing or not properly recorded. To address this, all eligibility workers will receive refresher training on documentation standards, with a focus on citizenship and income verification requirements. The lead worker for this program will conduct random case reviews monthly, in addition to 3 case reviews for each worker around their annual performance evaluation. These case reviews will be reviewed with the worker thoroughly, coaching provided if necessary, and any errors found will be corrected. The supervisor will retain these case reviews and analyze them for patterns and provide team training and guidance as appropriate. For staff with repeated errors, performance management will be enacted in the form of verbal coaching, performance improvement plans, etc. In addition, annual training on eligibility documentation, specifically around citizenship status, will be added to the Division's training plan. Progress will be tracked through internal audits and summarized for leadership review. These actions are intended to ensure all required documentation is properly obtained, verified, and recorded in METS, thereby strengthening internal controls, reducing the risk of ineligible individuals receiving benefits, and improving future audit compliance. Anticipated Completion Date: Refresher training for eligibility workers and thorough review of 2024 audit findings both individually and as a group: completed on August 7, 2025 Case reviews by lead worker: Already implemented at the time of this writing and ongoing Review and reporting to leadership: Beginning January 1, 2026 and ongoing Annual training incorporated into department plan: Effective December 1, 2025
View of Responsible Official: We have undertaken additional training and review of regulations in this area to ensure compliance. Finding resolved timeline: December 1, 2025. Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President and program Authoriz...
View of Responsible Official: We have undertaken additional training and review of regulations in this area to ensure compliance. Finding resolved timeline: December 1, 2025. Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President and program Authorized Representative
2024-004 CONTROLS OVER REPORTING Federal Agency: Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM and 2405MN5MAP, 2024 Pass-Through Agency: Minnesota Department of Health Pass-T...
2024-004 CONTROLS OVER REPORTING Federal Agency: Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM and 2405MN5MAP, 2024 Pass-Through Agency: Minnesota Department of Health Pass-Through Number: 2405MN5ADM and 2405MN5MAP Type of Finding: Significant Deficiency in Internal Controls over Compliance Recommendation: It is recommended Becker County implement procedures to ensure there is a second person reviewing these reports before they are submitted to DHS which includes receiving backup data to ensure the amounts match. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Becker County will implement procedures to ensure there is a second person reviewing these reports before they are submitted to DHS. Name of contact person responsible for corrective action plan: Mary Hendrickson, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2025
Finding 2024-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding 2024-005 Due to the financial situation the Project is in at June 30, 2024, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving depos...
Finding 2024-005 Due to the financial situation the Project is in at June 30, 2024, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving deposit requirement suspended permanently. If management is successful in negotiations with HUD, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding 2024-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding 2024-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Contact Person: William Bane Management’s Response: Management acknowledges that there were not sufficient controls in place to ensure written consent from HUD prior to incurring new debt or lease arrangements. Four of the five leases in question were all entered into and approved by individuals no ...
Contact Person: William Bane Management’s Response: Management acknowledges that there were not sufficient controls in place to ensure written consent from HUD prior to incurring new debt or lease arrangements. Four of the five leases in question were all entered into and approved by individuals no longer with the organization and without prior knowledge of hospital finance personnel. Current Management had previously established controls to ensure written consent is obtained prior to incurring any new debt or lease arrangements, but these arrangements were not caught before being signed. The HUD loan was retired and refinanced with another financial institution during 2024 so this will not be an issue going forward. Completion Date: September 23, 2025
The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and som...
The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and some at the decision of staff. Initial eligibility is currently being restructured with an emphasis on new admissions. All procedures and processes are being evaluated for accuracy, with emphasis on the noted area of noncompliance and includes a complete review and update to the Administrative Plan. There will be increased staff training and file review. In July 2024, TGHA transitioned project-based files from a property management team to the Housing Choice Voucher Department. The files had not been electronically stored. Evidence pointed to deficiencies in file maintenance. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the programs, including staff capability, training and monitoring. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. TGHA files were fully in order by July 2025.
Corrective Action Plan Xavier complies with the loan disbursement notification rules. During the audit we learned that, while our system was sending the emails to each student with a loan disbursement, our process for copying each individual email to xufinaid was not functioning. Further, the notifi...
Corrective Action Plan Xavier complies with the loan disbursement notification rules. During the audit we learned that, while our system was sending the emails to each student with a loan disbursement, our process for copying each individual email to xufinaid was not functioning. Further, the notification report was being overwritten daily, causing us to lose the audit trail for these notifications. We have implemented two steps to be able to document each individual email. 1. The xufinaid@xavier.edu email address is copied on every disbursement notification and each notification email is delivered into the xufinaid inbox in Outlook. Every Wednesday those emails are moved by financial aid personnel into a folder in Outlook where they remain stored. This weekly review allows personnel to know in a timely manner if there are issues with the email delivery process. 2. A log file which saves a list of the disbursement notification emails is saved on a daily basis. It includes the content of each email.
September 24, 2025 MILTON HOUSING AUTHORITY CORRECTIVE ACTION PLAN Finding No. 2024-003 – Special Tests and Provisions; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee’s Response and Planned Corrective Action Over the course of 2024, Milton Housing Authority worked on the creation o...
September 24, 2025 MILTON HOUSING AUTHORITY CORRECTIVE ACTION PLAN Finding No. 2024-003 – Special Tests and Provisions; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee’s Response and Planned Corrective Action Over the course of 2024, Milton Housing Authority worked on the creation of a comprehensive HCV Administrative Plan. The Administrative Plan was approved by the Board on December 3, 2024, and Chapter 17 discusses the Mainstream program and program eligibility. It is the opinion of Milton Housing Authority that the matter has been resolved. Planned Implementation Date of Corrective Action: Completed Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169
September 24, 2025 MILTON HOUSING AUTHORITY CORRECTIVE ACTION PLAN Finding No. 2024-002 – Reporting; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee’s Response and Planned Corrective Action Milton Housing Authority continues to develop better internal controls over the performance a...
September 24, 2025 MILTON HOUSING AUTHORITY CORRECTIVE ACTION PLAN Finding No. 2024-002 – Reporting; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee’s Response and Planned Corrective Action Milton Housing Authority continues to develop better internal controls over the performance and documentation of SEMAP. There has been staff turnover and increased training will assist this staff member to better understand the process. Staff is working more closely with local HUD staff to better understand their expectations and protocol. Planned Implementation Date of Corrective Action: September 24, 2024 Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169
Finding 2024-002 Information on the federal program: Subject: Home Investment Partnership Program – Internal Controls Federal Agency: Department of Housing and Urban Development Federal Program: Home Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Entity: N/A - Direct G...
Finding 2024-002 Information on the federal program: Subject: Home Investment Partnership Program – Internal Controls Federal Agency: Department of Housing and Urban Development Federal Program: Home Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Entity: N/A - Direct Grant Compliance Requirement: Special Tests and Provisions - Underwriting Requirements Audit Findings: Significant Deficiency Condition: The Consortium did not have a documented review control in place to ensure the underwriting calculation was prepared, reviewed, and maintained. Context: In a sample of three, the following items were noted: • For the first selection, project underwriting support was not available. The underwriting calculation was prepared by a former employee. Review of the calculation was also performed by a former employee. The Consortium does not have record of the calculation. • For the second selection, the underwriting calculation did not have formal sign off by the reviewer. Only the preparer signed the calculation. • For the third selection, the underwriting calculation did not have formal sign off by the preparer. Only the reviewer signed the calculation. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement a system of internal controls to ensure the required underwriting calculations are prepared, reviewed, and maintained. Responsible Party and Timeline for Completion: The Consortium Director (or their designee) and the Federal Grant Administrator are responsible for implementation, which will go into effect immediately.
2024-005 Reporting Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Sign...
2024-005 Reporting Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2024 Recommendation: It is recommended that the Couty implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2025.
View Audit 367943 Questioned Costs: $1
2024-004 Review of Casefiles Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Fin...
2024-004 Review of Casefiles Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2024 Recommendation: It is recommended that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2025
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