Corrective Action Plans

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Planned Corrective Action: Management acknowledges the finding. The Council currently maintains comprehensive fiscal policies and procedures governing its financial operations and internal controls. Management will review its existing policies against the applicable Uniform Guidance requirements ide...
Planned Corrective Action: Management acknowledges the finding. The Council currently maintains comprehensive fiscal policies and procedures governing its financial operations and internal controls. Management will review its existing policies against the applicable Uniform Guidance requirements identified during the audit and, where necessary, supplement or clarify existing policies to expressly document federal award requirements. Any necessary revisions will be incorporated into the Council’s existing fiscal policy framework. The Council will review its existing fiscal policies and procedures against applicable Uniform Guidance requirements. Existing policies will be supplemented or clarified, where necessary, to expressly address federal award administration requirements identified during the audit, including allowable costs, cash management, procurement, and conflicts of interest. The Council will incorporate any necessary revisions into its existing fiscal policy framework and maintain the policies as part of its ongoing compliance processes. Anticipated Completion Date: December 31, 2026
Federal Award Agency: Department of Housing and Urban Development Name of Contact Person: Jennifer Carter, Voucher Programs Director Corrective Action: In order to ensure all units are properly scheduled for inspection within the required period; Vancouver Housing Authority will continue to pull mon...
Federal Award Agency: Department of Housing and Urban Development Name of Contact Person: Jennifer Carter, Voucher Programs Director Corrective Action: In order to ensure all units are properly scheduled for inspection within the required period; Vancouver Housing Authority will continue to pull monthly reports for inspections due. VHA will continue to schedule inspections for tenant-based voucher households every 18 months to ensure we meet the two-year period and will continue to run reports for “missed” inspections that do not have a completed inspection within the expected time period. VHA staff have implemented additional reporting to review the assigned inspection schedule on active units at least annually. VHA has updated internal compliance process to review inspection and unit specific requirements during a PBV to tenant-based property conversion. Date of Planned Corrective Action: The above process has been completed.
FINDING 2025-003 – LATE REPORTING Due to turnover in the CFO and CEO roles, there was delay in the compiling of records related to the audit. CPH has strengthened internal controls by hiring a contract CFO and controller as well as a senior accountant on staff. These roles will ensure compliance wit...
FINDING 2025-003 – LATE REPORTING Due to turnover in the CFO and CEO roles, there was delay in the compiling of records related to the audit. CPH has strengthened internal controls by hiring a contract CFO and controller as well as a senior accountant on staff. These roles will ensure compliance with Uniform Guidance audit reporting by implementing procedures to track submission deadlines, assigning responsibility for timely filing of the audit report and FAC Data Collection Form, and establishing management review processes to ensure compliance with Uniform Guidance reporting requirements.
FINDING 2025-002 – SLIDING SCALE FEES CPH is implementing more robust review process for information that is input into the billing system. This will include new, simplified forms for patients to complete for the sliding fee scale application and an enhanced review process including review of each a...
FINDING 2025-002 – SLIDING SCALE FEES CPH is implementing more robust review process for information that is input into the billing system. This will include new, simplified forms for patients to complete for the sliding fee scale application and an enhanced review process including review of each application within the first 30 days of initial application. Crystal Wolf, Revenue Cycle Director, will oversee this effort. The implementation of the new forms and the training to correct the finding is scheduled to be completed by December 31, 2026.
Finding 1229202 (2025-003)
Material Weakness 2025
The County Clerk has implemented a program to ensure knowledge and awareness of all federal monies being expended. The County Treasurer will set up accounts within our financial software to account for all transactions.
The County Clerk has implemented a program to ensure knowledge and awareness of all federal monies being expended. The County Treasurer will set up accounts within our financial software to account for all transactions.
Finding 2025-004 – Noncompliance – Reasonable rent rates documentation Name of Contact Person: George Czerwionka, Director of Finance Corrective Action: Management will maintain documentation for all rental agreements along with an analysis of its evaluation of the reasonableness of rental rates in ...
Finding 2025-004 – Noncompliance – Reasonable rent rates documentation Name of Contact Person: George Czerwionka, Director of Finance Corrective Action: Management will maintain documentation for all rental agreements along with an analysis of its evaluation of the reasonableness of rental rates in accordance with the Uniform Guidance. Proposed Completion Date: October 1, 2026
Finding 2025-003 – Noncompliance – Reporting (Repeat) Name of Contact Person: George Czerwionka, Director of Finance Corrective Action: Management understands the data collection was not submitted within nine months of June 30 year-end. Procedures will be implemented to make sure the audit is comple...
Finding 2025-003 – Noncompliance – Reporting (Repeat) Name of Contact Person: George Czerwionka, Director of Finance Corrective Action: Management understands the data collection was not submitted within nine months of June 30 year-end. Procedures will be implemented to make sure the audit is completed before the nine-month deadline. Data collections will then be uploaded to the federal clearing hours before the ninemonth deadline or within 30 days of the audit report being issued. Proposed Completion Date: March 31, 2027
Before reviewing and updating it Fiscal Policies, including its purchasing and procurement policies, All Nations Finance Director and CEO will ensure that finance staff, the Audit and Finance Committee, and its accounting partner know how to adhere to and have a thorough understanding of the importa...
Before reviewing and updating it Fiscal Policies, including its purchasing and procurement policies, All Nations Finance Director and CEO will ensure that finance staff, the Audit and Finance Committee, and its accounting partner know how to adhere to and have a thorough understanding of the importance of complying with its purchasing and procurement policies.
All Nations Health Center will identify appropriate resources and implement procedures needed for timely submission of the Single Audit report in the future.
All Nations Health Center will identify appropriate resources and implement procedures needed for timely submission of the Single Audit report in the future.
Policies and procedures for review of quarterly financial and performance reports will be followed on a consistent basis.
Policies and procedures for review of quarterly financial and performance reports will be followed on a consistent basis.
Policies and procedures for review of payroll will be followed on a consistent basis.
Policies and procedures for review of payroll will be followed on a consistent basis.
The findings from the December 31, 2025, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding 2025-001 - Cash Management - U.S. Department of Agri...
The findings from the December 31, 2025, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding 2025-001 - Cash Management - U.S. Department of Agriculture ({Assistance Listing Number 10.557, WIC Special Supplemental Nutrition Program for Women, Infants, and Children} Passed Through New York State Department of Health, Contract Number C38291GG - (Significant Deficiency) SJGNFICANT DEFICIENCY During our audit, we noted that there is no evidence of review of WIC vouchers submitted for payments. Recommendation We recommend that the Center implement a policy that requires all WIC voucher and supporting records to be reviewed and that such review be documented. Action Taken WIC vouchers and supporting documentation were reviewed and approved in accordance with BSFHC's established policy. However, the reviews were not documented, resulting in insufficient evidence to demonstrate that the required review had been performed. Going forward, Management will ensure that all WIC vouchers and supporting documentation are reviewed and that the review is documented through the reviewer's signature or initials. Management will monitor compliance with this requirement to ensure that documentation ofthe review is consistently maintained.
Finding Number: 2025-003 Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. This secondary review will specifically include the Uniform Data System (UDS) report, and...
Finding Number: 2025-003 Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. This secondary review will specifically include the Uniform Data System (UDS) report, and the reviewer will verify that all reported amounts, including the applicable UDS table line items, are traceable to and supported by the underlying data prior to submission. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Anticipated Completion Date: 2/15/2026 Responsible Contact Person: Tyson Bouyack, Chief Financial Officer
Finding Number: 2025-002 Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the set-up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Furthe...
Finding Number: 2025-002 Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the set-up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Further, the Organization will implement a process to review a sample of sliding fee adjustments monthly to assess accuracy, correct any on-going issues, and maintain records as evidence of this review. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Tyson Bouyack, Chief Financial Officer
Views of Responsible Officials and Planned Corrective Actions: The inconsistencies found in the FFR report were from the report filed in early 2025 prior to the new CFO being hired. The CFO now takes full responsibility for grants management and the associated reporting. Grant records are now being ...
Views of Responsible Officials and Planned Corrective Actions: The inconsistencies found in the FFR report were from the report filed in early 2025 prior to the new CFO being hired. The CFO now takes full responsibility for grants management and the associated reporting. Grant records are now being kept in a more accurate and consistent manner, and all required filings are completed timely and in consultation with an external grant consultant when necessary. The 2025 UDS report was prepared with a new process and new staff members. This is an improved structure than previously used, and it will continue to be refined as staff gain more knowledge and experience with the UDS. Staff participate in all available training courses and use a Teams Channel to communicate and share information. The team will perform a final review and ensure that there is supporting documentation that incorporates any follow-up adjustments and agrees to the final UDS report.
Views of Responsible Officials and Planned Corrective Action: A more formal sliding fee training procedure was developed in 2026 and was administered to staff in June 2026. This training includes identifying patients, completing the application, income and household verifications, determination of t...
Views of Responsible Officials and Planned Corrective Action: A more formal sliding fee training procedure was developed in 2026 and was administered to staff in June 2026. This training includes identifying patients, completing the application, income and household verifications, determination of the correct fee schedule and how to check for accuracy. Along with this training, a process of weekly audits was implemented to check for accuracy and determine the need for any coaching or retraining. This is one of many training topics that are now in a regular, repeating rotation so the training will be recurring. A new Sliding Fee Discount Policy was approved by the Board of Directors on March 21, 2025 and March 19, 2026. The Sliding Fee Discount Schedule is on the board schedule to be review annually in conjunction with the updated federal poverty guidelines when they are issued. There has been a workflow developed for distributing t his information once the new Sliding Fee Discount Schedule is approved by the board of directors.
2025-001. Allowable Costs/Cost Principles United States Department of Education, Passed Through New York State, Department of Education: Special Education Cluster Special Education Grants to States: IDEA Part B ALN: 84.027 Special Education Preschool Grants: IDEA Preschool ALN: 84.173 Condition: Sub...
2025-001. Allowable Costs/Cost Principles United States Department of Education, Passed Through New York State, Department of Education: Special Education Cluster Special Education Grants to States: IDEA Part B ALN: 84.027 Special Education Preschool Grants: IDEA Preschool ALN: 84.173 Condition: Subpart E, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee’s compensation among specific activities if the employee works on more than one federal award, or a federal award and non-federal award. The preparation of personnel activity reports (PAR) or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, the District did not prepare this documentation, and therefore did not comply with Subpart E, 2 CFR §200.430. Planned Corrective Action: The District will adopt procedures that ensure that time performed will be used to support costs charged to the federal award, and comply with Subpart E, 2 CFR §200.430. Responsible Contact Person: Michael I. DeVito, Esq., Assistant Superintendent for Finance and Operations. Long Beach City School District 235 Lido Boulevard Lido Beach, New York 11561 mdevito@lbeach.org 516-897-2090 Anticipated Completion Date: June 30, 2026.
For the Rockford Supportive Housing Facility - FINDING 2025-002: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 TENANT FILE DID NOT CONTAIN A MOVE-IN INSPECTION REPORT Condition: One of the tenant files tested did not contain a move-in inspection report. Recommendation: The Project should obtain a co...
For the Rockford Supportive Housing Facility - FINDING 2025-002: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 TENANT FILE DID NOT CONTAIN A MOVE-IN INSPECTION REPORT Condition: One of the tenant files tested did not contain a move-in inspection report. Recommendation: The Project should obtain a copy of the move-in inspection report, if possible. If the report cannot be located, the Project should document the file stating that an inspection was performed but the report has been misplaced. Action Taken: The Project agrees with the finding and will document the file accordingly. If the Department of Housing and Urban Development has questions regarding these plans, please call Les Russo at 847-424-5601.
Over the Rainbow Association and Subsidiaries respectfully submits the following corrective action plans for the year ended December 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit period: De...
Over the Rainbow Association and Subsidiaries respectfully submits the following corrective action plans for the year ended December 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit period: December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT - NONE; FINDINGS - FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT For the Hill Housing Facility - FINDING 2025-001: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 SPONSOR LOAN PAYMENT WITHOUT HUD APPROVAL Condition: The Project repaid a portion of the sponsor loan without obtaining HUD approval. Recommendation: The Project should obtain HUD approval for the repayment of the sponsor loan. Action Taken: The Project agrees with the finding. The Sponsor will contact HUD to obtain permission to retain the unauthorized sponsor loan payments.
Management appreciates the opportunity to respond to Finding 2025-001. The questioned cost relates to payment for CRE’s federally required financial audit for the year ended December 31, 2025. The costs of the audit were in fact liquidated by virtue of an audit engagement letter received. The audit ...
Management appreciates the opportunity to respond to Finding 2025-001. The questioned cost relates to payment for CRE’s federally required financial audit for the year ended December 31, 2025. The costs of the audit were in fact liquidated by virtue of an audit engagement letter received. The audit procedures addressed financial activity, finalyear expenditures, financial reporting, internal control, and compliance requirements associated with the five-year ACF award that concluded in 2025. The payment was not intended to support future program operations, future service delivery, or activities to be performed under a subsequent award period. Management respectfully requests that ACF evaluate the questioned cost based on the purpose of the expenditure, the benefit received by the federal award, and the documentation supporting the transaction. The audit was required because of the financial activity conducted under the completed ACF award. The audit tested costs incurred, funds drawn, financial reporting, internal control, and compliance obligations arising from that award. Management does not believe the cost provided a programmatic or administrative benefit to a later federal award. CRE charged the audit cost to the award that received the benefit of the audit services because management determined that award to be the appropriate cost objective. Charging the cost to a subsequent award solely because the audit work or payment occurred after the award end date would have resulted in a different federal award, and potentially a different federal agency, bearing the cost of audit procedures performed on activity attributable to the completed ACF award. Management acknowledges that the period-of-performance requirements are an important compliance consideration and does not assert that the allocation rationale alone overrides those requirements. However, management believes the facts and circumstances distinguish this transaction from an advance payment or prepayment for future program services. The audit was completed, the amount was supported by documentation, the cost was not charged to another federal award, and the Federal Government received the intended financial oversight and compliance benefit associated with the completed award. Accordingly, management respectfully requests that ACF consider allowing the portion of the audit cost that is reasonably attributable to the completed ACF award. If ACF determines that a portion of the cost is not allowable based on the period of performance, management requests that the final determination clearly distinguish any disallowance based on timing from the allowability, reasonableness, allocability, and documentation of the audit service itself. Management also requests that the final finding accurately describe the nature of the questioned cost as a federally required financial audit of activity for the year ended December 31, 2025. The current characterization of the payment as a prepayment to a third party for services to be provided in 2026 does not fully describe the purpose of the expenditure and may imply that the payment supported 2026 program activity, which management believes is inconsistent with the underlying purpose and benefit of the audit services. CRE has procedures to review both the period in which contracted services are performed and the award that receives the benefit of those services. As a corrective action, for future grants approaching expiration, CRE will obtain written guidance from the awarding agency before charging audit, closeout, or other post-award professional service costs to an expiring award. CRE will also document the basis for any allocation decision, including the applicable award, period of performance, benefit received, and supporting documentation retained for audit review.
Finding 2025-004 Repeat Finding 2024-003 AL No.: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of Treasury Award Number/Year: 1505-0271 / 2021 Criteria: The Uniform Guidance requires that local entities receiving federal awards estab...
Finding 2025-004 Repeat Finding 2024-003 AL No.: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of Treasury Award Number/Year: 1505-0271 / 2021 Criteria: The Uniform Guidance requires that local entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. The Uniform Guidance further requires auditors to obtain an understanding of the local entity's internal control over federal programs. To minimize the risk offerors, internal controls should be in place for all program compliance requirements, including the approval of expenditures by a knowledgeable individual. Condition/Context: The County does not have controls in place to ensure there is documentation of the approval/review of reports prior to submission. The reports selected for testing did not have documentation of review and/or approval. The sample was not statistically valid. Cause: The County did not have internal control procedures in place requiring an independent person to document their review of the reports before submission and to ensure the reports were submitted timely. Questioned Costs: None noted. Effect: Reports could contain errors due to the lack of review and/or funding could be reduced as a result of not submitting reports by the due dates. Recommendation: The County should review its internal control procedures to ensure there is a process for documentation of proper review and approval over completeness and accuracy of reports are in place before submissions are completed. Corrective Action Planned: The Finance Department continues to work on the development of the Grant Manager module of Tyler MUNIS. In 2026 it was communicated with the Department Heads as to their responsibility to review each filing for completeness and accuracy before filing. Individual responsible: Angela Runde, Finance Director Anticipated completion date: Dec. 31, 2026
SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Section 202 Supportive Housing for the Elderly - Capital Advance, ALN 14.157 Recommendation: The Project should implement procedures to ensure that initial and ongoing tenant eligibility documentat...
SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Section 202 Supportive Housing for the Elderly - Capital Advance, ALN 14.157 Recommendation: The Project should implement procedures to ensure that initial and ongoing tenant eligibility documentation is obtained timely and maintained in tenants’ files. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips Irene Phillips CFO
Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University D...
Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-002: Section 202 Supportive Housing for the Elderly – Capital Advance, ALN 14.157 Recommendation: The Project should comply with HUD regulations for implementing rent increases upon receiving HUD approval, and ensure financial statements are recorded in accordance with GAAP. Action Taken: Staff training has been provided to insure timely applying of gross rent changes and requesting timely move out of tenants on the voucher. This is included in monthly reporting procedures.
FINDING No. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures for compliance with all HUD regulations and ensure that the supporting documents are prepared in a timely manner. Action Taken: Staff training has been provided re...
FINDING No. 2025-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures for compliance with all HUD regulations and ensure that the supporting documents are prepared in a timely manner. Action Taken: Staff training has been provided regarding UA support and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO
Oversight Agency for Audit, NCSC/USA Housing Development Corporation Three, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral...
Oversight Agency for Audit, NCSC/USA Housing Development Corporation Three, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 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. 2025-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to monitor the expiration of HUD required documents to ensure timely preparation and approval. Action Taken: Management is in the process of renewing all management certifications and will provide accountant extra training to monitor.
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