Corrective Action Plans

Finding 575411 (2025-002)

Significant Deficiency 2025

MI

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Actions – To address the identified issues related to student withdrawal processing and Return to Title IV (R2T4) calculations, the University will implement the following steps: 1. Process Review and Collaboration: A joint meeting will be held w...

Views of Responsible Officials and Planned Corrective Actions – To address the identified issues related to student withdrawal processing and Return to Title IV (R2T4) calculations, the University will implement the following steps: 1. Process Review and Collaboration: A joint meeting will be held with key personnel from Academic Records and Financial Aid to review current withdrawal procedures, including the use of drop and exit forms. Emphasis will be placed on ensuring that appropriate withdrawal codes are consistently applied to support accurate and automated R2T4 processing. The goal is to establish a unified and clearly documented process that meets the operational needs of both departments. 2. Systematic Scheduling and Monitoring: Withdrawal-related tasks, including the running of BANNER return reports and other custom reports developed by the IT team, will be scheduled at regular intervals to ensure timely identification and processing of student withdrawals. These tasks will be integrated into departmental calendars, with scheduled dates already entered for the Fall 2025 and Spring 2026 semesters. 3. Ongoing Oversight and Communication: A communication protocol will be developed to ensure that all relevant documentation, including drop forms, is consistently shared between departments. This will help prevent delays in processing and ensure compliance with federal financial aid regulations.

View Audit 365458

Finding 575409 (2025-001)

Significant Deficiency 2025

Andrews University

MI

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Actions – The National Student Clearinghouse (NSC) Graduation and Enrollment Change Status’ submission calendar will be updated to reflect the necessary reporting timeline. The report will be completed after verification of graduation requirement...

Views of Responsible Officials and Planned Corrective Actions – The National Student Clearinghouse (NSC) Graduation and Enrollment Change Status’ submission calendar will be updated to reflect the necessary reporting timeline. The report will be completed after verification of graduation requirements and credentialing are completed by the Academic Record’s Department. Additional training will be provided to all members within the department to ensure timely submissions.

View Audit 365458

Finding 574780 (2025-002)

None 2025

Heights Towers Services Company

TX

HUD Housing Programs Reporting Matching / Level of Effort / Earmarking

Audit Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months. -Response: Management believed that including this expenditure in its request for withdrawal of funds from the reserv...

Audit Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months. -Response: Management believed that including this expenditure in its request for withdrawal of funds from the reserve for replacement account was sufficient. Management also promptly replaced the funds taken temporarily from the residual receipts account, once they received the funds from the reserve for replacement account controlled by the lender. In the future, management will make sure to obtain prior approval from HUD before making any withdrawals from the residual receipts account.

View Audit 365067

Finding 573857 (2025-002)

Significant Deficiency 2025

Rannie Webster Foundation

NH

HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking

2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance cover...

2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance coverage is reviewed annually and adjusted as necessary to meet HUD requirements. Explanation of disagreement with audit finding: Management is in agreement with the finding. Prior to affiliating with Silverstone Living, the Foundation had a separate endorsement included in their Property Coverage policy that included increased crime coverage to comply with HUD requirements. After transferring coverage to Silverstone Living’s policies, the increased crime coverage did not get transferred over to keep the Foundation in compliance. Action taken in response to finding: The Foundation is actively working with its insurance provider to increase coverage to the required level. The revised policy is expected to be in place by July 31, 2025. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 31, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Janet Langlois at 603-589-4111.

View Audit 364508

Finding 573856 (2025-001)

Significant Deficiency 2025

Rannie Webster Foundation

NH

HUD Housing Programs Procurement, Suspension & Debarment Significant Deficiency

U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed bel...

U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 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 and Questioned Costs – Major Federal Programs U.S. Department of Housing and Urban Development 2025-001 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: CLA recommends that management ensures the regulatory agreement is being followed by all parties involved, unless otherwise instructed by a HUD representative. Any communication regarding changes to the regulatory agreement should come directly from HUD. Explanation of disagreement with audit finding: Management is in agreement with the finding. They received miscommunication from Lument. Since the Foundation goes through Lument for HUD requests and approvals, management thought the communication they received from Lument was approved by HUD. As a result, management was under the impression that the residual receipts account was fully funded, and the deposit of surplus cash was not required. Action taken in response to finding: On July 18, 2025, management submitted a formal request to HUD to suspend deposits to the residual receipts fund. On July 21, 2025, HUD approved a suspension of deposits to the reserve as long as a balance of $640,856.81 is maintained. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 21, 2025.

View Audit 364508

Finding 572429 (2025-001)

Significant Deficiency 2025

Regis University

CO

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non...

Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2025, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.

View Audit 363564

Finding 572209 (2025-001)

None 2025

Friendship Manor Housing Development Fund Company, Inc.

NY

Procurement, Suspension & Debarment HUD Housing Programs Matching / Level of Effort / Earmarking

Name of auditee: Friendship Manor Housing Development Fund Company, Inc. Project No.: 01411252 TIN: 20-8665840 Name of audit firm: EFPR Group, CPA, PLLC Period covered by audit: March 31, 2025 CAP prepared by: Andrea D. Mays President of the Managing Agent ADM Management Group, Inc. (716) 892-1799 C...

Name of auditee: Friendship Manor Housing Development Fund Company, Inc. Project No.: 01411252 TIN: 20-8665840 Name of audit firm: EFPR Group, CPA, PLLC Period covered by audit: March 31, 2025 CAP prepared by: Andrea D. Mays President of the Managing Agent ADM Management Group, Inc. (716) 892-1799 Current Findings on the Schedule of Findings and Questioned Costs and Recommendations (1) Finding 2025-001 Management will use the $42,926 of funds withdrawn from the reserves for replacements to payoff the loan acquired for the vehicle as originally intended.

View Audit 363342

Finding 572073 (2025-001)

Material Weakness 2025

Orlando Rehabilitation Group

FL

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. The advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware...

To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. The advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware that such an advance was not permitted to be made. Kane Financial Services was also unaware. The plan to correct it includes the following action steps: • Seeking approval from HUD for the $2.7M advance. • If the advance is not approved, then the repayment will occur by the organizations over an 18-month period beginning in October 2025. It is understood that such advances will not be made going forward without prior HUD approval. The contact information for oversight of the plan is: Susan Shain Executive Vice President of Finance, Kane Financial Services Email: Sshain@kanefs.com Phone: 561-223-4161 Sincerely, Susan Shain Executive Vice President of Finance Kane Financial Services

View Audit 363196 Questioned Costs: $1

Finding 1174797 (2024-001)

Material Weakness 2024

Mystic River Homes, Inc.

CT

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Eligibility

Finding 2024-001 Internal Control Over Compliance - Eligibility Program: Rural Rental Housing Loans Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.415 Internal Control Area: Internal Control Over Compliance – Eligibility Condition: The entity did not provide adequate do...

Finding 2024-001 Internal Control Over Compliance - Eligibility Program: Rural Rental Housing Loans Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.415 Internal Control Area: Internal Control Over Compliance – Eligibility Condition: The entity did not provide adequate documentation to the auditors to support eligibility determinations for certain tenants participating in the Rural Rental Housing Loans program. As a result, the auditors could not opine on compliance with this federal grant as it applies to tenant eligibility. Criteria: Uniform Guidance (§200.303) requires non-federal entities to establish and maintain effective internal control over federal programs to provide reasonable assurance of compliance with federal statutes, regulations, and the terms and conditions of federal awards. Effective internal control over eligibility with this federal award includes procedures for verifying, documenting, reviewing, and retaining tenant eligibility information. Cause: The deficiency appears to be due to insufficient internal controls over the retention of adequate documentation to support eligibility determinations made by management. Effect: Because internal controls over eligibility were not operating effectively, there was inadequate documentation available to provide to the auditors for testing of such eligibility determinations. Recommendation: We recommend that management strengthen internal controls over eligibility by establishing formal procedures for implementing supervisory review of tenant files, and ensuring eligibility documentation is retained in accordance with program requirements. Management’s Response and Corrective Action: Management agrees with this finding and will implement procedures to ensure that all supporting documentation related to tenant eligibility is retained and easily retrievable.

View Audit 388331

Finding 1174719 (2024-004)

Material Weakness 2024

City of Dexter, Missouri

IL

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding Type: Material weakness related to Procurement, Suspension and Debarment compliance requirements. Name of Contact Person: Ms. Crystal Bishop, City Clerk, (573) 624-5959. Recommendation: We recommend the City check the excluded parties list system or collect certifications from any vendor in ...

Finding Type: Material weakness related to Procurement, Suspension and Debarment compliance requirements. Name of Contact Person: Ms. Crystal Bishop, City Clerk, (573) 624-5959. Recommendation: We recommend the City check the excluded parties list system or collect certifications from any vendor in which the City expects to spend more than $25,000 of federal grant funds for the year. Corrective Action: We have already adopted the appropriate policies. Proposed Completion Date: Immediately.

View Audit 388275

Finding 1174718 (2024-003)

Material Weakness 2024

City of Dexter, Missouri

IL

Matching / Level of Effort / Earmarking

Finding Type: Compliance and material weakness related to Reporting compliance requirements. Name of Contact Person: Ms. Crystal Bishop, City Clerk, (573) 624-5959. Recommendation: We recommend the City should ensure that all reports are filed timely. Corrective Action: We have filed allr eports sin...

Finding Type: Compliance and material weakness related to Reporting compliance requirements. Name of Contact Person: Ms. Crystal Bishop, City Clerk, (573) 624-5959. Recommendation: We recommend the City should ensure that all reports are filed timely. Corrective Action: We have filed allr eports since this report as required. Proposed Completion Date: Immediately.

View Audit 388275

Finding 1174620 (2024-004)

Material Weakness 2024

Four Square Community Action, Inc.

NC

Cash Management Matching / Level of Effort / Earmarking

Management acknowledges the need to streamline the fund reconciliation process and plans to improve.

View Audit 388128

Finding 1173701 (2024-002)

Material Weakness 2024

City of Prescott

WI

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The City adopted written grant procedures that are in accordance with the Uniform Guidance as of October 2025.

View Audit 387418

Finding 1173434 (2024-001)

Material Weakness 2024

Richland-Lexington Airport District

SC

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.512

The Richland-Lexington Airport District respectfully submits this corrective action plan for the audit finding during the 2024 year-end audit. The management of the Richland-Lexington Airport District agrees with Item 2024-001 as presented in Section III- Federal Award Findings and Questioned Costs....

The Richland-Lexington Airport District respectfully submits this corrective action plan for the audit finding during the 2024 year-end audit. The management of the Richland-Lexington Airport District agrees with Item 2024-001 as presented in Section III- Federal Award Findings and Questioned Costs. The challenges associated with both roles and the time required to select the District’s next permanent Chief Executive Officer resulted in a delay in completing the audit of the District’s financial statements for the year ended December 31, 2024. The Richland-Lexington Airport Commission selected Mr. Christopher White, AAE as the District’s Chief Executive Officer and Mr. White assumed his new duties with the District on January 4, 2026. As of this date, the Chief Financial Officer was relieved of the Interim Chief Executive Officer duties and has completed all actions necessary to reconcile the general ledger and finalize the District’s Annual Comprehensive Financial Report (the “ACFR”) for the year ended December 31, 2024. The “full-staffing” status of the District’s senior management team will allow for the proper allocation of personnel resources to ensure the timely production of the ACFR and District’s Data Collection Form and Reporting Package in subsequent years.

View Audit 387125

Finding 1173423 (2024-002)

Material Weakness 2024

Aiken/barnwell Counties Community Action Agency INC

SC

Matching / Level of Effort / Earmarking Special Tests & Provisions

We acknowledge the findings of Compliance and Reporting. The lapse occurred during a period when multiple years’ audits were required within a short turnaround. We are completing these outstanding audits to comply by May 31, 2026, for year end of August 31, 2025. Management will be developing and im...

We acknowledge the findings of Compliance and Reporting. The lapse occurred during a period when multiple years’ audits were required within a short turnaround. We are completing these outstanding audits to comply by May 31, 2026, for year end of August 31, 2025. Management will be developing and implementing a calendar to standardized reporting for all federal programs and updated written policies and procedures to document reporting responsibilities, timelines, and required documentation.

View Audit 387122

Finding 1173390 (2024-004)

Material Weakness 2024

Jackson County

OH

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be ret...

Timesheets will be signed off on by the Health Commissioner or by the department director (Nursing, Environmental Health, Community Health, Administration). Staff will be required to present the timesheets to their supervisor before turning them in for processing. All unsigned timesheets will be returned to the department director and will not be processed until signed.

View Audit 387072

Finding 1173389 (2024-003)

Material Weakness 2024

Jackson County

OH

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Cash Management § 200.302 § 200.305 § 200.318 § 200.320 § 200.320(B)

The department will adopt written policies with the Uniform Guidance for federally funded grant programs accepted by the department.

View Audit 387072

Finding 1173363 (2024-561)

Material Weakness 2024

Holy Cross Head Start, INC

NY

Subrecipient Monitoring Matching / Level of Effort / Earmarking

The Organization has implemented new controls and staffing recently that are intended to remediate this matter.

View Audit 387018

Finding 1173251 (2024-002)

Material Weakness 2024

Morton County

ND

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Condition: Morton County did not properly report expenditures on the March 31, 2024, Project and Expenditure Report for the Coronavirus State and Local Fiscal Recovery Funds program. The total cumulative expenditures were understated by $233,268. Management’s Response: We Agree. We will ensure futur...

Condition: Morton County did not properly report expenditures on the March 31, 2024, Project and Expenditure Report for the Coronavirus State and Local Fiscal Recovery Funds program. The total cumulative expenditures were understated by $233,268. Management’s Response: We Agree. We will ensure future project and expenditure reports have correct and accurate amounts submitted. Anticipated Completion Date: FY 2025

View Audit 386760

Finding 1173146 (2024-001)

Material Weakness 2024

Northeast Organic Farming Association of Vermont, Inc.

VT

Matching / Level of Effort / Earmarking

Finding type: Significant deficiency

View Audit 386567

Finding 1173146 (2024-001)

Material Weakness 2024

Northeast Organic Farming Association of Vermont, Inc.

VT

Matching / Level of Effort / Earmarking

Federal awards: 10.165 Perishable Agricultural Commodities Act Passthrough organization: Pennsylvania Certified Organic 10.188 Organic Market Development Grant (OMDG) Program Passthrough organization: Direct funding/ Northeast Organic Family Farm Partnership 10.331 Gus Schumacher Nutrition Incentive...

Federal awards: 10.165 Perishable Agricultural Commodities Act Passthrough organization: Pennsylvania Certified Organic 10.188 Organic Market Development Grant (OMDG) Program Passthrough organization: Direct funding/ Northeast Organic Family Farm Partnership 10.331 Gus Schumacher Nutrition Incentive Program Passthrough organization: Farm Fresh Rhode Island

View Audit 386567

Finding 1173146 (2024-001)

Material Weakness 2024

Northeast Organic Farming Association of Vermont, Inc.

VT

Matching / Level of Effort / Earmarking

Criteria: Organizations spending more than the minimum threshold in Federal awards must submit an audit reporting package to the Federal Audit Clearinghouse within nine months of the end of the fiscal year per the requirements of the Uniform Guidance.

View Audit 386567

Finding 1173146 (2024-001)

Material Weakness 2024

Northeast Organic Farming Association of Vermont, Inc.

VT

Matching / Level of Effort / Earmarking

Condition: The Organization did not submit the reporting package by the required submission date for the year ended December 31, 2024.

View Audit 386567

Finding 1173146 (2024-001)

Material Weakness 2024

Northeast Organic Farming Association of Vermont, Inc.

VT

Matching / Level of Effort / Earmarking

The audit firm has acknowledged that the delay in completing the audit in a timely manner was due to their failure in managing the audit workload. Access to materials necessary to complete a large portion of the audit work was provided within five months of the year end. Furthermore, auditor request...

The audit firm has acknowledged that the delay in completing the audit in a timely manner was due to their failure in managing the audit workload. Access to materials necessary to complete a large portion of the audit work was provided within five months of the year end. Furthermore, auditor requests for more information were answered promptly by the Organization throughout the audit process. The Organization is willing to work with the audit firm to create an audit timeline that will work for both auditee and auditor. The goal is to file audit reports in a timely manner for years going forward. As noted, this was the first year with this audit firm and it is the Organization’s intention to stay with this firm for at least two more years. The audit firm showed a level of professionalism and expertise that has been a great benefit to the Organization.

View Audit 386567

Finding 1172672 (2024-030)

Material Weakness 2024

Maryland Water Infrastructure Financing Agency

MD

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Higher Education Institutional Aid– Assistance Listing No. 84.031 Condition: The institution did not have effective internal controls over cash management. Recommendation: We recommend the institution review and implement their internal controls and procedures over cash management so that expenditur...

Higher Education Institutional Aid– Assistance Listing No. 84.031 Condition: The institution did not have effective internal controls over cash management. Recommendation: We recommend the institution review and implement their internal controls and procedures over cash management so that expenditures are being properly tracked, reconciled, and reviewed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Drawdowns are currently prepared by one individual and reviewed by separate individual, however the supporting documentation does not consistently reflect that two individuals were involved in the drawdown; the procedures will require the sign off of both the preparer and the reviewer on the draw down documentation. Name(s) of the contact person(s) responsible for corrective action: Jeff Copeland Planned completion date for corrective action plan: March 31, 2025

View Audit 385911

Corrective Action Plans

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