Corrective Action Plans

Finding 574780 (2025-002)

None 2025

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Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months.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Finding 2025-002: During our testing of residual receipts account transactions, it was discovered that the Project had withdrawn $47,420 and transferred it back after 3 months.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 1218038 (2024-005)

Material Weakness 2024

Papa Ola Lokahi

HI

Material Weakness Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Fina...

Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…”, and recommendation made. The Organization further refers to the corrective action plan of Finding No. 2024-002: Subrecipient Monitoring, which describes the Organization’s implemented changes re: Subrecipient Monitoring and Management, Retroactive Subrecipient Portfolio Risk Assessment and Correction(s), and Subrecipient Policies and Procedures. Contractor Performance Collection and Substantiation – November 2024 The Organization has incorporated specific review procedures to ensure the timely collection and substantiation of contractor performance deliverables (e.g., products, goods, services, activities, reports), consistent with the terms and conditions of the contract. The current practices of the Organization, from the above date, to the present period of the report dated June 17, 2026, is consistent with such developed procedures.

View Audit 404207

Finding 1218030 (2024-004)

Material Weakness 2024

Papa Ola Lokahi

HI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.512 § 200.514

Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2023-004) and current year renumbered recommendation (2024-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a del...

Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2023-004) and current year renumbered recommendation (2024-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a delay in securing a new independent auditor (April 2023) continue to challenge the Organization, however, the Organization notes the status and progress of the following single audits: • June 30, 2022, filed in the Federal Audit Clearinghouse (FAC) in February 2025. • June 30, 2023, filed in the FAC in March 2026. • June 30, 2024, final review by Board in progress, projected filing in the FAC in June 2026. • June 30, 2025, engagement field work in progress with projected filing date no later than September 2026. • June 30, 2026, engagement letter signed with scheduled field work to commence after the June 30, 2025, audit FAC filing; projected to be completed with related FAC filing, no later than March 2027. The Organization notes the corrective actions that have been implemented, regarding internal controls to ensure compliance with the Uniform Guidance with respect to the submission deadline of single audit reports and the Data Collection Form: A. Internal Controls in Practice Since Inception of New Auditor Engagement – April 2023. As noted in the prior year corrective action response, the Organization established internal compliance controls related to the timely submission of single audit reports. Such process and review controls are implemented by the director of administrative operations, chief of staff (since December 2024), and chief executive officer; and subsequently communicated to the Board finance sub-committee and full Board, including the documented Board action(s) taken (e.g., Board agenda, minutes). B. Financial Policies and Procedures – May 2025. By May 2025, the Organization completed financial policies related to: implementation of significant accounting policies, internal control environment, cash and banking, cash disbursements and check issuance, payroll processes, procure to pay and revenue recognition policies, processes and procedures. Note the internal control policy of the Organization documents process and review controls, which were already in practice, applying to the timely filing of single audit reports. The current practices of the Organization, to the present period of the report dated June 17, 2026 is consistent with established process and review controls for timely submission of single audit reports.

View Audit 404207

Finding 1217939 (2024-003)

Material Weakness 2024

St. Luke's Hospital

ND

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Federal Agency Name: Department of Agriculture Assistance Listing Number: 10.766 Program Name: Community Facilities Loans and Grants Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure the proper disbursement and funding of the reserve account. Although ...

Federal Agency Name: Department of Agriculture Assistance Listing Number: 10.766 Program Name: Community Facilities Loans and Grants Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure the proper disbursement and funding of the reserve account. Although management obtained a waiver for the noncompliance, the lack of adequate policies governing proper funding of reserve increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Corrective Action Plan: Management will review and enhance internal control policies to ensure that there is proper funding of the reserve accounts. Responsible Individuals: Jody Nelson, CEO and Megan Peterson, CFO

View Audit 404103

Finding 1217419 (2024-010)

Material Weakness 2024

Community Legal Aid Society, Inc.

DE

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.1 § 200.303 § 200.32

This has been corrected with current staff. We are making sure that all reports are filed on time and correctly. Responsible Official: Director of Finance Expected Completion Date: The report was corrected 4/14/2026 with the completion of the 2025 SLFRF Compliance Report.

View Audit 403627

Finding 1217363 (2024-001)

Material Weakness 2024

PELHAM-BATESVILLE FIRE DEPARTMENT

SC

Reporting Matching / Level of Effort / Earmarking

The Town is working with its external auditor to issue the Single Audit for the year ended December 31, 2024. Anticipated Completion Date: May 28, 2026

View Audit 403550

Finding 1217307 (2024-005)

Material Weakness 2024

Anna Marie's Alliance

MN

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

Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdowns and reports prior to submission. Explanation of disagreement with audit finding: There is no disagree...

Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdowns and reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has designated an individual to review and approve the cash reimbursement requests and reports prior to submission. Name(s) of the contact person(s) responsible for corrective action: Tracy Johnson, Director of Finance Planned completion date for corrective action plan: June 30, 2025

View Audit 403475

Finding 1217305 (2024-003)

Material Weakness 2024

Anna Marie's Alliance

MN

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.318 § 200.326

Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: The Organization should continue to apply its current procurement policy to new and existing vendors to ensure proper documentation is retained in accordance with said procurement policy and SA UG. Explanation of disagreement wi...

Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: The Organization should continue to apply its current procurement policy to new and existing vendors to ensure proper documentation is retained in accordance with said procurement policy and SA UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will apply its current procurement policy to new and existing vendors in order to comply with applicable procurement requirements. Name(s) of the contact person(s) responsible for corrective action: Tracy Johnson, Director of Finance Planned completion date for corrective action plan: June 30, 2025

View Audit 403475

Finding 1217290 (2024-001)

Material Weakness 2024

North Central Alabama Regional Council of Local Governments

AL

Subrecipient Monitoring Reporting Significant Deficiency

FINDINGS - U.S ECONOMIC DEVELOPMENT ADMINISTRATION, ALN# 11.307 SIGNFICANT DEFICIENCY Finding 2024-001 - Reporting: The U.S. Economic Development Administration ALN # 11 .307 require reports to the appropriate federal agency for revolving loan funds and grants. Response to Aydjt finding 2024-001: Ba...

FINDINGS - U.S ECONOMIC DEVELOPMENT ADMINISTRATION, ALN# 11.307 SIGNFICANT DEFICIENCY Finding 2024-001 - Reporting: The U.S. Economic Development Administration ALN # 11 .307 require reports to the appropriate federal agency for revolving loan funds and grants. Response to Aydjt finding 2024-001: Background: The FY2024 Semi-Annual Revolving Loan Fund Financial Reports were not submitted within the required timeframe. Current accounting and RLF management were not responsible for report preparation during the reporting period and unable to verify the specific circumstances that resulted in the late submissions. The finding indicates that report controls and monitoring procedures in place at the time were not sufficient to ensure required deadlines were met primarily due to accounting and RLF staff turnover. Conclusion: Staffing turnover was mitigated in Fall 2025 allowing significant progress towards existing corrective action plan. Progress was as follows: • Developing updated and written procedures for RLF reporting. • Ensuring current key staff members and management have access to reporting instructions and supporting documentation. • Ensuring periodic management review of reporting deadlines and requirements.

View Audit 403451

Finding 1217228 (2024-005)

Material Weakness 2024

Family Promise of Hendricks County Inc.

IN

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs § 200.303

Management acknowledges the importance of maintaining appropriate segregation of duties and documented independent review for match calculations and supporting documentation. Corrective actions implemented include the development and implementation of written procedures for preparing, reviewing, and...

Management acknowledges the importance of maintaining appropriate segregation of duties and documented independent review for match calculations and supporting documentation. Corrective actions implemented include the development and implementation of written procedures for preparing, reviewing, and approving match calculations and supporting documentation as well as requiring independent review and documented approval of match calculations by a staff member not involved in the preparation.

View Audit 403362

Finding 1216953 (2024-011)

Material Weakness 2024

City of Waverly

OH

Reporting Matching / Level of Effort / Earmarking Program Income § 200.329

The Village will submit required reports on time.

View Audit 403245

Finding 1216735 (2024-001)

Material Weakness 2024

STEPS to Recovery Homes

AZ

Reporting Matching / Level of Effort / Earmarking Special Tests & Provisions

Management of the Organization has an accounting firm engaged who will perform future required audits.

View Audit 403178

Finding 1216684 (2024-006)

Material Weakness 2024

American Thoracic Society, Inc.

NY

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303 § 200.318 § 200.320

Views of Responsible Officials and Planned Corrective Actions: ATS has drafted an organization-wide procurement policy to ensure it includes all the Uniform guidance procurement elements. The draft will be reviewed by senior management for comment prior to formal issuance.

View Audit 403116

Finding 1216628 (2024-001)

Material Weakness 2024

My Sister's Place, Inc.

DC

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Response: MSP now performs and documents verification on all vendors and subcontractors. This practice has been implemented prior to the completion of the FY 2024 audit. Additionally, policies and procedures have been updated to reflect appropriate suspension and debarment considerations.

View Audit 403101

Finding 1216626 (2024-002)

Material Weakness 2024

My Sister's Place, Inc.

DC

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Response: MSP plans to implement changes overall to timekeeping processes to ensure that payroll costs accurately reflect the work performed and to reconcile and true up any budget estimates on a consistent basis.

View Audit 403101

Finding 1216555 (2024-007)

Material Weakness 2024

Glacierland Resource Conservation and Development Council, Inc.

WI

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

Finding 2023-007 ● Criteria or Specific Requirement: Title 2 U.S. Code of Federal Regulations section 200.303 requires a nonfederal entity to establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal...

Finding 2023-007 ● Criteria or Specific Requirement: Title 2 U.S. Code of Federal Regulations section 200.303 requires a nonfederal entity to establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. ● Condition: During out testing of expenses for allowability, we identified transactions where there was no evidence of being reviewed and approved by appropriate personnel for allowability. ● Corrective Action Plan: Management agrees with the finding and they will evaluate our findings to determine an appropriate corrective action. Financial policies and procedures will be created and implemented to ensure expenses are reviewed for allowability with federal programs.

View Audit 403049

Finding 1216528 (2024-014)

Material Weakness 2024

Pottawatomie County

OK

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.403

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 403025

Finding 1216333 (2024-003)

Material Weakness 2024

City of Dade City

FL

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Significant Deficiency Finding Number: 2024-003 Federal Award Finding and Questioned Costs Corrective Action Plan The City will evaluate their processes and procedures over internal controls to ensure that all employee rate changes and payroll registers are appropriately documented and maintained. W...

Significant Deficiency Finding Number: 2024-003 Federal Award Finding and Questioned Costs Corrective Action Plan The City will evaluate their processes and procedures over internal controls to ensure that all employee rate changes and payroll registers are appropriately documented and maintained. While we maintain that oversight was in place, we concur with the finding and have identified the responsibility of the process to be placed on the finance department's fiscal assistants. The lack of documented review of the reporting process is noted, and procedures are now in place for documentation of the review and approval of the data as it is reported on portals as required. The Finance Officer will direct an accountant on staff or a professional consultant to complete the preparation of the reporting so that he/she can review and authorize the submission of reports. The implementation of upgraded software and strengthened internal control policies and procedures is a priority. Anticipated Completion Date September 30, 2026 Responsible Party The Finance Officer

View Audit 402827

Finding 1216228 (2024-007)

Material Weakness 2024

Barclay College

KS

Student Financial Aid Material Weakness Matching / Level of Effort / Earmarking

Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Dat...

Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026

View Audit 402736

Finding 1216225 (2024-005)

Material Weakness 2024

Barclay College

KS

Eligibility Student Financial Aid Material Weakness

Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/...

Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026

View Audit 402736

Corrective Action Plans

Filters