Corrective Action Plans

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1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and...
1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and informal review procedures that were not consistently documented. Following organizational restructuring and personnel transitions, management has begun a broader effort to formalize and strengthen compliance monitoring, supervisory review procedures, and documentation practices across our housing portfolio. b. Action(s) Taken or Planned on the Finding: 1. Monthly Compliance and Financial Oversight Meetings: We are establishing recurring monthly oversight meetings with executive leadership, finance, and housing management personnel to review financial reporting, reserve activity, compliance requirements, tenant-related matters, and operational performance. We plan to document these meetings and retain evidence of supervisory review as part of our compliance monitoring procedures. 2. Expanded Finance and Compliance Oversight Structure: We have added a Director of Housing and Compliance responsible for operational and regulatory compliance oversight and have contracted an Interim CFO who is a licensed CPA. We plan to continue refining roles and further segregating responsibilities among the accounting, compliance, and operational functions to strengthen internal controls and management review. 3. Formalized Compliance Monitoring Procedures: We are developing standardized compliance monitoring procedures, including monthly reserve deposit tracking, supervisory review checklists, documented financial statement review procedures, reconciliation monitoring, and periodic compliance checklists addressing key HUD program requirements. 4. Ongoing Monitoring and Documentation Retention: We will strengthen documentation retention procedures so that evidence of compliance monitoring, supervisory review, and reconciliation activities is consistently maintained and available for future audits and regulatory reviews. c. Anticipated Completion Date: Full implementation is expected to be completed and documented by March 31, 2027.
1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and...
1. Finding 2026-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified. Historically, certain compliance oversight activities relied heavily on our staff’s operational knowledge and informal review procedures that were not consistently documented. Following organizational restructuring and personnel transitions, management has begun a broader effort to formalize and strengthen compliance monitoring, supervisory review procedures, and documentation practices across our housing portfolio. b. Action(s) Taken or Planned on the Finding: 1. Monthly Compliance and Financial Oversight Meetings: We are establishing recurring monthly oversight meetings with executive leadership, finance, and housing management personnel to review financial reporting, reserve activity, compliance requirements, tenant-related matters, and operational performance. We plan to document these meetings and retain evidence of supervisory review as part of our compliance monitoring procedures. 2. Expanded Finance and Compliance Oversight Structure: We have added a Director of Housing and Compliance responsible for operational and regulatory compliance oversight and have contracted an Interim CFO who is a licensed CPA. We plan to continue refining roles and further segregating responsibilities among the accounting, compliance, and operational functions to strengthen internal controls and management review. 3. Formalized Compliance Monitoring Procedures: We are developing standardized compliance monitoring procedures, including monthly reserve deposit tracking, supervisory review checklists, documented financial statement review procedures, reconciliation monitoring, and periodic compliance checklists addressing key HUD program requirements. 4. Ongoing Monitoring and Documentation Retention: We will strengthen documentation retention procedures so that evidence of compliance monitoring, supervisory review, and reconciliation activities is consistently maintained and available for future audits and regulatory reviews. c. Anticipated Completion Date: Full implementation is expected to be completed and documented by March 31, 2027.
Oversight Agency for Audit, Morse Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended March 31, 2026. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 3306...
Oversight Agency for Audit, Morse Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended March 31, 2026. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: April 1, 2025 through March 31, 2026 The findings from the March 31, 2026 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2026-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: Management should ensure adherence to and the monitoring of established controls over cash disbursements. Action Taken: Staff training has been provided to ensure proper procedures are followed.
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have an adequate internal control policy for subrecipient monitoring to ensure the procedures necess...
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have an adequate internal control policy for subrecipient monitoring to ensure the procedures necessary to comply with Uniform Guidance requirements are followed. Corrective Action Plan: We have implemented a formal subrecipient monitoring policy that complies with Uniform Guidance that includes procedures for conducting risk assessments, performing monitoring activities, obtaining and reviewing required subrecipient reports, maintaining subaward documentation, and following up on identified compliance issues. Responsible Individuals: David Whipps, CFO, and Kurt Waldbillig, CEO Anticipated Completion Date: 12/31/2026
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have adequate internal controls to ensure that the FFATA reporting requirements were completed in ac...
Federal Agency Name: U.S. Department of Health and Human Services Program Name: Rural Health Network Development Program Federal Assistance Listing #93.912 Finding Summary: The Health Center does not have adequate internal controls to ensure that the FFATA reporting requirements were completed in accordance with the grant agreement, and within the timeframe required. Corrective Action Plan: We will implement internal controls over FFATA reporting to ensure that all reportable first-tier subawards are appropriately identified, evaluated for reporting requirements, and submitted in SAM.gov accurately and within the required reporting timeframe. Responsible Individuals: David Whipps, CFO, and Kurt Waldbillig, CEO Anticipated Completion Date: 12/31/2026
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has recognized and acknowledges the deficiency in internal controls in regards to the determination, recording, and monitoring of the sliding fee discount process. Along with the safeguards that have been implemented previously, we are implementing a process that includes: - verification, during front desk eligibility check that slide information is complete; - if patient qualifies for the slide, note in billing notes, effective dates, slide category, and fee to be collected; - identify patients that are checking in that day and double check slide category and fee to collect; - if there is a discrepancy with any documentation, reach out to slide coordinator.
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS appli...
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.
Finding #2026-001 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: All programs. Condition and context: The SEFA originally provided by TALT did not correctly identify all federal awards. Certain federal awards were reported using incorrect award amounts and...
Finding #2026-001 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: All programs. Condition and context: The SEFA originally provided by TALT did not correctly identify all federal awards. Certain federal awards were reported using incorrect award amounts and identifying numbers, and awards received as a subrecipient were not appropriately identified on the SEFA. Recommendation: Develop policies and procedures to correctly identify and reflect all federal programs on the SEFA and formalize independent review process for the SEFA. Planned corrective action: Management will establish procedures for the preparation and review of the SEFA. The procedures will require reconciliation of federal awards to the general ledger and supporting grant records and verification of program names, Assistance Listing numbers, award amounts, identifying numbers, and subrecipient awards. The Director of Finance will perform and document a final review of the SEFA prior to submission to the independent auditors. Responsible officer: Dina McIlhenny, Director of Finance. Estimated completion date: March 31, 2027.
Finding #2026-001 Context Finding #2026-001 indicates that the University did not have effective internal controls to ensure required Federal Direct Loan disbursement notifications were sent to parents or students within the regulatory timeframe. 1. Interim Manual Processing of Nightly Communication...
Finding #2026-001 Context Finding #2026-001 indicates that the University did not have effective internal controls to ensure required Federal Direct Loan disbursement notifications were sent to parents or students within the regulatory timeframe. 1. Interim Manual Processing of Nightly Communications Effective June 6, 2026, all nightly communications will be manually reviewed and processed until the associated PeopleSoft PSJob has been fully audited and the process changes described in this corrective action plan have been implemented and validated by multiple staff members. This interim control will remain in place until management determines that the automated process has been adequately validated and that the associated monitoring controls are operating effectively. 2. Weekly Audit of Federal Direct Loan Disbursement Notifications The Financial Aid Office will conduct a weekly audit of Direct Loan disbursement notifications using the PeopleSoft PSQuery XCFA_LN_DISB_NOTICE_AUDIT_QRY. The query will be run at the beginning of each week, normally on Monday or, when Monday is a holiday, on the next business day. The review will cover the preceding Sunday through Saturday. The reviewer will examine the results to identify Direct Loan disbursements for which the required notification was not generated or for which the notification date falls outside the applicable regulatory timeframe. Any communication for which the date of the disbursement exceeds 30 days from the date of the notification will be flagged for further review and resolution. The completed query results will be saved to: J:\PeopleSoft\Communications\Disbursement Notice Audit The file name will identify the beginning and ending dates of the period reviewed. 3. Additional Review When the Disbursement Audit Report Is Blank If the XCFA_LN_DISB_NOTICE_AUDIT_QRY produces no results for a weekly review period, an additional audit will be performed to confirm that disbursement activity occurred and that the absence of Direct Loan notifications is not the result of a system or query-processing issue. The additional report will include surrounding disbursement transactions, including non-Direct Loan disbursements, to determine whether disbursements were processed during the review period but no Direct Loan transactions were included in the notification audit. This report will be saved in the same location: J:\PeopleSoft\Communications\Disbursement Notice Audit The report will use the same date convention as the primary audit report and will have a distinct file name identifying it as the supplemental or anomalous activity review. Any unexpected result will be investigated and documented. 4. Enhanced Controls for Nightly Communication Processing Communication selection queries will be modified to include defined processing time parameters. For example, revisions older than 14 days will not be selected for automatic processing without additional review. For each communication type, a report will identify communications that fall outside the established processing window and have not already been satisfied by a successfully processed communication. A separate report will provide the communication's add date and processing status following the nightly selection and processing of the communication batch. Following completion of each communication's processing job, the applicable reports will be distributed by email to: • Alexander Musser (amusser) • Lauren Musser (musser) • Jenni Swindell (jswindel) Email subject lines will clearly identify the communication type and report type. The email body will describe the applicable processing activity and identify any exceptions requiring review. The reports and associated documentation will be reviewed and retained in: J:\PeopleSoft\Communications\Weekly Communications Files will be named using the applicable communication type, report type, and processing date. 5. Monthly Audit of Automated PeopleSoft PSJobs All automated PeopleSoft PSJobs supporting financial aid communications will be subject to a monthly control audit. The monthly review will include a manual review of each step within the applicable PSJob to verify that: • Each step remains properly configured; • Selection criteria and processing parameters remain appropriate; • The correct processes and queries are being executed; • The PSJob is running under the appropriate user account; • No unauthorized or unexplained changes have been made; and • The overall sequence and configuration of the PSJob remain consistent with the intended business process. The review will be documented in the PSJob Log, maintained in: J:\PeopleSoft\PSJobs The PSJob Log will contain a separate worksheet for each applicable PSJob and will document the PSJob's current status, configuration changes, the individual making each change, the user account under which the automation operates, and the date and time of changes. Monthly reviews, system configuration adjustments, and user-related adjustments will be documented in the log. 6. Management Monitoring Management will review the results of the weekly Direct Loan disbursement notification audits and monthly PSJob audits to identify recurring exceptions, processing failures, or trends that could indicate a deficiency in the underlying automated process. Exceptions identified through these reviews will be investigated and corrected. Where appropriate, corrective actions will include modification of the automated process, additional staff review, or modification of the monitoring control. Documentation of the reviews, exceptions, and corrective actions will be retained in accordance with the University's established record-retention practices. Expected Outcome These corrective actions are designed to provide multiple levels of control over Federal Direct Loan disbursement notifications. The combination of automated processing, weekly transaction-level review, exception reporting, supplemental review when expected activity is absent, and monthly PSJob configuration audits is intended to provide reasonable assurance that required Direct Loan disbursement notifications are generated and provided within the applicable federal timeframe and that failures in automated processing are identified promptly. Responsible Parties Jenni Swindell, Associate Director Alex Musser, Business Analyst
Finding #2026-002 Context Finding #2026-02 indicates the University did not have effective internal controls over the review of Federal Pell Grant disbursements and did not report Pell Grant program data to the Common Origination and Disbursements (COD) system within the required timeframes. 1. Week...
Finding #2026-002 Context Finding #2026-02 indicates the University did not have effective internal controls over the review of Federal Pell Grant disbursements and did not report Pell Grant program data to the Common Origination and Disbursements (COD) system within the required timeframes. 1. Weekly Monitoring of Pell Disbursement Reporting Beginning with the 2026-27 academic year, the Grants and Scholarships Specialist will perform a weekly reconciliation at the beginning of each week to confirm that Pell Grant disbursements are being reported to COD within the required 15-calendar-day reporting period. The review will reconcile the applicable Pell disbursement activity against the corresponding COD reporting activity and identify any disbursements that have not been reported within the required timeframe. This control is intended to provide an ongoing, timely review of Pell reporting compliance rather than relying solely on the underlying automated reporting process. 2. Exception Review and Resolution The Grants and Scholarships Specialist will investigate all exceptions identified through the weekly reconciliation. Each exception will be documented, including the nature of the exception and the corrective action taken. The Specialist will ensure that identified records are reported to COD before the next reporting cycle, as appropriate. This process will provide a documented exception-management process and establish clear responsibility for resolving reporting discrepancies. To strengthen documentation and traceability going forward, we will implement the following measures: Retain all reconciliation reports on a shared drive, organized by date and year, to maintain a clear historical record of each weekly cycle. A column will be added to each report capturing the resolution finding for every identified discrepancy. A comment will be added to each affected student's Financial Aid status page in PeopleSoft (PS) documenting the resolution. 3. Monitoring of Federal and State Regulatory Changes The Assistant Director of Compliance is responsible for monitoring federal and state regulatory changes affecting financial aid programs and for evaluating changes that may affect University policies, procedures, and reporting requirements. The Assistant Director of Compliance will update the Financial Aid Office’s policy and procedure manual as necessary and will communicate applicable regulatory changes to the areas affected by those changes. Attention will be given to temporary guidance, waivers, extensions, and other regulatory provisions that have defined award-year applicability or expiration dates. 4. Management Review of Regulatory Changes To provide an additional level of oversight, the Assistant Director of Compliance will bring regulatory changes to the Financial Aid management team for review prior to implementation. The management review will provide an opportunity to confirm the applicability of new or revised guidance to the appropriate award year and to ensure that temporary provisions or reporting extensions are not inadvertently carried forward after their expiration. This additional review is intended to strengthen the University’s internal control over the interpretation and implementation of federal reporting requirements. Expected Outcome The combination of weekly Pell reporting reconciliation, documented exception management, designated responsibility for monitoring regulatory changes, and management review of significant regulatory changes is designed to provide reasonable assurance that Pell Grant disbursements are reported to COD within the required 15-calendar-day timeframe. These controls also strengthen the University’s process for identifying changes in federal guidance and ensuring that temporary or award-year-specific provisions are appropriately applied and discontinued when no longer applicable. Responsible Parties Chauncey Piazza, Assistant Director Christopher Shane, Grants and Scholarships Specialist
Finding 2026-004 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will maintain lease agreements in tenant files and establish processes and procedures to ensure compliance with...
Finding 2026-004 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will maintain lease agreements in tenant files and establish processes and procedures to ensure compliance with the provisions in the Regulatory Agreement. Anticipated Completion Date September 30, 2026
Finding 2026-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will maintain the premises in reasonable condition for proper audit and subject to examination and inspection. ...
Finding 2026-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will maintain the premises in reasonable condition for proper audit and subject to examination and inspection. Anticipated Completion Date September 30, 2026
Finding 2026-002 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 The Board of Directors will conduct board meetings as frequently as needed to allow them t...
Finding 2026-002 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 The Board of Directors will conduct board meetings as frequently as needed to allow them to fulfill their responsibilities and/or obtain counsel if meetings cannot be scheduled/held. Anticipated Completion Date September 30, 2026
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2026 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, 2026 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, 2026. 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 2026-001 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 follow our policies and procedures to ensure accounting records are accurate and complete. Anticipated Completion Date September 30, 2026
The High Technology Foundation has updated all subaward agreements for the project referred to in the finding above. In addition, the High Technology Foundation is working to update the subaward agreements on one other project as required by CFR 200.332. Lastly, before October 31, 2026, the High Tec...
The High Technology Foundation has updated all subaward agreements for the project referred to in the finding above. In addition, the High Technology Foundation is working to update the subaward agreements on one other project as required by CFR 200.332. Lastly, before October 31, 2026, the High Technology Foundation will update its Policies and Procedures to include specific language required by Code of Federal Regulations (“CFR”) section 200.332 in all subaward agreements.
Student Financial Assistance Cluster– Assistance Listing Nos. 84.268 Recommendation: We recommend Augsburg University implement controls to ensure that disbursement dates reported to COD are aligned with the actual date funds are credited to the student’s account. This could include system controls ...
Student Financial Assistance Cluster– Assistance Listing Nos. 84.268 Recommendation: We recommend Augsburg University implement controls to ensure that disbursement dates reported to COD are aligned with the actual date funds are credited to the student’s account. This could include system controls that delay COD reporting until disbursements are fully processed or periodic reconciliations between COD records and the student ledger to identify and correct discrepancies in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student Financial Services will conduct bi-weekly reconciliations between COD records and the student ledger to identify and correct any discrepancies. Name(s) of the contact person(s) responsible for corrective action: Catherine Maun Planned completion date for corrective action plan: May 31, 2027
Finding 1239975 (2026-001)
Material Weakness 2026
Audit Finding Reference: 2026-001 (Federal) Eligibility - Child and Adult Care Food Program, Assistance Listing 10.558 Planned Corrective Action: • Initial determination and first-level review. Participant eligibility is determined by the Site Director in accordance with the applicable CACFP Income ...
Audit Finding Reference: 2026-001 (Federal) Eligibility - Child and Adult Care Food Program, Assistance Listing 10.558 Planned Corrective Action: • Initial determination and first-level review. Participant eligibility is determined by the Site Director in accordance with the applicable CACFP Income Eligibility Guidelines. Income Eligibility Application forms are reviewed for completeness and accuracy by the Site Director. • Independent secondary review. Beginning September 2026, before any determination is transferred to the Master List used for claim reimbursement, TEAM's Early Childhood Quality Assurance Manager will independently review each determination by recalculating reported household income and household size and comparing the result to the current program-year Income Eligibility Guidelines. This applies to 100% of initial determinations and to every re-determination or mid-year change in reported household income or household size. • Guideline currency. The Quality Assurance Manager will obtain the Income Eligibility Guidelines issued for each program year upon publication, confirm that the table in use is the current-year table. • Documentation. The reviewer initials and dates each Income Eligibility Application. The eligibility category recorded on the Master List is traced to the reviewed form. Reviewed forms are retained for audit. • Correction of the identified errors. The two participants identified in the finding were reclassified as of April 2026. The claims will be amended post CACFP review in September 2026. Name of Contact Person: Jamie Peterson, Lead Director of Early Childhood Jpeterson@teaminc.org Designated backup: Jamie Cullen, Early Childhood Quality Assurance Manager jcullen@teaminc.org 203.757.8888 x3241 Completion date: September 15, 2026
All staff responsible for registration and income verification in all service lines, programs, and sites received training on income eligibility assessment, documentation, and application in October of 2025. Chart Auditing and Staff Coaching and Corrective Action: ▪ Annual competency assessments for...
All staff responsible for registration and income verification in all service lines, programs, and sites received training on income eligibility assessment, documentation, and application in October of 2025. Chart Auditing and Staff Coaching and Corrective Action: ▪ Annual competency assessments for all registration staff in all service lines, programs, and sites will be part of clinical compliance training between January 1 and February 28, 2027. Competency assessment includes eligibility assessment, documentation, and application. Failure to complete the assessment in the assigned time or failure to complete the assessment successfully will result in letter of expectation with 14 days to demonstrate improvement, followed by formal disciplinary action in the form of a verbal reprimand and 14 business days to remediate before a written reprimand is issued. Completion date for action: 03/31/2027 ▪ Conducting random audits of 2 percent of patients with a visit in a calendar month across all service lines and programs, or a minimum of 90 charts with a standard audit tool that provides scoring to prompt coaching and additional training for staff who fail to meet a 90% benchmark. Completion date for action: On-going. Will have full 2% compliance by 10/31/2026 ▪ Develop automated audit tool that provides real-time feedback on all patient registration records for consistency and accuracy of SFDS screening and documentation. Completion date for action: 12/31/2026 ▪ Work with OCHIN to allow SFDS and income verification in one service line to flow into accounts for all service lines to mitigate issues stemming from different FPLs depending on service line. Completion date for action: 12/31/2026 Contact person: Angela Hurley, Director of Operations Completion date for action: 03/31/2027
Finding #2026-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Sherrill-Kenwood Community Retirement Housi...
Finding #2026-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Sherrill-Kenwood Community Retirement Housing Corporation agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Dawn Olmstead, Director of Finance, at (315) 337-1401.
Finding 2026-003: Grant Account Reconciliation Procedures Type of Finding: Control U.S. Department of Housing and Urban Development Direct program Assistance Listing Number: 14.251 Award Numbers: B-24-CP-MI-1149 Award Year End: August 31, 2032 Recommendation: The Township should establish procedures...
Finding 2026-003: Grant Account Reconciliation Procedures Type of Finding: Control U.S. Department of Housing and Urban Development Direct program Assistance Listing Number: 14.251 Award Numbers: B-24-CP-MI-1149 Award Year End: August 31, 2032 Recommendation: The Township should establish procedures to verify that expenditures are properly tracked by each individual grant to ensure that individual disbursements are not allocated to more than one grant. Action Taken: The Township has created and is utilizing a spreadsheet to track expenditures by each individual grants that will be updated as individual disbursements and receipts occur. Responsible Person and Completion Date: Township Treasurer, March 31, 2026. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Rebecca Griffin at 231-861-5853.
Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2026-001: Statement of condition #2026-001: Management fees of $17,198 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the fol...
Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2026-001: Statement of condition #2026-001: Management fees of $17,198 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent reimbursed $17,198 to the Corporation on August 11, 2026.
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 th...
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 through August 26, 2029 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR 200.332 (e), (g) and (h) - pass-through entities must monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Condition: AACHC implemented revised subrecipient monitoring procedures in October 2025 as part of its corrective action plan to address the prior-year finding. The revised procedures were applied to all active and new subrecipient agreements beginning October 2025. However, because certain subrecipient agreements had already concluded before the new procedures were implemented, AACHC did not retrospectively apply the monitoring process to those closed agreements. As a result, AACHC did not obtain and review financial statement audit or Single Audit reports for three subrecipients whose agreements ended prior to implementation of the revised procedures. Name of Contact Person: Brenda Hanserd, CFO Phone Number: 602-288-7559 Anticipated Completion Date: March 31, 2027 Views of Responsible Officials and Corrective Action Plan: In October 2025, AACHC implemented revised subrecipient monitoring procedures in response to the prior-year audit finding. The exception identified in the current audit relates solely to three subrecipient agreements that had already concluded before the revised procedures were implemented and therefore could not be incorporated into the new monitoring process. Effective October 1, 2025, AACHC implemented enhanced procedures requiring evaluation of Single Audit applicability, collection and review of applicable audit reports, and follow-up on any findings. In addition, AACHC now requires subrecipients to submit audit documentation covering the entire period of performance under the agreement, ensuring that monitoring activities are completed even when a subrecipient agreement ends prior to the completion of the audit cycle. This corrective action addresses the circumstances that gave rise to the finding and provides assurance that all subrecipient agreements are subject to appropriate audit review and follow-up moving forward.
Comments on the Finding and Each Recommendation: During the year ended May 31, 2026, $11,836 was withdrawn from the reserve for replacements without HUD approval. Management should transfer $11,836 from the operating account to the reserve for replacements account. Action(s) taken or planned on the ...
Comments on the Finding and Each Recommendation: During the year ended May 31, 2026, $11,836 was withdrawn from the reserve for replacements without HUD approval. Management should transfer $11,836 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding Agree. Management concurs with the finding and recommendation. On August 11, 2026, management transferred $11,836 from the operating account to the reserve for replacements account.
Finding 2026-001: Statement of condition #2026-001: Management fees of $3,192 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the findin...
Finding 2026-001: Statement of condition #2026-001: Management fees of $3,192 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent reimbursed $3,192 to the Corporation on August 11, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will ...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will be in compliance with Uniform Guidance to ensure proper annual monitoring. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
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