Corrective Action Plans

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Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new p...
Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new property manager has been hired to ensure compliance with established procedures and to oversee the continued implementation of corrective measures.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Management deposited $619.17 on April 3, 2025 and $619.17 on April 10, 2025 to fully fund the reserve for replacement account.
Management deposited $619.17 on April 3, 2025 and $619.17 on April 10, 2025 to fully fund the reserve for replacement account.
View Audit 359677 Questioned Costs: $1
The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This w...
The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This will be done in conjunction with the procurement policy and be in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
The Capital District YMCA will develop and implement a written procurement policy in accordance with 2 CFR Section 200.318 and have it in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
The Capital District YMCA will develop and implement a written procurement policy in accordance with 2 CFR Section 200.318 and have it in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
2025-001 Special Tests and Provisions - Sliding Fee Scale Discounts Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications o...
2025-001 Special Tests and Provisions - Sliding Fee Scale Discounts Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications on a timely basis. Corrective Action Taken: 1. Immediate Review and Correction Upon determination of the finding, we conducted a full review of the affected patient account. 2. Staff Training All Outreach and Eligibility staff have received refresher training on the proper application of the sl iding fee scale, including income verification processes and documentation standards. This training now occurs as part of onboarding and annually thereafter. 3. Policy and Procedure Review We reviewed our internal policies and procedures to ensure clear guidance on income documentation requirements, allowable income sources, and how to properly apply the sliding scale. 4. Double-Verification Process A second-level review has been instituted for all new patient applications and renewals involving sliding fee scale determinations. This ensures that income is correctly assessed, and the appropriate fee level is applied before any charges are finalized. 5. Audit and Monitoring A quarterly internal audit process has been implemented to review a random sample of sliding fee scale determinations for accuracy. Findings from these audits will be tracked, and any trends will be addressed through targeted training or process changes. Ongoing Commitment: We are committed to continuous improvement and will monitor the effectiveness of these corrective actions over the next year. Adjustments will be made as necessary to ensure sustained compliance and fairness in our billing practices. Our goal is to uphold transparency and affordability in patient care while maintaining full adherence to regulatory standards. Contact Person: Tamie Olson, Chief Financial Officer Completion Date: Fiscal year ending January 31, 2026
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and t...
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and the area support manager. Additional training reviews for specific compliance findings with all management staff.
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and t...
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and the area support manager. Additional training reviews for specific compliance findings with all management staff.
2025-002 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for two withdrawals from the Reserves for Replacement account totaling $2,500 during the year. Action taken: $2,000 has been returned to the Reserves for Replacement account. Contact person: Nan...
2025-002 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for two withdrawals from the Reserves for Replacement account totaling $2,500 during the year. Action taken: $2,000 has been returned to the Reserves for Replacement account. Contact person: Nancy Jordan Completion date: May 15, 2025 Explanation of Disagreement: Not applicable Repeat finding: No
2025-001 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for three withdrawals from the Residual Receipts account totaling $18,354 during the year. Action taken: $5,000 has been returned to the Residual Receipts account. Contact person: Nancy Jordan C...
2025-001 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for three withdrawals from the Residual Receipts account totaling $18,354 during the year. Action taken: $5,000 has been returned to the Residual Receipts account. Contact person: Nancy Jordan Completion date: May 15, 2025 Explanation of Disagreement: Not applicable Repeat finding: No
Statement of Condition 2025-002 (Assistance Listing 14.157): During the year ended January 31, 2025, 1 move-out resident file selected for testing under the compliance supplement were missing necessary documents required by the PRAC and HUD Handbook 4350.3. Recommendation: Management should ensure ...
Statement of Condition 2025-002 (Assistance Listing 14.157): During the year ended January 31, 2025, 1 move-out resident file selected for testing under the compliance supplement were missing necessary documents required by the PRAC and HUD Handbook 4350.3. Recommendation: Management should ensure that all resident files are maintained at the site for each resident of the Property in accordance with the HUD Handbook 4350.3. Management Response: Management agrees with the recommendation and will ensure that resident files are retained in accordance with the HUD Handbook 4350.3. The resident moved-out on June 13, 2024. No further action is required.
Statement of Condition 2025-001 (Assistance Listing 14.157): During the year ended January 31, 2025, HUD approved $83,950 of withdrawals as a pre-release to pay for HVAC replacements and boilers at the Property. The Corporation used $24,300 of the pre-release to fund operations, instead of paying th...
Statement of Condition 2025-001 (Assistance Listing 14.157): During the year ended January 31, 2025, HUD approved $83,950 of withdrawals as a pre-release to pay for HVAC replacements and boilers at the Property. The Corporation used $24,300 of the pre-release to fund operations, instead of paying the invoices approved by HUD and had not paid as of January 31, 2025. Recommendation: Management should ensure that HUD approved reserve for replacement withdrawals are used for the approved purposes. Management Response: Agree. The Corporation paid the remaining costs included in the HUD approved withdrawal on March 3, 2025. There is no further action required.
View Audit 355850 Questioned Costs: $1
The responsible official for the corrective action plan is Valerie Vallee, Vice President. The anticipated completion date is April 9, 2025. Response: Unpaid replacement reserve escrow from August 2024 was paid in April 2025.
The responsible official for the corrective action plan is Valerie Vallee, Vice President. The anticipated completion date is April 9, 2025. Response: Unpaid replacement reserve escrow from August 2024 was paid in April 2025.
Finding 1218369 (2024-004)
Material Weakness 2024
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the Organization develop and implement formal policies and procedures or workflow restrictions that prevent employees from self‑approving their own timecards. Explanation of disagreement wi...
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the Organization develop and implement formal policies and procedures or workflow restrictions that prevent employees from self‑approving their own timecards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. During 2024, the Organization implemented BanbooHR to replace manual timekeeping and strengthen payroll controls. The self-approval issue occurred during initial system implementation and was identified through audit procedures. A corrective control has since been established whereby the Human Resources Manager reviews and approves the Executive Director's timecards, eliminating the ability for self-approval. In addition, payroll continues to be independently processed and reviewed by the Senior Director of Finanice, providing an additional layer of oversight. These control enhancements ensure proper segregation of duties and prevent self-approval of timecards going forward. Name(s) of the contact person(s) responsible for corrective action: Monique Valenzuela, Executive Director and Theo Everheart, Senior Director of Finance. Planned completion date for corrective action plan: May 2026
Finding 1218367 (2024-003)
Material Weakness 2024
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the Organization develop and implement formal policies and procedures to ensure required performance reports are prepared, reviewed, and submitted in a timely manner. Such procedures should...
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the Organization develop and implement formal policies and procedures to ensure required performance reports are prepared, reviewed, and submitted in a timely manner. Such procedures should include clearly defined roles and responsibilities, tracking of reporting deadlines, and documented evidence of supervisory review and approval prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finding was related to a one-time ARPA grant during a period of staff transition, where performance reports were not consistently documented as reviewed and approved prior to submission. Since then, management has implemented formalized procedures for grant reporting. All performance reports are now prepared by designated program staff, tracked against reporting deadlines, and subject to supervisory review and approval by the Executive Director prior to submission. These procedures establish clear roles and responsibilities and ensure timely, documented review and submission of required reports. Name(s) of the contact person(s) responsible for corrective action: Monique Valenzuela, Executive Director and Theo Everhearts, Senior Director of Finance. Planned completion date for corrective action plan: June 2024
Management will review reports on a more frequent basis and will to the best of our abilities, schedule recertifications well in advance to advance to ensure recertifications are completed timely. Verterans will now be notified at the 60 day mark in order to retain eligibility.
Management will review reports on a more frequent basis and will to the best of our abilities, schedule recertifications well in advance to advance to ensure recertifications are completed timely. Verterans will now be notified at the 60 day mark in order to retain eligibility.
CRT will initiate an outreach plan for low-income representation to fill the open positions on the Board. The President and Chief Executive Officer or designee will solicit Low-Income Director nominations from organizations and groups within the agency or the community that are recognized as serving...
CRT will initiate an outreach plan for low-income representation to fill the open positions on the Board. The President and Chief Executive Officer or designee will solicit Low-Income Director nominations from organizations and groups within the agency or the community that are recognized as serving or representing low-income residents following federal regulations, State statutes, CRT By-Laws and agency approved Democratic Selection Procedures. Upon review of the qualifications of the nominated candidates by the CRT Nominating Subcomittee, they will vote to select the best qualified candidate(s) for appointment to the Board. After the candidate(s) have been determined by the Nominating Subcommitee to meet the qualifications, the Board will vote whether to elect the proposed individual to the Board.
Management Corrective Action Plan: The District acknowledges the finding regarding the untimely submission of required reports to the Pennsylvania Department of Education related to federal grant programs. Management recognizes the importance of timely and accurate reporting to ensure compliance wit...
Management Corrective Action Plan: The District acknowledges the finding regarding the untimely submission of required reports to the Pennsylvania Department of Education related to federal grant programs. Management recognizes the importance of timely and accurate reporting to ensure compliance with grant requirements and maintain effective oversight of federal funding. The delays in submission were primarily the result of staffing transitions within the Business Office and challenges associated with completing prior year financial information needed for reporting purposes. The District has worked cooperatively with the Pennsylvania Department of Education throughout this process and has taken steps to address outstanding reporting requirements. To address this matter, the District has begun implementing corrective actions which include: · Establishing internal reporting calendars and compliance deadlines for all required state and federal submissions; · Assigning specific staff responsibilities for grant reporting and monitoring; · Implementing supervisory review procedures to ensure reports are completed accurately and submitted timely; and · Providing additional oversight and coordination related to federal grant compliance and reporting requirements. Individual(s) Responsible: CFO, Finance Officer Anticipated Completion Date: Prior to issuance of the Fiscal Year 2025 Financial Statements
The Organization is recording all revenue per the conditions the Organization is subjected to in the grant agreement..
The Organization is recording all revenue per the conditions the Organization is subjected to in the grant agreement..
The Organization is recording all fixed assets per their capitalization policy.
The Organization is recording all fixed assets per their capitalization policy.
The Organization is recording non cash donations based on policy
The Organization is recording non cash donations based on policy
The Organization is documenting their review for proper suspension and debarment compliance prior to entering a transaction.
The Organization is documenting their review for proper suspension and debarment compliance prior to entering a transaction.
Finding 2024-007: During the year ended June 30, 2024, Housing Choice Voucher Program funds were used by other federal programs, resulting in Housing Choice Voucher Program funds being used to cover expenses for other federal programs and defederalized funds. a. Comments on the Finding We agree with...
Finding 2024-007: During the year ended June 30, 2024, Housing Choice Voucher Program funds were used by other federal programs, resulting in Housing Choice Voucher Program funds being used to cover expenses for other federal programs and defederalized funds. a. Comments on the Finding We agree with finding 2024-007 b. Action(s) Taken or Planned on the Finding The Authority has hired a new CFO who will provide the leadership and technical assistance needed to ensure the Finance department operates effectively within regulations. The Authority has created new policies ensuring monthly reconciliations and implemented the process of reconciling interfund balances to ensure balances are settled monthly, to ensure funds are not intermingled with other federal programs. Columbia Housing is also in the process of implementing a new software system that will provide software solutions to ensure accurate financial processing.
Finding 2024-006: No electronic income verification was done within the required time period for 1 of 40 participant selections. No abatement of housing assistance payments of failed unit inspections after 30 day maintenance windows was completed on 25 participant selections. a. Comments on the Find...
Finding 2024-006: No electronic income verification was done within the required time period for 1 of 40 participant selections. No abatement of housing assistance payments of failed unit inspections after 30 day maintenance windows was completed on 25 participant selections. a. Comments on the Finding We agree with finding 2024-006 b. Action(s) Taken or Planned on the Finding Annual training on program rules has been established for the Housing Choice Voucher Program, to ensure staff are aware of the proper implementation of the program rules. Additionally, a quality control protocol will be established that will require a review of at least 15% of all files. All failed inspection actions will be reviewed to ensure compliance with abatement protocols.
All federal programs requiring engineering assistance will be also be tracked internally for compliance.
All federal programs requiring engineering assistance will be also be tracked internally for compliance.
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