Corrective Action Plans

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(3) Estimated Completion Date.The 100% tenant-file audit and correction process will be completed by October 31, 2026. Training and implementation of the enhanced recertification checklist and QC process will be completed by October 15, 2026. The monthly quality-control process will become a permane...
(3) Estimated Completion Date.The 100% tenant-file audit and correction process will be completed by October 31, 2026. Training and implementation of the enhanced recertification checklist and QC process will be completed by October 15, 2026. The monthly quality-control process will become a permanent management control beginning November 1, 2026. Management will maintain documentation demonstrating completion of the corrective actions and will make the documentation available for HUD, the auditor, or other authorized reviewers upon request.
Finding Reference Number: 2025-002 View of Responsible Officials and Planned Corrective Action Date: Corrective Action: Management will take appropriate corrective action to address the identified issue and strengthen internal controls. The organization has initiated a corrective action plan that in...
Finding Reference Number: 2025-002 View of Responsible Officials and Planned Corrective Action Date: Corrective Action: Management will take appropriate corrective action to address the identified issue and strengthen internal controls. The organization has initiated a corrective action plan that includes engaging an external accounting service to provide additional oversight and support for accounting functions. In addition, the Business Office Manager position is being restructured into two separate positions to provide clearer separation of duties, accountability, and internal controls. One of the new positions will be the Business Office and Accounting Coordinator, with defined responsibility for accounting-related functions and processes. The second position will focus on employee services and administrative responsibilities. These organizational changes are intended to strengthen oversight, improve segregation of duties, and reduce the risk of errors or inappropriate financial practices. Management will monitor implementation of these changes to ensure the corrective actions are effective and sustained. Name of Contact Person: Dawn Palowski, Executive Director Project Completion Date: December 31, 2026
Finding Reference Number: 2025-001 View of Responsible Officials and Planned Corrective Action Date: Corrective Action: Management will take appropriate corrective action to address the identified issue and strengthen internal controls. The organization has initiated a corrective action plan that in...
Finding Reference Number: 2025-001 View of Responsible Officials and Planned Corrective Action Date: Corrective Action: Management will take appropriate corrective action to address the identified issue and strengthen internal controls. The organization has initiated a corrective action plan that includes engaging an external accounting service to provide additional oversight and support for accounting functions. In addition, the Business Office Manager position is being restructured into two separate positions to provide clearer separation of duties, accountability, and internal controls. One of the new positions will be the Business Office and Accounting Coordinator, with defined responsibility for accounting-related functions and processes. The second position will focus on employee services and administrative responsibilities. These organizational changes are intended to strengthen oversight, improve segregation of duties, and reduce the risk of errors or inappropriate financial practices. Management will monitor implementation of these changes to ensure the corrective actions are effective and sustained. Name of Contact Person: Dawn Palowski, Executive Director Project Completion Date: December 31, 2026
Finding 1238484 (2025-002)
Material Weakness 2025
Finding Number: 2025-002 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kelly Schroeder, County Administrator/Interim County Auditor-Treasurer Corrective Action Planned: A ...
Finding Number: 2025-002 Finding Title: Suspension and Debarment Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kelly Schroeder, County Administrator/Interim County Auditor-Treasurer Corrective Action Planned: A dedicated folder has been established on the network drive to store all suspension and debarment verification records completed through SAM.gov. Pine County has reviewed all existing vendors receiving federal funds, completed the required checks, and placed the supporting documentation in this folder. Going forward, all new Pine County contracts funded with federal dollars will include a suspension and debarment certification to ensure compliance with federal requirements. Anticipated Completion Date: September 1, 2026
Name of auditee: TELACU Housing-Riverside, Inc. HUD auditee identification number: 143-EE052-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone num...
Name of auditee: TELACU Housing-Riverside, Inc. HUD auditee identification number: 143-EE052-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $37,688 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-Monterey Park, Inc. HUD auditee identification number: 122-EE085-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone...
Name of auditee: TELACU Housing-Monterey Park, Inc. HUD auditee identification number: 122-EE085-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $6,099 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-Riverside II, Inc. HUD auditee identification number: 143-EE064-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone ...
Name of auditee: TELACU Housing-Riverside II, Inc. HUD auditee identification number: 143-EE064-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $17,484 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-Rialto III, Inc. HUD auditee identification number: 143-EE072-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone nu...
Name of auditee: TELACU Housing-Rialto III, Inc. HUD auditee identification number: 143-EE072-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $2,841 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-El Monte II, Inc. HUD auditee identification number: 122-EE125-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone n...
Name of auditee: TELACU Housing-El Monte II, Inc. HUD auditee identification number: 122-EE125-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $1,884 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-San Bernardino III, Inc. HUD auditee identification number: 143-EE049-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Tele...
Name of auditee: TELACU Housing-San Bernardino III, Inc. HUD auditee identification number: 143-EE049-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $19,978 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Views of responsible officials and planned corrective actions: Management agrees with the recommendation. NDN Collective has strengthened its review procedures over payroll allocations charged to federal awards. When a Program Manager identifies a change to an employee's payroll allocation, the chan...
Views of responsible officials and planned corrective actions: Management agrees with the recommendation. NDN Collective has strengthened its review procedures over payroll allocations charged to federal awards. When a Program Manager identifies a change to an employee's payroll allocation, the change will be communicated directly to the Finance team for timely review and processing. The Finance team will review payroll allocations to ensure they are consistent with approved time-andeffort documentation prior to processing. In addition, there will be a secondary review of payroll allocations and supporting documentation to verify that charges to federal awards are accurate, properly supported, and consistently applied in accordance with Uniform Guidance requirements. These review procedures have been documented and incorporated into the Organization's payroll allocation process for all federal awards. Management believes these enhanced controls will strengthen compliance over allowable costs and reduce the risk of payroll allocation discrepancies in future reporting periods.
Name of auditee: TELACU Housing-Alhambra, Inc. HUD auditee identification number: 122-EE103-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone numb...
Name of auditee: TELACU Housing-Alhambra, Inc. HUD auditee identification number: 122-EE103-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $7,863 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-El Monte, Inc. HUD auditee identification number: 122-EE034-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone numb...
Name of auditee: TELACU Housing-El Monte, Inc. HUD auditee identification number: 122-EE034-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $11,586 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-San Bernardino II, Inc. HUD auditee identification number: 143-EE044-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telep...
Name of auditee: TELACU Housing-San Bernardino II, Inc. HUD auditee identification number: 143-EE044-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $16,406 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-San Bernardino, Inc. HUD auditee identification number: 143-EE040-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephon...
Name of auditee: TELACU Housing-San Bernardino, Inc. HUD auditee identification number: 143-EE040-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $12,391 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At the point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Name of auditee: TELACU Housing-Baldwin Park, Inc. HUD auditee identification number: 122-EE126-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone ...
Name of auditee: TELACU Housing-Baldwin Park, Inc. HUD auditee identification number: 122-EE126-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: Management fees of $12,112 were prepaid at December 31, 2025. Recommendation: The Corporation should reduce management fees to the limits communicated by HUD going forward and the Agent should repay the amount prepaid at December 31, 2025. Actions Taken or Planned on the Finding: Management concurs with the finding. On June 17, 2026, HUD clarified its notification regarding Section 1(e) of the HUD approved Management Agent Certification (form HUD-9839-B). At that point, the Agent took prompt corrective action. The identified prepayment was returned to the Corporation in full on July 15, 2026.
Management Response and Action Taken: Drawdown with No Subsequent Payment • MHA will reconcile and match all end-of-year grant receivables with the invoices and subsequent payment in the ensuing year. • MHA will confirm payments are made timely, within the required three-day period. Duplicate Invoic...
Management Response and Action Taken: Drawdown with No Subsequent Payment • MHA will reconcile and match all end-of-year grant receivables with the invoices and subsequent payment in the ensuing year. • MHA will confirm payments are made timely, within the required three-day period. Duplicate Invoices • MHA will include a direct sign-off, date, and matching requirement on our invoice package that reconciles the draw down date, amount to the invoice payment amount, invoice number(s) and date paid. • MHA will log all invoices prior to drawdown to ensure any duplicate invoices are identified prior to drawdown. Name of Responsible Person(s): Ken Cross, Head of Finance Projected Completion Date: November 30, 2026
Management Response and Action Taken: Within 30 days, site management and staff will review internal processes and tracking systems to ensure accuracy and compliance with Public Housing guidelines. Additionally, the MHA file audit checklist will be revised to include the identified deficiencies as a...
Management Response and Action Taken: Within 30 days, site management and staff will review internal processes and tracking systems to ensure accuracy and compliance with Public Housing guidelines. Additionally, the MHA file audit checklist will be revised to include the identified deficiencies as applicable and mandate use of the checklist at each annual recertification. Name of Responsible Person(s): Casey Dickinson, Interim CEO and Chief Asset Officer Projected Completion Date: October 30, 2026
Management Response and Actions Taken: Incorrect Utility Allowance • MHA will expand its system’s bedroom count to include 6-bedroom units. This will eliminate the need to manually calculate Utility Allowances above 5-bedrooms. Additionally, management will review all 5+ bedroom unit files to ensure...
Management Response and Actions Taken: Incorrect Utility Allowance • MHA will expand its system’s bedroom count to include 6-bedroom units. This will eliminate the need to manually calculate Utility Allowances above 5-bedrooms. Additionally, management will review all 5+ bedroom unit files to ensure Utility Allowances are correctly reflected. • MHA will confirm the validation report is properly identifying any conflicts in the Utility Allowance selected versus voucher size and household composition to ensure errors are properly captured and corrected. Incorrect Payment Standard • MHA will review with all staff procedures for: o Requesting Payment Standard overrides; o Administrative Plan policies for application of a decrease in payment standards; o We have affirmed that the Yardi system settings accurately reflect MHA Administrative Plan policies regarding the handling of year-over-year Payment Standard decreases; and o MHA will add system validation checks to compare selected payment standards against household composition for each file and to evaluate if the current year selected payment standard has decreased from the prior year payment standard. Missing 9886 Form • Management will work with its software provider to develop a new system report to identify all minors whose date of birth would result in them turning 18 (becoming adults) after the effective date of the family’s annual recertification. This report will be run monthly and will identify all minors who have turned 18 during the month. Staff can then send appropriate notice and paperwork to the “new adult” to have them complete Form 9886a. Name of Responsible Person(s): Paul Watkins, HCV Program Administrator Projected Completion Date: December 31, 2026
Submitted to: U.S. Department of Agriculture The Land Trust Alliance, Inc. (“the Alliance”) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: CBIZ CPAs 1899 L Street, NW, Suite 850 Washington, DC 20...
Submitted to: U.S. Department of Agriculture The Land Trust Alliance, Inc. (“the Alliance”) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: CBIZ CPAs 1899 L Street, NW, Suite 850 Washington, DC 20036 Audit Period: January 1, 2025 through December 31, 2025 The finding from the December 31, 2025 schedule of findings is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING – FEDERAL AWARD PROGRAM AUDIT U.S. Department of Agriculture 2025-001 - Federal Funding Accountability and Transparency Act (FFATA) Reporting – Assistance Listing No. 10.676, Forest Legacy Program Recommendation: The Alliance should implement a procedure to allow for the consistent, timely reporting of subaward obligations of $30,000 or more to the SAM system. Action Taken: The Alliance had already submitted the required reporting in SAM.gov for each of the three subawards on June 30, 2026. Execution of the required reporting was not fully aligned across the relevant teams, resulting in the late filing of the FFATA reporting. As a result of the detection of the misalignment, Management has implemented the following actions: 1. Enhanced federal awards training: The Alliance engaged “Management Concepts”, a third-party firm expert in federal grants management, to deliver a three-day training on federal award compliance requirements back in May 2026. All staff responsible for managing federal awards participated actively in the training. 2. Policy clarification: The Alliance has explicitly incorporated the applicable requirement into its Subaward Management Policy, providing clear and consistent guidance for staff responsible for subaward administration. 3. Strengthened end-to-end process and Standard Operating Procedures (SOP): The Alliance has established and communicated an enhanced process with clearly defined roles, responsibilities, and coordination points across internal teams to support consistent execution of FFATA reporting, when applicable. If the U.S. Department of Agriculture has questions regarding this plan, please contact Ashley Demosthenes at 202-638-4725 or ADemosthenes@lta.org
Department of Health and Human Services Dirne Health Centers, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: 01/1/25 – 12/31/25 The findings from the schedule of findings and questioned costs are discussed below. The findings are nu...
Department of Health and Human Services Dirne Health Centers, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: 01/1/25 – 12/31/25 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT There were no financial statement findings in the audit period. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2025-01 Health Center Cluster– Assistance Listing No. 93.224 and 93.527 Recommendation: CLA recommends that the Clinic strengthen its review process over sliding fee discount determinations by implementing procedures to verify that each patient application is evaluated using current eligibility information and that the corresponding sliding fee scale level is accurately applied. CLA further recommends that the Clinic document evidence of review and approval before discounts are applied to patient encounters and establish a process for timely identification and correction of any discrepancies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing and strengthening Heritage Health’s Sliding Fee Discount Program procedures to ensure that sliding fee eligibility determinations are completed and documented consistently in accordance with the organization’s board-approved policies. Management will clarify procedures related to eligibility and income verification, the application of the appropriate sliding fee scale, and documentation of the review and approval process. Staff responsible for sliding fee determinations will receive training on the updated procedures. Management will also review system configuration and workflows related to the application of sliding fee discounts and establish a periodic internal monitoring process to verify that eligibility determinations are appropriately documented, the correct sliding fee level is applied, and identified discrepancies are investigated and corrected in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Sonya Zhang Planned completion date for corrective action plan: December 31, 2026 If the Department of Health and Human Services has questions regarding this plan, please call Sonya Zhang at 520-667-6333.
Management concurs with the finding, and the actions described below will be implemented. 1. Staff Training - Mandatory training will be implemented for Front Office, Billing, and Eligibility staff focusing on proper income verification, patient classification, documentation requirements, and accura...
Management concurs with the finding, and the actions described below will be implemented. 1. Staff Training - Mandatory training will be implemented for Front Office, Billing, and Eligibility staff focusing on proper income verification, patient classification, documentation requirements, and accurate application of the Sliding Fee Discount Program in accordance with HRSA Compliance Manual and HRSA Operational Site Visit Protocol. 2. Policy and Procedure Changes - The Sliding Fee Discount Program policies and procedures are being revised to provide clearer guidance regarding eligibility determination, income verification, discount application, annual renewals, staff responsibilities, and supervisory oversight. 3. Ongoing Monitoring - Quarterly compliance reviews are now conducted to monitor accurate application of the sliding fee schedule, completeness of supporting documentation, and compliance with established procedures. Corrective action and retraining are provided promptly when discrepancies are identified. Personnel responsible for implementation: Kristopher Zuniga Position of responsible personnel: Interim Chief Financial Officer Expected date of implementation: Implemented as of June 30, 2026.
Management concurs with the finding. Previous CFO submitted a SEFA based on revenue recognized without reconciling grant allowable expenses. To remediate the identified material weakness in financial reporting oversight, the CEO has initiated a restructuring of the fiscal leadership team. Effective ...
Management concurs with the finding. Previous CFO submitted a SEFA based on revenue recognized without reconciling grant allowable expenses. To remediate the identified material weakness in financial reporting oversight, the CEO has initiated a restructuring of the fiscal leadership team. Effective May 22, 2026, an interim CFO with extensive knowledge of healthcare accounting, GAAP and Uniform Guidance has been appointed. Corrective Action Plan: Senior accountants have been provided training on federal grant accounting procedures. Drawdowns are now performed after proper reconciliation of allowable expenses per grant budgets. Personnel responsible for implementation: Kristopher Zuniga Position of responsible personnel: Interim Chief Financial Officer Expected date of implementation: Implemented as of June 30, 2026.
Disaster Grants – Public Assistance – Assistance Listing No. 97.036 Recommendation: We recommend that management implement and system of internal controls to ensure that reports are reviewed by a second person and that the reports are reconciled to the Organizations accrual basis accounting records....
Disaster Grants – Public Assistance – Assistance Listing No. 97.036 Recommendation: We recommend that management implement and system of internal controls to ensure that reports are reviewed by a second person and that the reports are reconciled to the Organizations accrual basis accounting records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • The Chair of the Rebuild Finance Committee (RFC) and the MFUMC Finance Secretary will prepare monthly updates to summarize the payments made for invoices related to the federal award programs. These reports will include updates to the Contract Summary and Forced Accounts Summary for the previous month. • The Rebuild Finance Committee (RFC) will review the payments to grant related invoices on a monthly basis. • The RFC will review all charges submitted related to the Administrative Support reimbursement portion of the grant on a monthly basis. This will include all finance support staff and administrative support consultant’s submitted invoices. • On a quarterly basis, the RFC will review the summary of investment accounts including funds transferred from the UM Development group, money market funds, and CDs. The finance secretary will receive copies of all money transfers, roll-overs, and interest paid. • The RFC will, on a quarterly basis, reconcile the reports from items 1.and 2. with the submitted quarterly report submitted to KYEM. Name(s) of the contact person(s) responsible for corrective action: Mitzi Guhy and Adam Rush. Planned completion date for corrective action plan: December 31, 2026. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Mitzi Guhy or Adam Rush at (270) 247-5678.
Name of auditee: TELACU Manor, Inc. HUD auditee identification number: 122-11373 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 C...
Name of auditee: TELACU Manor, Inc. HUD auditee identification number: 122-11373 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Christien Tran Position: Management agent representative Telephone number: 323-838-8556 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2025-001: The Corporation's required deposit of $3,319 to the residual receipts account per the December 31, 2026 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Comments on the Finding and Each Recommendation: Management should make all required residual receipt deposits per the annual Computation of Surplus Cash, Distributions and Residual Receipts within 90 days after fiscal year end. Action(s) taken or planned on the finding: Management deposited $3,319 into the residual receipts fund on May 7, 2026. No further action is required.
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