Corrective Action Plans

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Corrective Action Plan A recurring payable will be created to ensure future deposits are made timely. Anticipated Completion Date September 1, 2026 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL 62353 (217) 773-3325
Corrective Action Plan A recurring payable will be created to ensure future deposits are made timely. Anticipated Completion Date September 1, 2026 Responsible Parties Dane Jansen, Financial Director 700 S. E. Cross Mt. Sterling, IL 62353 (217) 773-3325
Finding 2026-003: Grant 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...
Finding 2026-003: Grant 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 each individual grant to ensure that individual disbursements are not allocated to more than one grant. Action Taken: The Township has created and is utilizing a spreadsheet to track expenditures by each individual grants that will be updated as individual disbursements and receipts occur. Responsible Person and Completion Date: Township Treasurer, March 31, 2026. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Rebecca Griffin at 231-861-5853.
Milwaukee Health Services, Inc. (the “Organization”) submits the following corrective action plan for the identified finding and questioned costs for the year ending January 31, 2026. Finding 2026-001: Special Tests and Provisions - Sliding Fees Statement of Condition: External auditors reviewed 40 ...
Milwaukee Health Services, Inc. (the “Organization”) submits the following corrective action plan for the identified finding and questioned costs for the year ending January 31, 2026. Finding 2026-001: Special Tests and Provisions - Sliding Fees Statement of Condition: External auditors reviewed 40 sliding fee transactions to verify if the amount charged under the Organization’s sliding fee program was calculated properly based on the patient’s income level and in compliance with the Organization’s sliding fee policy. External auditors noted that for four (4) of the sampled transactions the sliding fee category was properly determined but amounts charged for services were incorrectly applied resulting in the guarantors being over or undercharged for services. Corrective Action: The Organization will review its sliding fee policies and monitor determinations. Staff responsible for sliding fee determinations will be trained on properly computing sliding fees, including manual adjustments within the electronic health record system when necessary. The Organization will also review the Organization’s electronic health record system’s controls and safeguards for assisting in sliding fee calculation and billing accuracy. Person Responsible for Corrective Action: Lorraine Sether, Interim CFO Anticipated Timing for Completion of Corrective Action: November 30, 2026.
2026-002 – Deposits in excess of FDIC insured limits Corrective action planned: Appleway Court 202 will review the current deposit situation and related FDIC coverage and split cash deposits between multiple banks or work with our current bank to ensure that amounts in excess of FDIC limits are full...
2026-002 – Deposits in excess of FDIC insured limits Corrective action planned: Appleway Court 202 will review the current deposit situation and related FDIC coverage and split cash deposits between multiple banks or work with our current bank to ensure that amounts in excess of FDIC limits are fully insured and collateralized. Anticipated completion date: May 31, 2027 Contact person responsible for corrective action: Charles Wells, CFO
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.
Finding No. 2026-002 – Tenant Files Recommendation: Management should establish procedures to ensure that EIV reports and HUD forms are completed in accordance with HUD requirements. Planned Corrective Action: The proper procedure and regulatory requirements for running and reviewing all EIV Reports...
Finding No. 2026-002 – Tenant Files Recommendation: Management should establish procedures to ensure that EIV reports and HUD forms are completed in accordance with HUD requirements. Planned Corrective Action: The proper procedure and regulatory requirements for running and reviewing all EIV Reports and the completion, execution, and retention of signed HUD- 50059 forms have been reviewed with Property Management staff for implementation effective immediately. Anticipated Completion Date - September 2026 Responsible Contact Person – Michael Wolak, President, Board of Directors, E-mail: mawolak1950@gmail.com
Finding No. 2026-001 – Rent Increases Recommendation: Management should establish procedures to ensure that rent increase requests to HUD are submitted timely. Planned Corrective Action: The proper procedure and regulatory requirements regarding timely rent increase submission have been reviewed wit...
Finding No. 2026-001 – Rent Increases Recommendation: Management should establish procedures to ensure that rent increase requests to HUD are submitted timely. Planned Corrective Action: The proper procedure and regulatory requirements regarding timely rent increase submission have been reviewed with current Property Management staff for implementation effective immediately. Anticipated Completion Date - September 2026 Responsible Contact Person – Michael Wolak, President, Board of Directors, E-mail: mawolak1950@gmail.com
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 has searched the state procurement office webpage to check if any vendor for a federal project i...
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 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 2027 fiscal year. The plan for adherence is the Council will review and 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 that the Board will review all proposed policies and adopt them, the Board will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2026-001: Statement of condition #2026-001: Management fees of $17,198 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the fol...
Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2026-001: Statement of condition #2026-001: Management fees of $17,198 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent reimbursed $17,198 to the Corporation on August 11, 2026.
Auditee/owner agrees with this finding. The organization will implement effective internal controls to avoid this issue in the future.
Auditee/owner agrees with this finding. The organization will implement effective internal controls to avoid this issue in the future.
2026-005 Special Tests and Provisions Corrective action planned: In December 2025, responsibility for administration of the Sliding Fee Discount Program (SFDP) was transferred from the COO to the CFO/DFO. Several upgrades in tools used for determinations, reporting, and quality assurance were immedi...
2026-005 Special Tests and Provisions Corrective action planned: In December 2025, responsibility for administration of the Sliding Fee Discount Program (SFDP) was transferred from the COO to the CFO/DFO. Several upgrades in tools used for determinations, reporting, and quality assurance were immediately instituted. OMC review now includes electronic calculations of income, and several instances of documenting the SFDP appear on the application. Furthermore, each application package now includes a copy of the OMC Federal Poverty Level sliding scale with the determination clearly marked on the form. OMC’s SFDP Scales are also displayed in the lobby area and other visible areas at all OMC sites. Finally, the CFO/DFO performs a quarterly audit of all applications entered in that quarterly period. Each application is reviewed for completeness, and each participant’s account is reviewed for proper application of the SFDP. Any findings are corrected immediately and reported to the Quality Assurance committee so methods can be developed to prevent future errors. Anticipated completion date: 12/31/2025 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
2026-004 Procurement Corrective action planned: OMC will follow its current procurement policy and will seek bids for contracts with autorenewals, utilities, and professional services. However, OMC will also review its current procurement policy to see if changes are necessary to reflect the current...
2026-004 Procurement Corrective action planned: OMC will follow its current procurement policy and will seek bids for contracts with autorenewals, utilities, and professional services. However, OMC will also review its current procurement policy to see if changes are necessary to reflect the current environment to exclude items such as certain utilities and services from the bid process if such utilities and services are unique and limited to the service area of the health center and if only one option exists or the current vendor is performing sufficiently so that undue burden would be placed on the Organization to switch vendors, then a sole source justification will be documented, in both paper format and electronically so that records are readily available for review. Anticipated completion date: 08/31/2026 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
2026-003 Period of Performance (repeat of finding 2025-003) Corrective action planned: The former CEO of OMC did not understand Generally Accepted Accounting Principles and, specifically, Accrual Accounting. He did not allow the Accounting Department to make accrual entries monthly. At the beginning...
2026-003 Period of Performance (repeat of finding 2025-003) Corrective action planned: The former CEO of OMC did not understand Generally Accepted Accounting Principles and, specifically, Accrual Accounting. He did not allow the Accounting Department to make accrual entries monthly. At the beginning of FY 2026 - 2027, the CFO/DFO required the accrual of payroll each month to accurately reflect the personnel expense of OMC. OMC accounting staff will utilize the Sage Impact® Accounting System to accrue other expenses that were incurred in the period but not yet paid, so that only cost for goods and/or services incurred within the approved budget period are reflected accurately in monthly financial reporting and costs are not allocated outside the budget period. The CFO/DFO has developed an accrual template so that utility bills that cross periods, such as one example in this report, are properly accounted for and allocated to the correct period. This will also be monitored by the external independent financial consultant and the CEO who is a degreed accountant. Anticipated completion date: 08/31/2026 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
2026-002 Allowable Costs/Cost Principles (repeat of finding 2025-002) Corrective action planned: The accounting treatment of the $5,500 fee for preparation of the IRS Form 990 resulted from a misinterpretation of the Uniform Guidance and treatment of professional fees, as well as an error when revie...
2026-002 Allowable Costs/Cost Principles (repeat of finding 2025-002) Corrective action planned: The accounting treatment of the $5,500 fee for preparation of the IRS Form 990 resulted from a misinterpretation of the Uniform Guidance and treatment of professional fees, as well as an error when reviewing historical transactions regarding the preparation fee. The CFO/DFO currently reviews transactions prior charging to federal awards and will add a thorough review of the Uniform Guidance and Cost Principles prior to charging expenses to federal awards. OMC will add two additional review layers including the external independent financial consultant and the CEO, who is a degreed accountant. Anticipated completion date: 08/31/2026 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 th...
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 through August 26, 2029 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR 200.332 (e), (g) and (h) - pass-through entities must monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Condition: AACHC implemented revised subrecipient monitoring procedures in October 2025 as part of its corrective action plan to address the prior-year finding. The revised procedures were applied to all active and new subrecipient agreements beginning October 2025. However, because certain subrecipient agreements had already concluded before the new procedures were implemented, AACHC did not retrospectively apply the monitoring process to those closed agreements. As a result, AACHC did not obtain and review financial statement audit or Single Audit reports for three subrecipients whose agreements ended prior to implementation of the revised procedures. Name of Contact Person: Brenda Hanserd, CFO Phone Number: 602-288-7559 Anticipated Completion Date: March 31, 2027 Views of Responsible Officials and Corrective Action Plan: In October 2025, AACHC implemented revised subrecipient monitoring procedures in response to the prior-year audit finding. The exception identified in the current audit relates solely to three subrecipient agreements that had already concluded before the revised procedures were implemented and therefore could not be incorporated into the new monitoring process. Effective October 1, 2025, AACHC implemented enhanced procedures requiring evaluation of Single Audit applicability, collection and review of applicable audit reports, and follow-up on any findings. In addition, AACHC now requires subrecipients to submit audit documentation covering the entire period of performance under the agreement, ensuring that monitoring activities are completed even when a subrecipient agreement ends prior to the completion of the audit cycle. This corrective action addresses the circumstances that gave rise to the finding and provides assurance that all subrecipient agreements are subject to appropriate audit review and follow-up moving forward.
As explained in Management’s response to Finding 2026-002, Baptist Retirement Village had been approved for MFCS’s reduced (25%) monthly sampling of annual recertifications based on the property’s prior compliance history, its continuous 100% review of move-in and interim certifications, and MFCS’s ...
As explained in Management’s response to Finding 2026-002, Baptist Retirement Village had been approved for MFCS’s reduced (25%) monthly sampling of annual recertifications based on the property’s prior compliance history, its continuous 100% review of move-in and interim certifications, and MFCS’s ongoing availability for certification and compliance support. Because errors were identified during this reduced-sample review, the property is returning to 100% file review for all certifications, which will remain in place until Baptist Retirement Village again meets all criteria for reduced sampling — two consecutive years without MOR resident-file findings, a minimum two-year site manager tenure, and at least one year of error-free annual recertifications. In addition, SPM is updating the standardized tenant file checklist and written internal control procedures covering eligibility determination, income/rent calculation, and required certifications, with a documented compliance sign-off required before a file is considered complete
As with other high-performing SPM-managed properties, Baptist Retirement Village had been approved for a reduced-sampling protocol under which Multifamily Compliance Services (MFCS) reviews 25% of annual recertifications monthly, selected on a rotating basis, while continuing to review 100% of all m...
As with other high-performing SPM-managed properties, Baptist Retirement Village had been approved for a reduced-sampling protocol under which Multifamily Compliance Services (MFCS) reviews 25% of annual recertifications monthly, selected on a rotating basis, while continuing to review 100% of all move-in and interim certification files. Properties are approved for this 25% protocol only when: (1) the resident file audit section of the property’s HUD Management and Occupancy Review scores decline, or on-site management turns over, the property returns to 100% file review for all certifications. Because the errors addressed in this finding were identified during the reduced-sample review, Baptist Retirement Village is returning to 100% file review for all certifications. In addition, SPM is correcting the three affected tenant files, including any retroactive adjustment to Total Tenant Payment and subsidy, and property personnel responsible for completing 50059s are receiving refresher training on income determination requirements under HUD Handbook 4350.3 REV-1.
SPM has developed and issued a new company-wide Extended Absence from the Apartment policy applicable to all HUD-assisted and LIHTC communities, including Section 8, PRAC, Section 202, and LIHTC properties. The policy requires written resident notice of any absence expected to exceed 14 consecutive ...
SPM has developed and issued a new company-wide Extended Absence from the Apartment policy applicable to all HUD-assisted and LIHTC communities, including Section 8, PRAC, Section 202, and LIHTC properties. The policy requires written resident notice of any absence expected to exceed 14 consecutive days; documentation supporting the reason for and expected length of the absence (e.g., a physician’s statement, discharge plan, or nursing facility admission/discharge documentation); a maximum absence of 90 consecutive days, extendable to a total of 180 days only with documentation supporting the need for additional time, with any absence beyond 90 days requiring written approval from the Divisional Vice President; and, when a medical absence triggers an interim certification, a determination of whether program rent requires adjustment based on income or benefit changes. All notices, documentation, approvals, and follow-up contacts must be logged on the new Extended Absence Request and Tracking Form and retained in the resident file. MFCS and property management staff — including the Property Manager, Regional Property Manager and Compliance Specialist — are being trained on this policy, and supervisory review of all extended-absence cases will confirm ongoing compliance going forward. Management is also reviewing the specific resident file identified in the finding and is coordinating with the HUD Account Manager to determine the appropriate disposition of assistance payments, certification corrections, and occupancy status in accordance with HUD requirements.
1. The Project Sponsor acknowledges the requirements of the HUD Regulatory Agreement regarding the safeguarding and segregation of tenant security deposits. With the transition of management in these areas, additional review controls were implemented, including monthly programmatic and financial rev...
1. The Project Sponsor acknowledges the requirements of the HUD Regulatory Agreement regarding the safeguarding and segregation of tenant security deposits. With the transition of management in these areas, additional review controls were implemented, including monthly programmatic and financial reviews of security deposit collections, postings, and account balances to ensure proper classification and maintenance of restricted funds. 2. On September 4, 2026, the $50 security deposit was transferred to the appropriate security deposit account, fully correcting the deficiency. Management will continue to perform monthly monitoring procedures to verify that all tenant security deposits are accurately recorded and maintained in compliance with HUD requirements.
Management will transfer the required deposit to the security deposit cash account
Management will transfer the required deposit to the security deposit cash account
The unauthorized advances have been reimbursed in the subsequent year
The unauthorized advances have been reimbursed in the subsequent year
Management will coordinate with the bank to ensure that there is sufficient collateral on all deposits in the future.
Management will coordinate with the bank to ensure that there is sufficient collateral on all deposits in the future.
The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
The Cooperative returned the reimbursed funds to the replacement reserve. The management agent will implement a process to ensure that future reimbursed funds are returned to the replacement reserve as required by the regulatory agreement.
Finding 2026-001: Considered a material weakness
Finding 2026-001: Considered a material weakness
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