Corrective Action Plans

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2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures...
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures claimed for reimbursement and retains this documentation along with supporting invoices. A qualified, knowledgeable CFO will continue to ensure compliance with these requirements. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
2025-003 Period of Performance (repeat of finding 2024-005) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will monitor expenses, and a separate prepaid schedule ha...
2025-003 Period of Performance (repeat of finding 2024-005) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will monitor expenses, and a separate prepaid schedule has been developed to track future period expenses. OMC’s current CFO/Designee has a basic understanding of GAAP. All coding will be reviewed and approved by an authorized, knowledgeable CFO/Designee. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393 Questioned Costs: $1
2025-002 Allowable Costs/Cost Principles (repeat of finding 2024-004) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will continue to monitor to assure compliance w...
2025-002 Allowable Costs/Cost Principles (repeat of finding 2024-004) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will continue to monitor to assure compliance with documentation for all federal expenditures, whether payroll or procurement transactions. All supporting documentation is currently being retained electronically and linked to the corresponding transaction in the financial system. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393 Questioned Costs: $1
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Management is in the process of drafting an updated procurement policy to comply with the new requirements of the Uniform Guidance.
Management is in the process of drafting an updated procurement policy to comply with the new requirements of the Uniform Guidance.
Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.
Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.
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 fe...
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. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will 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. Management meetings will be scheduled with the COO, Director of Operations, and Dental Billing Supervisor(s) to provide updates on progress. Periodic internal auditing of sliding fee scale dental files will be completed. Quarterly management review of sliding fee scale program progress until Athena Dental is fully integrated with Athena Medical, where electronic health record issues were not detected regarding sliding fee scale adjustments. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kevin Maddox, CFO, at 636-236-5180
The Agency acknowledges this error and agrees with the recommendations. With the completion of this audit, the Agency will be caught up after completing four audits in an 18 month time period. This current audit will be submitted by the required deadline and the next regular audit is scheduled to be...
The Agency acknowledges this error and agrees with the recommendations. With the completion of this audit, the Agency will be caught up after completing four audits in an 18 month time period. This current audit will be submitted by the required deadline and the next regular audit is scheduled to begin shortly after the close of FY 25-26.
The Agency acknowledges this error and agrees with the recommendations. It is the Agency's opinion that this finding is a direct outcome of the reconciliation issues outlined in Findings 001-003. As those deficiencies are addressed systemically, the accuracy of SF-425 reports will be restored and ma...
The Agency acknowledges this error and agrees with the recommendations. It is the Agency's opinion that this finding is a direct outcome of the reconciliation issues outlined in Findings 001-003. As those deficiencies are addressed systemically, the accuracy of SF-425 reports will be restored and maintained.
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that the referenced actions took place in 2020, more than four years before the current audit period. This issue is not reflective of CASI's current internal control environment and doe...
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that the referenced actions took place in 2020, more than four years before the current audit period. This issue is not reflective of CASI's current internal control environment and does not represent an active or ongoing failure. This was an isolated instance resulting from the actions of a previous administration, whose financial and compliance oversight practices have since been fully overhauled.Since then, CASI has undergone significant changes in staff and Board leadership, financial controls, and Head Start compliance procedures, which directly mitigate any recurrence of this issue. The current leadership bas self-disclosed the issue and is actively working to resolve it. This matter was voluntarily identified and disclosed by current leadership to both the auditors and the Head Start Regional Office. Efforts are ongoing to correct the SF-429 and properly record a Notice of Federal Interest in collaboration with OHS, despite delays resulting from the broader federal restructuring of the Head Start regional offices.
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that it has been determined that where incorrect drawdowns were made - they were underdrawn, not overdrawn. No drawdowns were determined to include anything beyond known, justifiable, a...
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that it has been determined that where incorrect drawdowns were made - they were underdrawn, not overdrawn. No drawdowns were determined to include anything beyond known, justifiable, and allowable expenses. Previous T &TA support from the Office of Head Start and monitoring reviews from other fiscal agencies had not previously revealed this concern and recommendations were made to carry out drawdowns in this manner. The Finance department is actively working with the new recommendation from the auditors to use the accounting system (MIP) and to implement a new payroll and reconciliation procedure which will prevent future errors.
FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should incr...
FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was increased from $1,182,615 to $1 ,282,815 effective 6/1/2025 with annual insurance renewals to be above the minimum required threshold. The new process implemented will now assess the budgeted potential organizational revenue growth prospectively in the current fiscal year and any calculation increase required will be made prior to the end of the current fiscal year before the insurance renewal for the next fiscal year to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Completion date for corrective action plan: 06/01/2025 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Edward Forfa, Executive Director at 413-445-4056 ext. 160.
Finding 576088 (2025-003)
Significant Deficiency 2025
Finding 2025-003: 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 proced...
Finding 2025-003: 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 individual grant to ensure that individual disbursements are not allocated to more than one grant. Action Taken: The Township will create a spreadsheet to track expenditures by individual grants that will be updated as individual disbursements and receipts occur. Responsible Person and Anticipated Completion Date: Township Treasurer, March 31, 2026. If the Michigan Strategic Fund has questions regarding this plan, please call Rebecca Griffin at 231-861-5853.
FINDING NUMBER 2025-001 Reporting views of responsible officials: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Auditors' summary of auditee's comments on the findings and recommendati...
FINDING NUMBER 2025-001 Reporting views of responsible officials: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Auditors' summary of auditee's comments on the findings and recommendations: The Company will develop a plan to monitor the cash balances in the financial institutions to ensure that cash balances are maintained within HUD’s guidelines. Response indicator: Agree. Response: The Company will work with the financial institutions to ensure that HUD’s requirements are followed. Completion date: September 30, 2025
Finding: We found one (1) instance where adequate documentation was not maintained to ensure the appropriate amount was charged to a patient based on the sliding fee policy in place. Upon further analysis, there were a total of four (4) instances where appropriate documentation was not maintained re...
Finding: We found one (1) instance where adequate documentation was not maintained to ensure the appropriate amount was charged to a patient based on the sliding fee policy in place. Upon further analysis, there were a total of four (4) instances where appropriate documentation was not maintained relating to fiscal year 2025. Uniform Guidance requires the Organization to be in compliance with special tests and provisions. This includes maintaining appropriate documentation of the application and fee determination for every patient utilizing the sliding fee discount. This is a repeat of finding 2024-003 from the prior year. One error was identified during our testing. Expanded procedures identified that the population impacted were four individuals. The amount of questioned costs cannot be determined. A sample of 40 individuals were selected and tested for compliance with the Organization's sliding fee policy. One (1) known compliance error was found during testing of the 40 individuals. Upon analyzing the entire population, it was determined that a total of four (4) files were not in compliance. The Organization was not in compliance with the requirements of the federal program due to a scanner malfunction where the application and supporting documentation were not adequately scanned, resulting in a corrupt file. Cause: Management has indicated that the scanner malfunction lead to the noncompliance. Upon the realization of the scanner issue, it was replaced and an analysis was performed for any other patient files that may have been corrupted. Management review of the entire population identified a total of (4) four files that were corrupt relating to fiscal year 2025. Corrective Response: Management is in agreement with the above analysis by the auditors. The issue was discovered and corrected with an update to the server and an update to the process to ensure that all scans are reviewed prior to the destruction of the original documents. This was fully resolved prior to the fiscal year end. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: CFO/Revenue Cycle Director/Director of Clinical Ops/Vice President of IT
The replacement reserve account was underfunded in the amount of $1,120 during the year ended May 31, 2025. Management will deposit the required amount into the replacement reserve and confirm all future required deposit increases are implemented.
The replacement reserve account was underfunded in the amount of $1,120 during the year ended May 31, 2025. Management will deposit the required amount into the replacement reserve and confirm all future required deposit increases are implemented.
View Audit 365848 Questioned Costs: $1
Total annual withdrawals made from the general operating reserve were in excess of 20% of prior year’s ending balance. Management will obtain approval from HUD for withdrawals made from the general operating reserve during the year ended May 31, 2025 in the amount of $24,741.
Total annual withdrawals made from the general operating reserve were in excess of 20% of prior year’s ending balance. Management will obtain approval from HUD for withdrawals made from the general operating reserve during the year ended May 31, 2025 in the amount of $24,741.
View Audit 365848 Questioned Costs: $1
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforc...
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforcement, including rent abatement. Further internal procedures implemented to ensure additional contractor oversight and postrepair audits to ensure that failed HQS inspections are remedied properly and timely. Responsible Party: Andrea Fink, Housing Programs & Services Manager Timeline: Full implementation of the CAP by 9/15/2025 This Corrective Action Plan has been reviewed and approved by: -;t((t ih= Rob L. Fredericks (Aug 20. 2025 10:00:43 PDT) Rob L. Fredericks Executive Director/CEO
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of ...
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of March 31, 2025, the physical inspection is closed. Action(s) taken or planned on the finding: Management has responded to HUD in regard to this inspection report and has addressed all exigent health and safety issues.
Finding: The enrollment statuses in the National Student Loan Data System for students who took a Regular Academic Hiatus were incorrect during the time of their hiatus. Corrective Actions Taken or Planned: FNU will change the reported enrollment status of all students on a regular Academic Hiatus...
Finding: The enrollment statuses in the National Student Loan Data System for students who took a Regular Academic Hiatus were incorrect during the time of their hiatus. Corrective Actions Taken or Planned: FNU will change the reported enrollment status of all students on a regular Academic Hiatus (AH) from “Enrolled” to “Leave of Absence (LOA)” in the National Student Clearinghouse (NSC). Note that both status types indicate an enrolled status per NSC. To support this change, FNU will revise its internal procedures to ensure that students on a regular AH are coded as “Leave” in the Student Learning Management System. This status accurately reflects a temporary interruption in their program of study and aligns with enrollment reporting requirements. We will strengthen training for all staff involved in enrollment status reporting to ensure consistent understanding and proper implementation of the updated procedures. We believe these steps are important for improving the accuracy of our reporting and staying in compliance with federal student aid requirements. Estimated Completion Date: September 30, 2025 Responsible Personnel: Janice Ponstein, Director of Academic Records & Registrar
Finding 575602 (2025-004)
Significant Deficiency 2025
Finding 2025-004: Coronavirus State and Local Fiscal Recovery Funds Reporting Procedures Type of Finding: Control U.S. Department of Treasury Pass-through Entities: The Right Place, Inc. and Michigan Department of Treasury. Assistance Listing Number: 21.027 Award Numbers: COVID-19 Revitaliza...
Finding 2025-004: Coronavirus State and Local Fiscal Recovery Funds Reporting Procedures Type of Finding: Control U.S. Department of Treasury Pass-through Entities: The Right Place, Inc. and Michigan Department of Treasury. Assistance Listing Number: 21.027 Award Numbers: COVID-19 Revitalization and Placemaking Grant, COVID-19 American Rescue Plan Act Award Year End: June 30, 2026 and December 31, 2026 Specific Requirement: (L.) Reporting Recommendation: The Village should follow established procedures to require the documented review and approval of both RAP and ARPA grant reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Village is implementing a new procedure requiring that ARPA grant reports be reviewed and approved by a designated reviewer before submission in addition to RAP grant reports. The reviewer, who must possess the appropriate skills, knowledge, and experience relevant to the report's content, will ensure that the information is accurate, complete, and compliant with organizational standards and regulatory requirements. Responsible Person and Anticipated Completion Date: The Village Clerk/Treasurer will oversee the implementation of this plan by February 28, 2026. If the Michigan Strategic Fund has questions regarding this plan, please call Phillip Morse at 231-861-4401.
Finding 575601 (2025-003)
Significant Deficiency 2025
Finding 2025-003: Community Development Block Grants Equipment Procedures Type of Finding: Both Compliance and Control U.S. Department of Housing and Urban Development Pass-through Entity: Michigan Strategic Fund Assistance Listing Number: 14.228 Award Numbers: MSC 22003-PGS and MSC-221009-WRI ...
Finding 2025-003: Community Development Block Grants Equipment Procedures Type of Finding: Both Compliance and Control U.S. Department of Housing and Urban Development Pass-through Entity: Michigan Strategic Fund Assistance Listing Number: 14.228 Award Numbers: MSC 22003-PGS and MSC-221009-WRI Award Year Ends: November 30, 2024, and December 31, 2024 Recommendation: The Village should establish procedures to require the maintenance of detailed fixed asset records that include all specified elements. In addition, the Village should perform a physical inventory of the property and reconcile the results with fixed asset records at least once every two years to help prevent loss, damage, or theft of the property. Action Taken: The Village will establish a standard operating procedure that requires the maintenance of detailed asset records and the performance of a documented physical inventory of the assets acquired with federal funds on an annual basis. Responsible Person and Anticipated Completion Date: The Village Clerk/Treasurer will oversee the implementation of this plan by February 28, 2026.
The Authority agrees that this deficiency exists. Management plans to review policies and procedures and revise them as needed to include procedures related to suspension and debarment.
The Authority agrees that this deficiency exists. Management plans to review policies and procedures and revise them as needed to include procedures related to suspension and debarment.
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.
Finding 575411 (2025-002)
Significant Deficiency 2025
Views of Responsible Officials and Planned Corrective Actions – To address the identified issues related to student withdrawal processing and Return to Title IV (R2T4) calculations, the University will implement the following steps: 1. Process Review and Collaboration: A joint meeting will be held w...
Views of Responsible Officials and Planned Corrective Actions – To address the identified issues related to student withdrawal processing and Return to Title IV (R2T4) calculations, the University will implement the following steps: 1. Process Review and Collaboration: A joint meeting will be held with key personnel from Academic Records and Financial Aid to review current withdrawal procedures, including the use of drop and exit forms. Emphasis will be placed on ensuring that appropriate withdrawal codes are consistently applied to support accurate and automated R2T4 processing. The goal is to establish a unified and clearly documented process that meets the operational needs of both departments. 2. Systematic Scheduling and Monitoring: Withdrawal-related tasks, including the running of BANNER return reports and other custom reports developed by the IT team, will be scheduled at regular intervals to ensure timely identification and processing of student withdrawals. These tasks will be integrated into departmental calendars, with scheduled dates already entered for the Fall 2025 and Spring 2026 semesters. 3. Ongoing Oversight and Communication: A communication protocol will be developed to ensure that all relevant documentation, including drop forms, is consistently shared between departments. This will help prevent delays in processing and ensure compliance with federal financial aid regulations.
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