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Corrective Action Plans

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Finding 1153460 (2025-003)
Material Weakness 2025
Cheboygan Housing Commission
MI
Internal Control / Segregation of Duties
The current Occupancy Specialist is developing a training and implementation plan to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that HQS inspections are pe...
The current Occupancy Specialist is developing a training and implementation plan to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements.
View Audit 366709
Finding 1153459 (2025-002)
Material Weakness 2025
Cheboygan Housing Commission
MI
HUD Housing Programs Internal Control / Segregation of Duties
The current Occupancy Specialist is developing a training and implementation plan to ensure that rent reasonableness calculations are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenan...
The current Occupancy Specialist is developing a training and implementation plan to ensure that rent reasonableness calculations are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of rent reasonableness calculations and other required paperwork is included in the tenant files.
View Audit 366709
Finding 1153458 (2025-001)
Material Weakness 2025
Cheboygan Housing Commission
MI
HUD Housing Programs Internal Control / Segregation of Duties
The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant ...
The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of income from tenants and other required paperwork is included in the tenant files.
View Audit 366709
Finding 1153433 (2025-001)
Material Weakness 2025
Blue Ridge Rural Water CO INC
SC
HUD Housing Programs
The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.
The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.
View Audit 366673
Finding 1153310 (2025-002)
Material Weakness 2025
Mountain Famly Health Centers
CO
Questioned Costs Subrecipient Monitoring Eligibility
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.
View Audit 366550 Questioned Costs: $1
Finding 1153268 (2025-001)
Material Weakness 2025
B.r.l Housing Corporation
OH
HUD Housing Programs Reporting Special Tests & Provisions
Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the f...
Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the full amount was deposited, the delay constituted noncompliance with HUD's timing rules. To address this, management will implement procedures to ensure surplus cash deposits are made within 60 days based on unaudited computations, track and schedule deposits in advance, formally request HUD approval if deferrals are necessary, and maintain documentation of all related communications and approvals for compliance purposes. Actions Taken or Planned on the Findings: This was paid on check # 9841 Working on an implementation program for the future. Completion Date: August 25, 2025 Finding Resolution Status: In-Process Contact Person: Controller: Don Trigg Accountant: Charley Hinkle
View Audit 366462
Finding 1153168 (2025-005)
Material Weakness 2025
Outpatient Medical Center, Inc.
LA
Procurement, Suspension & Debarment § 200.214
2025-005 Suspension and Debarment Corrective action planned: OMC currently has a policy and procedure for vendor exclusion checks prior to executing contracts. This finding appears to be an incidental omission that resulted in no excluded vendors being identified. In one case, the vendor was an exis...
2025-005 Suspension and Debarment Corrective action planned: OMC currently has a policy and procedure for vendor exclusion checks prior to executing contracts. This finding appears to be an incidental omission that resulted in no excluded vendors being identified. In one case, the vendor was an existing one for many years. The CFO/Designee will monitor to assure exclusion checks prior to CEO signing any contracts or purchase orders with any vendor over $25,000 per year and will update policy as necessary in accordance with regulations. OMC will seek HRSA guidance on periodic review of existing vendors Anticipated completion date: September 30, 2025 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393
Finding 1153166 (2025-004)
Material Weakness 2025
Outpatient Medical Center, Inc.
LA
Cash Management Subrecipient Monitoring Material Weakness § 200.305
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
View Audit 366393
Finding 1153164 (2025-003)
Material Weakness 2025
Outpatient Medical Center, Inc.
LA
Questioned Costs Allowable Costs / Cost Principles § 200.403
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
Finding 1153162 (2025-002)
Material Weakness 2025
Outpatient Medical Center, Inc.
LA
Questioned Costs Allowable Costs / Cost Principles
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
Finding 1152940 (2025-001)
Material Weakness 2025
Community Workshop Residentials, INC G / Fha Project No. 072-Hd057
IL
Internal Control / Segregation of Duties HUD Housing Programs
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.
View Audit 366276
Finding 1152930 (2025-002)
Material Weakness 2025
Village of Shepherd
MI
Procurement, Suspension & Debarment
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.
View Audit 366266
Finding 576208 (2025-001)
Material Weakness 2025
Freedom First Federal Credit Union
VA
Material Weakness Period of Performance Reporting
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.
View Audit 366124
Finding 576159 (2025-001)
Material Weakness 2025
Sunrise Community Health
CO
Subrecipient Monitoring Internal Control / Segregation of Duties
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
View Audit 366069
Finding 576151 (2025-006)
Significant Deficiency 2025
Community Action of Southern Indiana
IN
Reporting
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.
View Audit 366061
Finding 576149 (2025-005)
Material Weakness 2025
Community Action of Southern Indiana
IN
Reporting
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.
View Audit 366061
Finding 576147 (2025-004)
Material Weakness 2025
Community Action of Southern Indiana
IN
Internal Control / Segregation of Duties Equipment & Real Property Management Procurement, Suspension & Debarment
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.
View Audit 366061
Finding 576145 (2025-003)
Significant Deficiency 2025
Community Action of Southern Indiana
IN
Cash Management Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303
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.
View Audit 366061
Finding 576119 (2025-001)
Significant Deficiency 2025
Berkshire Retirement Home INC
MA
HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties
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.
View Audit 366047
Finding 576088 (2025-003)
Significant Deficiency 2025
Shelby Township
MI
Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management
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.
View Audit 365991
Finding 576060 (2025-001)
Material Weakness 2025
Verdugo Tower, Inc.
CA
Cash Management HUD Housing Programs
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
View Audit 365952
Sixteenth Street Community Health Centers, Inc.
WI
Special Tests & Provisions HUD Housing Programs
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
View Audit 365931
Grandview Square Cooperative, Inc.
IN
Questioned Costs HUD Housing Programs
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
Grandview Square Cooperative, Inc.
IN
Questioned Costs HUD Housing Programs
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 575878 (2025-001)
Significant Deficiency 2025
Housing Authority of the City of Santa Barbara
CA
HUD Housing Programs Subrecipient Monitoring
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
View Audit 365826
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