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Corrective Action Plans

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Finding 576049 (2024-002)
Material Weakness 2024
City of Winslow, Arizona
AZ
HUD Housing Programs Material Weakness Internal Control / Segregation of Duties
Finding Number: 2024‐002 Program Name/Assistance Listing Title: Housing Voucher Cluster Assistance Listing Number: 14.871 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective Action: The City concurs with the finding and has updated...
Finding Number: 2024‐002 Program Name/Assistance Listing Title: Housing Voucher Cluster Assistance Listing Number: 14.871 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective Action: The City concurs with the finding and has updated its policies and procedures and implemented the recommendation. Vacancies for certain position are hard to fill in rural Arizona such as the City of Winslow. Due to a vacancy in the PHA, the Director was managing the financials and the day‐to‐day activities for the rental properties onsite as well as doing the required inspections of housing vouchers offsite. The overwhelming responsibilities have been the cause of the aforementioned findings. Moving forward, management acknowledges the need to reassign staff to the PHA when there is a vacancy. The PHA has been fully staffed the latter part of fiscal year 2024 and has implemented the recommendations of the independent auditors during fiscal year 2025.
View Audit 365941
Finding 576047 (2024-001)
Material Weakness 2024
City of Winslow, Arizona
AZ
Reporting HUD Housing Programs § 200.303 § 200.512
Finding Number: 2024‐001 Program Name/Assistance Listing Title: Housing Voucher Cluster, Coronavirus State and Local Fiscal Recovery Fund Assistance Listing Number: 14.871, 21.207 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective...
Finding Number: 2024‐001 Program Name/Assistance Listing Title: Housing Voucher Cluster, Coronavirus State and Local Fiscal Recovery Fund Assistance Listing Number: 14.871, 21.207 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective Action: The City concurs with the finding and has updated its policies and procedures and implemented the recommendation.
View Audit 365941
Finding 576045 (2024-004)
Significant Deficiency 2024
Cimarron Watershed Alliance, Inc.
NM
Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management § 200.302 § 200.305 § 200.318
Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible C...
Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible Contact Person: Rick Smith, Executive Director
View Audit 365934
Third Street Community Clinic Dba Third Street Family Health Services
OH
Reporting
Finding Number: 2024-003 Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of th...
Finding Number: 2024-003 Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Peggy Anderson, Chief Executive Officer
View Audit 365929
Finding 576035 (2024-002)
Significant Deficiency 2024
Third Street Community Clinic Dba Third Street Family Health Services
OH
Special Tests & Provisions
Finding Number: 2024-002 Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the set up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Furth...
Finding Number: 2024-002 Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the set up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Further, the Organization will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Peggy Anderson, Chief Executive Officer
View Audit 365929
Finding 576033 (2024-002)
Significant Deficiency 2024
Public Housing Authority of Butte
MT
HUD Housing Programs Eligibility Reporting
2024‐002 HUD Required Reporting HUD regulations and federal requirements mandate timely submission of the Unaudited Financial Assessment Subsystem for Public Housing Agencies (FASSPHA). During the audit, it was noted that the Authority did not meet the prescribed deadlines for submitting the unaudit...
2024‐002 HUD Required Reporting HUD regulations and federal requirements mandate timely submission of the Unaudited Financial Assessment Subsystem for Public Housing Agencies (FASSPHA). During the audit, it was noted that the Authority did not meet the prescribed deadlines for submitting the unaudited FASSPHA to federal agencies. The Public Housing Authority of Butte has contracted with BDO to prepare and submit the unaudited FASSPH. BDO prepared and submitted the unaudited FASSPH for fiscal year ending 2024. Going forward BDO will continue to assist the Public Housing Authority of Butte with preparing and submitting the unaudited financial reports. The Public Housing Authority of Butte has hired a Deputy Executive Director who will be able to closely monitor HUD deadlines and reporting requirements.
View Audit 365924
Finding 576029 (2024-002)
Significant Deficiency 2024
Pomona Community Health Center Dba Parktree Community Health Center
CA
Special Tests & Provisions Eligibility Significant Deficiency
2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents ...
2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents are retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on document retention policies in relation to the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review of current patient sliding fee applications to ensure all required documents are maintained and retained for the appropriate length of time as per PCHC Board of Director approved policies. Weekly audits verifying supporting documents for the sliding fee applications are conducted under the supervision of management, and improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025
View Audit 365919
Finding 576025 (2024-001)
Significant Deficiency 2024
Pomona Community Health Center Dba Parktree Community Health Center
CA
Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties
2024-001 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over demographic data and income verification information entered into the patient billing system in order to ensure the financial classification ...
2024-001 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over demographic data and income verification information entered into the patient billing system in order to ensure the financial classification is correct. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review process of prior period patient sliding fee applications and approved slide adjustment calculations. Weekly audits of patient applications are conducted under the supervision of management to ensure the financial classification is correct. Improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025.
View Audit 365919
Barrett Dewitt Housing Development Fund Company, Inc.
NY
Subrecipient Monitoring Reporting § 200.512
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Barrett Dewitt Housing Development Fund...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Barrett Dewitt Housing Development Fund Company, Inc. agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
View Audit 365903
Byrne Manor Housing Development Fund Company, Inc.
NY
HUD Housing Programs Cash Management
Finding #2024-003 Section 202 Supportive Housing for the Elderly – (Capital Advance); ALN 14.157: Recommendation: We recommend that management implement procedures to ensure that required funds are deposited into the residual receipts reserve account in the future within the 60-day requirement. Ac...
Finding #2024-003 Section 202 Supportive Housing for the Elderly – (Capital Advance); ALN 14.157: Recommendation: We recommend that management implement procedures to ensure that required funds are deposited into the residual receipts reserve account in the future within the 60-day requirement. Action taken: Byrne Manor Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely and accurate deposits in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
View Audit 365902
Byrne Manor Housing Development Fund Company, Inc.
NY
Reporting § 200.512
Finding #2024-002 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Byrne Manor Apartments agrees with the au...
Finding #2024-002 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Byrne Manor Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
View Audit 365902
Byrne Manor Housing Development Fund Company, Inc.
NY
Subrecipient Monitoring Reporting § 200.512
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Byrne Manor Apartments agrees with the ...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Byrne Manor Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
View Audit 365902
R.j. Barrett Manor Housing Development Fund Company, Inc.
NY
Subrecipient Monitoring Reporting § 200.512
Finding #2024-002 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: R.J. Barrett Manor Housing Development Fu...
Finding #2024-002 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: R.J. Barrett Manor Housing Development Fund Company, Inc. agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
View Audit 365901
R.j. Barrett Manor Housing Development Fund Company, Inc.
NY
Subrecipient Monitoring Reporting § 200.512
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: R.J. Barrett Manor Housing Development ...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: R.J. Barrett Manor Housing Development Fund Company, Inc. agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
View Audit 365901
Finding 575996 (2024-003)
Material Weakness 2024
Young Women's Christian Association of Northeast Kansas
KS
Reporting Subrecipient Monitoring § 200.303 § 200.329
Contact person responsible for correction action – Linda Aziz, Chief Financial Officer Anticipated completion date – August 29, 2025 Corrective action The YWCA agrees with the finding. Grant reporting responsibilities will be clarified in policy updates. A Grant Compliance Manager position will be c...
Contact person responsible for correction action – Linda Aziz, Chief Financial Officer Anticipated completion date – August 29, 2025 Corrective action The YWCA agrees with the finding. Grant reporting responsibilities will be clarified in policy updates. A Grant Compliance Manager position will be created to support timely, accurate reporting. Staff will receive additional training, and regular internal reviews will be conducted to ensure compliance and address discrepancies.
View Audit 365889
Finding 575995 (2024-002)
Significant Deficiency 2024
Young Women's Christian Association of Northeast Kansas
KS
Questioned Costs Subrecipient Monitoring Significant Deficiency § 200.303
Contact person responsible for correction action – Linda Aziz, Chief Financial Officer Anticipated completion date – August 29, 2025 Corrective action YWCA of Northeast Kansas agrees with the finding. An addendum to the Grant Oversight Policy will require quarterly reviews of grant expenditures. The...
Contact person responsible for correction action – Linda Aziz, Chief Financial Officer Anticipated completion date – August 29, 2025 Corrective action YWCA of Northeast Kansas agrees with the finding. An addendum to the Grant Oversight Policy will require quarterly reviews of grant expenditures. The CFO will ensure expenditures are properly coded and reported in the correct period, in collaboration with accounting partners. Discrepancies will be promptly addressed.
View Audit 365889 Questioned Costs: $1
The Indianapolis Foundation
IN
Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring
Corrective Action Taken: Upon being notified of the discrepancies, The Indianapolis Foundation notified the City of Indianapolis. A forensic financial review was conducted to verify the questioned costs and all findings were shared with relevant stakeholders. The funds were repaid by the subrecip...
Corrective Action Taken: Upon being notified of the discrepancies, The Indianapolis Foundation notified the City of Indianapolis. A forensic financial review was conducted to verify the questioned costs and all findings were shared with relevant stakeholders. The funds were repaid by the subrecipient to The Indianapolis Foundation on December 23, 2024, and the unspent remaining grant funds were subsequently returned as well. The Indianapolis Foundation and subrecipient took decisive action to address the malfeasance, recover funds and prevent future occurences. Individual Responsible: Lorenzo Esters, President - The Indianapolis Foundation Anticipated Date of Completion: December 31, 2024
View Audit 365878 Questioned Costs: $1
Finding 575955 (2024-004)
Significant Deficiency 2024
Town of Gorham
ME
Reporting
Management response/corrective action: The Town Council approves the projects for ARPA and the department that the project is related to manages the project and codes the invoices. The Finance Department has two staff and has been implementing new financial software. Due to the volume of work the Fi...
Management response/corrective action: The Town Council approves the projects for ARPA and the department that the project is related to manages the project and codes the invoices. The Finance Department has two staff and has been implementing new financial software. Due to the volume of work the Finance Department cannot reconcile the Town’s expenditure routinely. Everything posted to ARPA is reviewed to make sure the cost is appropriate during the reporting period ending March 31st. The report is filed as of 4/30/24, based on the snapshot of what was coded to the ARPA expense lines as of March 31st. No costs reported were not considered ARPA expenses. At year end, a thorough review of all the Town’s expenditure is done, and some ARPA costs were found coded to non-ARPA account. These costs were moved to the ARPA account in June as part of year end entries. Some of these costs were paid in the reporting period of March 31st and had they been coded correctly they would have been in that report. These costs were captured in the next annual report that is due 04/30/25. The Finance Department staff will be increasing to three in FY26 so this will give the Finance Director more time to review the monthly expenditure to find any miscoded invoices.
View Audit 365875
Finding 575954 (2024-003)
Significant Deficiency 2024
Town of Gorham
ME
Procurement, Suspension & Debarment
Management’s response/corrective action plan: The School routinely looks for competitive pricing before the procurement of micro-purchases but does not retain evidence of doing so. The School will develop and implement a procedure for recording and retaining the comparison of minimally three source ...
Management’s response/corrective action plan: The School routinely looks for competitive pricing before the procurement of micro-purchases but does not retain evidence of doing so. The School will develop and implement a procedure for recording and retaining the comparison of minimally three source vendors.
View Audit 365875
Finding 575953 (2024-002)
Significant Deficiency 2024
Town of Gorham
ME
Procurement, Suspension & Debarment
Management’s response/corrective action plan: School: The School verifies vendors are not suspended or disbarred but does not retain the evidence of doing so. The School will develop and implement a procedure for recording and retaining the verification of vendors. Town: The Town was unaware of this...
Management’s response/corrective action plan: School: The School verifies vendors are not suspended or disbarred but does not retain the evidence of doing so. The School will develop and implement a procedure for recording and retaining the verification of vendors. Town: The Town was unaware of this step in the federal procurement process until April 2024. At this point, most of the ARPA projects have already begun which makes this a repeat finding. The Town has checked the vendors of any projects that started after the finding notification. The Finance Director has communicated to the departments that administer the grant expenditure that this process needs to be done. The Town has checked the vendors of any projects that started after the original finding notification.
View Audit 365875
Finding 575952 (2024-001)
Significant Deficiency 2024
Town of Gorham
ME
HUD Housing Programs Cash Management Reporting
Management response/corrective action: The Town of Gorham does not have a grant manager. The Finance Department consists of two staff and are unable to manage all the Town’s grants. The Town was awarded this grant in March 2023, but the grant application was not fully approved by HUD until 2/28/24, ...
Management response/corrective action: The Town of Gorham does not have a grant manager. The Finance Department consists of two staff and are unable to manage all the Town’s grants. The Town was awarded this grant in March 2023, but the grant application was not fully approved by HUD until 2/28/24, due to HUD staff turnover. Until the grant was fully approved, the Town did not have access to the HUD portal to do the progress reports. The Town had trouble accessing the HUD portal which took months of troubleshooting. The Town was in constant contact with HUD in the progress reporting and voucher reimbursement process, so HUD was aware that the reports would be late. The Town will emphasize the importance of filing reports on time and putting the deadlines in their work calendars.
View Audit 365875
Finding 575951 (2024-001)
Significant Deficiency 2024
Hazelden Betty Ford Foundation and Subsidiaries
MN
Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking
Finding 2024-001: Non-compliance with Special Tests and Provisions: Disbursements Condition For 3 of 25 students selected for testing, the disbursement dates did not agree between the student’s institutional account and the data reported to COD. Each student had disbursements that were later partial...
Finding 2024-001: Non-compliance with Special Tests and Provisions: Disbursements Condition For 3 of 25 students selected for testing, the disbursement dates did not agree between the student’s institutional account and the data reported to COD. Each student had disbursements that were later partially or fully refunded. The sample was not a statistically valid sample. Recommendation It is recommended that policies, procedures and effective controls are put in place to verify that the disbursement dates for federal funds are matching between the student account detail and the COD system. Corrective Action The Foundation will ensure that policies, procedures and effective controls are in place to verify the matching of the disbursement dates for federal funds between the student account detail and the COD system. Anticipated completion date of implementing the corrective action plan will be immediate.
View Audit 365871 Questioned Costs: $1
Senior Citizens Housing Development Corporation of Washington
FL
HUD Housing Programs Internal Control / Segregation of Duties Reporting
FINDING No. 2024-002: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should make the appropriate transfers out of the insurance escrow account to remedy the over funding and perform regular analysis to ensure...
FINDING No. 2024-002: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: The Project should make the appropriate transfers out of the insurance escrow account to remedy the over funding and perform regular analysis to ensure that funding is adequate but not excessive. Action Taken: The verification of the correct funding amounts is now confirmed on a monthly basis and has been added to the monthly close checklist. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO
View Audit 365868
Senior Citizens Housing Development Corporation of Washington
FL
HUD Housing Programs Reporting
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Washington respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 2...
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Washington respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2024 through December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: Management should implement the following procedures regarding its replacement reserve account: the correct authorized amount is deposited each month, requests for increases to the replacement reserve are submitted timely, and an executed approval with HUD’s signature is maintained. Action Taken: Staff training has been provided with additional HUD training to make sure a signed 9250 is in the file before making any increased deposit.
View Audit 365868
City of College Park, Georgia
GA
1. Policy Development: We will initiate the development of a comprehensive document retention policy that outlines clear guidelines for the retention, storage, and disposal of documentation. This policy will be designed to meet the City’s operational needs as well as compliance requirements. 2. Appr...
1. Policy Development: We will initiate the development of a comprehensive document retention policy that outlines clear guidelines for the retention, storage, and disposal of documentation. This policy will be designed to meet the City’s operational needs as well as compliance requirements. 2. Approval Process: The draft policy will be presented to the City Council for approval. We will ensure that the policy is well-structured and takes into account the perspectives and needs of all stakeholders. 3. Implementation Plan: Following approval, we will establish a detailed implementation plan that includes timelines, responsibilities, and training for staff involved in document management. 4. Training and Awareness: We will conduct training sessions for employees to familiarize them with the new policy and procedures. This will include workshops and resources that emphasize the importance of compliance and proper documentation practices. 5. Regular Reviews: A schedule for regular reviews and audits will be implemented to ensure adherence to the policy. Feedback mechanisms will be established so that any challenges can be addressed timely. 6. Monitoring and Reporting: We will set up monitoring systems to track compliance with the policy and allow for regular reporting to the City Council on adherence levels and any issues that arise.
View Audit 365853
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