Corrective Action Plans

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Finding 575409 (2025-001)
Significant Deficiency 2025
Views of Responsible Officials and Planned Corrective Actions – The National Student Clearinghouse (NSC) Graduation and Enrollment Change Status’ submission calendar will be updated to reflect the necessary reporting timeline. The report will be completed after verification of graduation requirement...
Views of Responsible Officials and Planned Corrective Actions – The National Student Clearinghouse (NSC) Graduation and Enrollment Change Status’ submission calendar will be updated to reflect the necessary reporting timeline. The report will be completed after verification of graduation requirements and credentialing are completed by the Academic Record’s Department. Additional training will be provided to all members within the department to ensure timely submissions.
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residua...
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residual receipts deposit is made within 90 days of fiscal year end. Management response: Agree. Management made the required residual receipts deposit on January 8, 2025.
View Audit 365221 Questioned Costs: $1
Finding 574904 (2025-001)
Significant Deficiency 2025
A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA VIII, Inc. requires segregation of duties. We recognize that the current structure does not adequatel...
A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA VIII, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Finance Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Accountant who has assumed responsibility for the day-to-day accounting tasks previously performed by the Senior Director of Housing & Facilities. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.
Finding 574903 (2025-001)
Significant Deficiency 2025
A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA VII, Inc. requires segregation of duties. We recognize that the current structure does not adequately...
A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA VII, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Finance Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Accountant who has assumed responsibility for the day-to-day accounting tasks previously performed by the Senior Director of Housing & Facilities. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.
Finding 574902 (2025-001)
Significant Deficiency 2025
A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA IV, Inc. requires segregation of duties. We recognize that the current structure does not adequately ...
A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA IV, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Finance Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Accountant who has assumed responsibility for the day-to-day accounting tasks previously performed by the Senior Director of Housing & Facilities. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.
Views of responsible official and planned corrective actions: The financial personnel of the Organization will document their review and approval of all grant related expenditures. Any issues brought to the attention of the Organization staff have been addressed and corrective actions have been take...
Views of responsible official and planned corrective actions: The financial personnel of the Organization will document their review and approval of all grant related expenditures. Any issues brought to the attention of the Organization staff have been addressed and corrective actions have been taken where applicable.
Audit Finding 2025-002: The regulatory agreement stipulates that all withdrawals from the Reserve for Replacement Account be supported by invoices and payments as proof of amounts expended. An invoice of $1,707 was duplicated while calculating the funds to be withdrawn from the Reserve for Replacem...
Audit Finding 2025-002: The regulatory agreement stipulates that all withdrawals from the Reserve for Replacement Account be supported by invoices and payments as proof of amounts expended. An invoice of $1,707 was duplicated while calculating the funds to be withdrawn from the Reserve for Replacement account . Response: Management agrees with the finding and has refunded $1,707 to the Reserve for Replacement Account on August 12, 2025.
Audit Finding 2025-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. Several withdrawals totaling $108,111 for emergency repairs and improvements, to cover payroll, pay audit fees and for ...
Audit Finding 2025-001: The regulatory agreement stipulates that all withdrawals exceeding $2,500 from the Reserve for Replacement Account need prior written consent of the lender. Several withdrawals totaling $108,111 for emergency repairs and improvements, to cover payroll, pay audit fees and for other operating expenses were made from the Reserve for Replacement account without prior approval from the lender. Response: Management agrees with the finding, was aware of the requirement for prior approval and on April 30, 2025, and has obtained retroactive approval from the lender for the withdrawal of 108,111.
Audit Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months. -Response: Management believed that including this expenditure in its request for withdrawal of funds from the reserv...
Audit Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months. -Response: Management believed that including this expenditure in its request for withdrawal of funds from the reserve for replacement account was sufficient. Management also promptly replaced the funds taken temporarily from the residual receipts account, once they received the funds from the reserve for replacement account controlled by the lender. In the future, management will make sure to obtain prior approval from HUD before making any withdrawals from the residual receipts account.
Audit Finding 2025-001: During our testing of reserve for replacement account transactions, it was discovered that the Project had made deposits of an insufficient amount each month for 22 months through September 2024. -Response: The reserve for replacement account is controlled by the lender and ...
Audit Finding 2025-001: During our testing of reserve for replacement account transactions, it was discovered that the Project had made deposits of an insufficient amount each month for 22 months through September 2024. -Response: The reserve for replacement account is controlled by the lender and when the lender discovered the deficiency during the year ended May 31, 2025 a lumpsum amount was drafted from the Project's monthly payment to cover the shortfall. In future, Management will inform the lender of changes to the monthly required deposit to the reserve for replacement account made by HUD.
Finding No. 2025-001 Residual receipts deposit We agree. Condition: The residual cash surplus of $49,570 for the fiscal year ended March 31, 2024, was deposited into the Residual Receipts account approximately 12 months after the fiscal year-end, exceeding the 90-day HUD requirement. Cause: The dela...
Finding No. 2025-001 Residual receipts deposit We agree. Condition: The residual cash surplus of $49,570 for the fiscal year ended March 31, 2024, was deposited into the Residual Receipts account approximately 12 months after the fiscal year-end, exceeding the 90-day HUD requirement. Cause: The delay was due to a discrepancy in the Employer Identification Number (EIN) on file with the financial institution, which prevented the timely opening of the required account. Planned Corrective Actions: A formal review will be conducted within 30 days after the fiscal year-end to assess surplus cash status and initiate the deposit process. All communications and actions related to the residual receipt deposit will be documented and retained for audit purposes.
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer, Fleis & Vandenbrink, has searched the state procurement office webpage to check if any vendor f...
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer, Fleis & Vandenbrink, has searched the state procurement office webpage to check if any vendor for a federal project is on the debarment list, which they are not. In the future, the Village will have controls in place to ensure that vendors are not debarred or suspended from federal funding awards. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2026 fiscal year. The plan for adherence is the Council will review implement controls to ensure that vendors are not suspended, debarred, or otherwise excluded.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2026 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2025 Estimated Completion Date: September 2025 Finding #2025-001 – Statement of Condition Patients did not receive the proper sliding f...
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2025 Estimated Completion Date: September 2025 Finding #2025-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. The Office Managers have continued reviewing all new sliding fee applications on a monthly basis to ensure accuracy. The Billing Manager have continued to conduct quarterly audits of sliding fee claims to ensure the adjustments are entered correctly by the billing department. The Organization has also launched additional training for all individuals involved in the sliding fee application process as well as automated sliding fee adjustments to reduce errors.
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, an...
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, and if there is a balance that cannot be repaid, a payment plan will be established. Working with fee accountants during this process monthly will ensure there are no balances remaining at year end.
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 reg...
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 regarding required reference year for financial data used in preparing HUD Form 52723. o Each year prior to submission of HUD form 52723, the Authority will review all relevant PIH notices regarding calculation of the Public Housing Operating Subsidy, will adhere to the most current requirements, and will update its internal control documents and procedures to ensure consistency with current HUD guidance. Specifically, formula income, audit costs, and PILOT will be based on the Financial Data Schedule defined by HUD.
Grant accountants will review all new grant awards for reporting schedules at their inception to ensure that off-cycle reporting requirements are included in the calendar, and review that the reports are available in the Payment Management Services (PMS) system monthly and include all known reports ...
Grant accountants will review all new grant awards for reporting schedules at their inception to ensure that off-cycle reporting requirements are included in the calendar, and review that the reports are available in the Payment Management Services (PMS) system monthly and include all known reports due. Grants Manager will review the calendar monthly to ensure that it is maintained with accurate information and the reporting steps are being addressed.
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance cover...
2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance coverage is reviewed annually and adjusted as necessary to meet HUD requirements. Explanation of disagreement with audit finding: Management is in agreement with the finding. Prior to affiliating with Silverstone Living, the Foundation had a separate endorsement included in their Property Coverage policy that included increased crime coverage to comply with HUD requirements. After transferring coverage to Silverstone Living’s policies, the increased crime coverage did not get transferred over to keep the Foundation in compliance. Action taken in response to finding: The Foundation is actively working with its insurance provider to increase coverage to the required level. The revised policy is expected to be in place by July 31, 2025. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 31, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Janet Langlois at 603-589-4111.
U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed bel...
U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs – Major Federal Programs U.S. Department of Housing and Urban Development 2025-001 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: CLA recommends that management ensures the regulatory agreement is being followed by all parties involved, unless otherwise instructed by a HUD representative. Any communication regarding changes to the regulatory agreement should come directly from HUD. Explanation of disagreement with audit finding: Management is in agreement with the finding. They received miscommunication from Lument. Since the Foundation goes through Lument for HUD requests and approvals, management thought the communication they received from Lument was approved by HUD. As a result, management was under the impression that the residual receipts account was fully funded, and the deposit of surplus cash was not required. Action taken in response to finding: On July 18, 2025, management submitted a formal request to HUD to suspend deposits to the residual receipts fund. On July 21, 2025, HUD approved a suspension of deposits to the reserve as long as a balance of $640,856.81 is maintained. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 21, 2025.
The Organization should keep track of the monthly payments required as set by the annual form HUD-9250.
The Organization should keep track of the monthly payments required as set by the annual form HUD-9250.
Upon Management’s review of the finding it was decided that the Chief Operations Officer and the Chief Financial Officer will each audit 10 sliding fee scale patient profiles per month (totaling 20 per month) to determine if necessary documentation has been filed. This practice will help management ...
Upon Management’s review of the finding it was decided that the Chief Operations Officer and the Chief Financial Officer will each audit 10 sliding fee scale patient profiles per month (totaling 20 per month) to determine if necessary documentation has been filed. This practice will help management discover deficiencies in the execution of our sliding fee scale policies and to implement corrective practices accordingly.
The Finance and Compliance Team has an established comprehensive process for managing new grant awards. Upon receiving a new grant, the team meticulously reviews all relevant documents to ensure that all compliance requirements, including reporting deadlines, are accurately recorded in the HUB. A Fi...
The Finance and Compliance Team has an established comprehensive process for managing new grant awards. Upon receiving a new grant, the team meticulously reviews all relevant documents to ensure that all compliance requirements, including reporting deadlines, are accurately recorded in the HUB. A Finance and Compliance Business Partner (FCBP) is assigned to each grant and is responsible for preparing and submitting grant reports. These reports must be approved by the Head of Finance and Compliance before submission to ensure accuracy and compliance with grantor requirements. Regarding the quarterly report due on January 31, 2025 submitted three business days past the original deadline, the delay was due to the unprecedented crisis following the announcement of the stop order from President Trump. During this period, we were unable to reach our contacts at the United States Agency for International Development (USAID) and were in continuous discussions with our Legal team to determine the best course of action during that time. This situation required us to make critical decisions concerning the Women in the Digital Economy Fund (WIDEF) team in London and New Delhi. The Foundation was timely on all other quarterly and annual reporting requirements. We believe that our current process for managing grants and reporting to grantors is robust and effective. The delay in the submission of the quarterly report was an exceptional circumstance, and we do not anticipate any significant changes to our existing procedures. Further, based termination notice reference in footnote 6, the Foundation no longer has access to this grant.
The $4,945.78 has been transferred back into the reserve for replacement account. To ensure this will not happen again the Assistant Controller will review the Reserve for Replacement Request before sending to HUD.
The $4,945.78 has been transferred back into the reserve for replacement account. To ensure this will not happen again the Assistant Controller will review the Reserve for Replacement Request before sending to HUD.
View Audit 363992 Questioned Costs: $1
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