Corrective Action Plans

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Classes of financial transactions have been segregated to the extent possible among the existing employees. However, due to the limited number of individuals involved in the accounting and bookkeeping functions, a corrective action plan to fully remedy the lack of segregation of duties is not cost j...
Classes of financial transactions have been segregated to the extent possible among the existing employees. However, due to the limited number of individuals involved in the accounting and bookkeeping functions, a corrective action plan to fully remedy the lack of segregation of duties is not cost justified. Instead, each level of management, the Board of Directors, and the Administrator remain aware of the principles of segregation of duties and the potential risks that exist when full segregation is not achievable. Because of this awareness, management is responsible for ongoing review and follow-up on any transactions or circumstances that appear unusual. This oversight is considered a mitigating control to reduce the risk of undetected errors or irregularities. Contact person: Tim Nichols Anticipated completion date: Unknown
Name of auditee: Dolan Manor II HUD auditee identification number: FHA/Contract 053-EE072 Name of audit firm: O. Douglas Covington, C.P.A., P.A. Period covered by the audit: January 1, 2024 thru December 31, 2024 CAP Prepared By: Name: Kenya Owens Position: Vice President of Operations Teleph...
Name of auditee: Dolan Manor II HUD auditee identification number: FHA/Contract 053-EE072 Name of audit firm: O. Douglas Covington, C.P.A., P.A. Period covered by the audit: January 1, 2024 thru December 31, 2024 CAP Prepared By: Name: Kenya Owens Position: Vice President of Operations Telephone: 336-944-5847 1. Finding 2024-001 a. Comments on the Finding and Each Recommendation At the time of audit, we are in agreement with the findings. b. Action(s) Taken or planned on the finding Due to an oversight on management duplicate invoices was submitted and approve through HUD. We have since corrected and returned the duplicated funds in the amount of $2,077.59 from the operating account back to the reserves account. *Regional Compliance Manager will review prior RFR previously submitted.
View Audit 363000 Questioned Costs: $1
U. S. Department of Housing and Urban Development; Heritage Fields III, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024.; Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 3...
U. S. Department of Housing and Urban Development; Heritage Fields III, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024.; Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024. The findings from the June 30, 2024 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 - Federal Award Programs Audit: Department of Housing and Urban Development: Supportive Housing for Persons with Disabilities Program (Section 811), Assistance Listing # 14.181: 2024 - 002 Recommendation: Finding is closed as of June 30, 2024. If the Department of Housing and Urban Development has questions regarding this plan, please call Mary Garrison, Heritage Grove, Inc. at (217) 362-6262.
Finding 571923 (2024-003)
Significant Deficiency 2024
U. S. Department of Housing and Urban Development. Heritage Fields, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 202...
U. S. Department of Housing and Urban Development. Heritage Fields, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2024.The findings from the June 30, 2024 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule.Department of Housing and Urban Development: Supportive Housing for Persons with Disabilities Program (Section 811), Assistance Listing # 14.181: 2024 - 003 Recommendation: Finding is closed as of June 30, 2024. If the Department of Housing and Urban Development has questions regarding this plan, please call Mary Garrison, Heritage Fields, Inc. at (217) 362-6262.
We will obtain written documentation of the period of performance for all applicable projects to ensure compliance.
We will obtain written documentation of the period of performance for all applicable projects to ensure compliance.
View Audit 362973 Questioned Costs: $1
Going forward, we will obtain and retain quotes via email and ensure that a sufficient number of qualified sources are solicited, in accordance with procurement guidelines.
Going forward, we will obtain and retain quotes via email and ensure that a sufficient number of qualified sources are solicited, in accordance with procurement guidelines.
View Audit 362973 Questioned Costs: $1
As with Finding 2024-002, employees will now use the time tracking software to log fleet assets with time entries. All submissions will be reviewed and approved by someone other than the submitter or Line Foreman.
As with Finding 2024-002, employees will now use the time tracking software to log fleet assets with time entries. All submissions will be reviewed and approved by someone other than the submitter or Line Foreman.
View Audit 362973 Questioned Costs: $1
We have implemented a time tracking software feature allowing employees to associate fleet assets with their time entries. Entries will be submitted by the employee or Line Foreman, then reviewed and approved by a separate supervisor or manager.
We have implemented a time tracking software feature allowing employees to associate fleet assets with their time entries. Entries will be submitted by the employee or Line Foreman, then reviewed and approved by a separate supervisor or manager.
For all future large-scale weather events, two employees will jointly pull materials and document quantities. Both will sign a material charge-out sheet. Any unused materials will be charged back to the appropriate work order.
For all future large-scale weather events, two employees will jointly pull materials and document quantities. Both will sign a material charge-out sheet. Any unused materials will be charged back to the appropriate work order.
View Audit 362973 Questioned Costs: $1
2024-004) Late Completion and Filing of Single Audit Assistance Listing Numbers Name of Federal Program or Cluster 97.036 Disaster Grants-Public Assistance (Presidentially Declared Disasters) Management will implement procedures referenced in Finding 2023-001 and 2023-003 that will help facil...
2024-004) Late Completion and Filing of Single Audit Assistance Listing Numbers Name of Federal Program or Cluster 97.036 Disaster Grants-Public Assistance (Presidentially Declared Disasters) Management will implement procedures referenced in Finding 2023-001 and 2023-003 that will help facilitate gathering information necessary for proper recording at year end to avoid this issue in the future and allow timely completion of the audit. Persons responsible: Dennis Bent, C.F.O.; Martha Witherwax, Director of Accounting Expected Completion date: July, 2025
2024-003) Preparation of Schedule of Expenditures and Federal Awards CFDA Listing Numbers Name of Federal Program or Cluster 97.036 Disaster Grants-Public Assistance (Presidentially Declared Disasters) Disaster Grants through FEMA are managed by rules and processes that are not easily acco...
2024-003) Preparation of Schedule of Expenditures and Federal Awards CFDA Listing Numbers Name of Federal Program or Cluster 97.036 Disaster Grants-Public Assistance (Presidentially Declared Disasters) Disaster Grants through FEMA are managed by rules and processes that are not easily accounted for in traditional accounting systems. Procedures will be strengthened to fully and accurately identify all federal program expenditures and record in the appropriate accounting funds. Procedures will be implemented to prepare documentation necessary to support the information in the financial statements earlier and more accurately, for the information to be completed, available and provided to auditors for the audit. Persons responsible: Dennis Bent, C.F.O.; Martha Witherwax, Director of Accounting Expected Completion date: July, 2025
PRAC Budgets Recommendation: We recommend audits are completed timely to ensure the annual budget is submitted to HUD as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process for submitting the budg...
PRAC Budgets Recommendation: We recommend audits are completed timely to ensure the annual budget is submitted to HUD as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process for submitting the budget for 2025 has already begun. Management is monitoring the process to ensure timely submission. Name(s) of the contact person(s) responsible for corrective action: Alex Lueth, VP of Finance Planned completion date for corrective action plan: June 2025
Replacement Reserve Deposits Recommendation: We recommend management implement a control to ensure the monthly transfer is completed automatically and in accordance with the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...
Replacement Reserve Deposits Recommendation: We recommend management implement a control to ensure the monthly transfer is completed automatically and in accordance with the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization agrees with the finding and the recommendation will be implemented. Controls implemented include scheduling of automatic transfers to our reserve for replacement savings account as well as updating our treasury standard operating procedures to ensure funds are available for the transfer. Monthly bank reconciliation will also confirm that the transfer occurred. Name(s) of the contact person(s) responsible for corrective action: Alex Lueth, VP of Finance Planned completion date for corrective action plan: June 2025
View Audit 362961 Questioned Costs: $1
PRAC Budgets Recommendation: We recommend audits are completed timely to ensure the annual budget is submitted to HUD as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process for submitting the budg...
PRAC Budgets Recommendation: We recommend audits are completed timely to ensure the annual budget is submitted to HUD as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The process for submitting the budget for 2025 has already begun. Management is monitoring the process to ensure timely submission. Name(s) of the contact person(s) responsible for corrective action: Alex Lueth, VP of Finance Planned completion date for corrective action plan: June 2025
Replacement Reserve Deposits Recommendation: We recommend management implement a control to ensure the monthly transfer is completed automatically and in accordance with the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...
Replacement Reserve Deposits Recommendation: We recommend management implement a control to ensure the monthly transfer is completed automatically and in accordance with the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization agrees with the finding and the recommendation will be implemented. Controls implemented include scheduling of automatic transfers to our reserve for replacement savings account as well as updating our treasury standard operating procedures to ensure funds are available for the transfer. Monthly bank reconciliation will also confirm that the transfer occurred. Name(s) of the contact person(s) responsible for corrective action: Alex Lueth, VP of Finance Planned completion date for corrective action plan: June 2025
View Audit 362958 Questioned Costs: $1
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule...
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend the Authority review their process for scheduling quality control reinspections to ensure they are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit f...
Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend the Authority review their process for scheduling quality control reinspections to ensure they are performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CMHA would like to note that the 2024 sample size for QC for SEMAP compliance is approximately 95-100 inspections. Nonetheless, CMHA’s contracted vendor conducted over 170 QC inspections in 2024 and scheduled nearly double that amount. We are on track to far exceed the volume required by SEMAP sampling again this year. The team continues to review our inspections processes to ensure compliance with HQS guidelines and requirements. Name of the contact person responsible for corrective action: Claire Russ, Chief of Agency Analytics, Inspections and Technology Planned completion date for corrective action plan: December 31, 2025
Unauthorized disbursements from the reserve fund were made. Recommendation: CLA recommends the Project return the withdrawn funds back to the reserve funds when the funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in respon...
Unauthorized disbursements from the reserve fund were made. Recommendation: CLA recommends the Project return the withdrawn funds back to the reserve funds when the funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has received the delayed rental income payments and is working to return the funds. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: May 30, 2025 If the U.S. Department of Housing and Urban Development (HUD) has questions regarding this plan, please call Sabine Cox at 203-230-4809 ext. 1005
View Audit 362935 Questioned Costs: $1
Reserve for replacement funds were not maintained in a separate bank account. Recommendation: CLA Recommends withdrawing the reserve for replacement funds and opening a separate bank account. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action pla...
Reserve for replacement funds were not maintained in a separate bank account. Recommendation: CLA Recommends withdrawing the reserve for replacement funds and opening a separate bank account. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: During 2025, the funds were withdrawn from the operating account and deposited into a separate bank account. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: March 4, 2025
Approved expenditures of federal awards without proper control completed. Recommendation: CLA Recommends enforcing control procedures over expenditures of federal awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response t...
Approved expenditures of federal awards without proper control completed. Recommendation: CLA Recommends enforcing control procedures over expenditures of federal awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: During 2024, a new management company was hired as of July 1, 2024 and has implemented and enforced proper controls over expenditures of federal awards. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: May 30, 2025
Deposits required by HUD were not made during fiscal year 2024 to the reserve fund. Recommendation: CLA Recommends the Project make all fiscal year 2024 deposits as soon as funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned ...
Deposits required by HUD were not made during fiscal year 2024 to the reserve fund. Recommendation: CLA Recommends the Project make all fiscal year 2024 deposits as soon as funds allow. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has received the delayed rental income payments and is working to make the back deposits. However, due to the turnover in management company the delay was extended. Name of the contact person responsible for corrective action: Sabine Cox, EHM Comptroller Planned completion date for corrective action plan: May 30, 2025
View Audit 362935 Questioned Costs: $1
Finding: Procurement, Suspension and Debarment: Special Education – Special Olympics Education Programs The recipient must maintain and use documented (written) procedures for procurement transactions under a Federal Award or subaward, including for acquisition of property or services. These documen...
Finding: Procurement, Suspension and Debarment: Special Education – Special Olympics Education Programs The recipient must maintain and use documented (written) procedures for procurement transactions under a Federal Award or subaward, including for acquisition of property or services. These documented procedures must be consistent with applicable State, and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in the Uniform Guidance (2 CFR 200.317-200.327). The Organization has a written purchasing policy in place, but it does not include all required elements for a procurement policy in accordance with Federal statutes . Views of Responsible Officials and Planned Corrective Actions: Management is in agreement with this finding. Management will review the organization’s current Procurement Policy and make adjustments to the policy to ensure that it contains the required criteria to meet the federal procurement guidelines. An updated copy of the organization's Procurement Policy will be finalized by Oct 31, 2025. This policy will be reviewed regularly to ensure that it remains in compliance with federal procurement guidelines. Responsible Official: Greg Vanselow, Chief Operating Officer Completion Date: Oct 31, 2025
Finding Number: 2024-003 Planned Corrective Action: The District will closely review the Final Expenditure Report for all grants to ensure accuracy. Anticipated Completion Date: 6/30/26 Responsible Contact Person: Kaitlin Huck, Treasurer/CFO
Finding Number: 2024-003 Planned Corrective Action: The District will closely review the Final Expenditure Report for all grants to ensure accuracy. Anticipated Completion Date: 6/30/26 Responsible Contact Person: Kaitlin Huck, Treasurer/CFO
Finding Number: 2024-002 Planned Corrective Action: The District will update the capital asset listing. Anticipated Completion Date: 6/30/26 Responsible Contact Person: Kaitlin Huck, Treasurer/CFO
Finding Number: 2024-002 Planned Corrective Action: The District will update the capital asset listing. Anticipated Completion Date: 6/30/26 Responsible Contact Person: Kaitlin Huck, Treasurer/CFO
Material Adjustment to Fund Balance and Net Position Condition: The District audit resulted in a material restatement to fund balance/net position that was detected by auditing procedures. Plan: The District acknowledges the finding and will continue to review new standards as part of the fiscal aud...
Material Adjustment to Fund Balance and Net Position Condition: The District audit resulted in a material restatement to fund balance/net position that was detected by auditing procedures. Plan: The District acknowledges the finding and will continue to review new standards as part of the fiscal audit process. Anticipated Date of Completion: The District will immediately implement yearly review of new standards as part of the fiscal audit process. Name of Contact Person: Nicki Ells, Business Manager Management Response: The District acknowledges the Plan and will begin reviewing regulatory requirements and capital assets on an annual basis.
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