Corrective Action Plans

Finding 573856 (2025-001)

Significant Deficiency 2025

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 Questioned Costs Special Tests & Provisions

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 1241763 (2024-004)

Material Weakness 2024

Bristol Township

PA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

U.S. Department of Treasury COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that management review their policies and procedures to ensure that all monthly and quarterly reports are submitted timely, and the supporting docu...

U.S. Department of Treasury COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that management review their policies and procedures to ensure that all monthly and quarterly reports are submitted timely, and the supporting documentation used to prepare the reports retained for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review and update existing policies and procedures for the SLFRF program to establish formal requirements for preparing, reviewing, approving, and submitting all applicable monthly and quarterly reports by their respective deadlines. Management will develop a reporting calendar identifying all required reports and submission deadlines. Management will Conduct periodic monitoring to verify that reports are submitted timely, supporting documentation is retained, and any identified reporting deficiencies are corrected promptly. Name(s) of the contact person(s) responsible for corrective action: Township Manager and Finance Officer Planned completion date for corrective action plan: Initial procedures and checklists will be developed within 60 days. The revised controls will be fully applied during the next year-end close, subject to the applicable fiscal year-end schedule.

View Audit 415766

Finding 1241474 (2024-003)

Material Weakness 2024

Elder Care Services, Inc.

FL

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

Eligibility – Foster Grandparent/Senior Companion Programs ECS is strengthening its existing review procedures by implementing a more structured and documented secondary review process. Income eligibility determinations will be reviewed for completeness and mathematical accuracy, including proper an...

Eligibility – Foster Grandparent/Senior Companion Programs ECS is strengthening its existing review procedures by implementing a more structured and documented secondary review process. Income eligibility determinations will be reviewed for completeness and mathematical accuracy, including proper annualization of income and inclusion of applicable income sources. Program staff responsible for preparing and reviewing eligibility determinations will receive training regarding calculation procedures, required supporting documentation, document retention, and evidence of review and approval. The SVP Director will serve as the second level of review for all completed income eligibility forms. A Director’s signature line has been added to the income eligibility form to provide documented evidence that the secondary review was completed. Periodic file reviews will be performed to verify that eligibility calculations are accurate, required supporting documentation is maintained, and Director review is appropriately documented. A formal annual completion timeline will be incorporated into departmental procedures to establish deadlines for completion, secondary review, approval, and retention of annual income eligibility documentation.

View Audit 415564

Finding 1241319 (2024-002)

Material Weakness 2024

Northeast Washington County Community Health, Inc.

VT

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

We will establish written procedures reconciling patient billing reports to the general ledger for receivables, pharmacy, dental and medical revenues, contractual adjustments, and cash collections, as applicable. Complete cross training using written procedures, demonstrations, and supervised perfor...

We will establish written procedures reconciling patient billing reports to the general ledger for receivables, pharmacy, dental and medical revenues, contractual adjustments, and cash collections, as applicable. Complete cross training using written procedures, demonstrations, and supervised performance. After implementation, complete reconciliations monthly, target close within 45 days after month end, and provide financial results and unresolved exceptions to management and the governing board or its designated committee. Escalate staffing gaps and overdue reconciliations promptly. Reconcile federal award reporting to the accounting records and track audit deliverables and applicable reporting deadlines.

View Audit 415475

Finding 1241236 (2024-003)

Material Weakness 2024

Black Womens Health Imperative

DC

Cash Management Internal Control / Segregation of Duties Significant Deficiency § 200.303 § 200.305

Audit Finding Number 2024-003 Audit Finding Title Cash Management Planned Corrective Action Effective September 2026, each drawdown will be prepared by Kim Cockerham, Sr. Director of Finance and Accounting and then reviewed by a separate employee before submission. Preparation and review are time st...

Audit Finding Number 2024-003 Audit Finding Title Cash Management Planned Corrective Action Effective September 2026, each drawdown will be prepared by Kim Cockerham, Sr. Director of Finance and Accounting and then reviewed by a separate employee before submission. Preparation and review are time stamped and documented in the CDC payment system. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting

View Audit 415344

Finding 1240753 (2024-001)

Material Weakness 2024

Public Buildings Authority

PR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

IMPLEMENT SEFA RECONCILIATION CONTROL MATRIX DOCUMENTATION, MONITORING AND TRAINNING

View Audit 415138

Finding 1240511 (2024-002)

Material Weakness 2024

Central New York Regional Planning & Development Board

NY

Reporting Matching / Level of Effort / Earmarking § 200.512

Name of Auditee: Central New York Regional Planning and Development Board Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: David Bottar, Executive Director Phone: (315) 422-8276 (2) Audit Finding 2024-002 (a) Comments on the Findin...

Name of Auditee: Central New York Regional Planning and Development Board Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: David Bottar, Executive Director Phone: (315) 422-8276 (2) Audit Finding 2024-002 (a) Comments on the Finding and Recommendation - The Board agrees with the finding. The Board also agrees with the recommendation. See below for actions taken. (b) Actions Taken - The Board acknowledges the finding and is working with third parties to ensure that all future reporting deadlines can be met. (c) Anticipated Completion - Management anticipates this finding to be resolved by December 31, 2026. (d) Persons Responsible for Implementation - David Bottar, Executive Director.

View Audit 414970

Finding 1240462 (2024-005)

Material Weakness 2024

Recovery Connections of Central Florida, Inc.

FL

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

Matching Recommendation: Recommended Recovery Connections of Central Florida, Inc. create formal procedures to track grant matching and ensure that there is a monthly review of matching requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Act...

Matching Recommendation: Recommended Recovery Connections of Central Florida, Inc. create formal procedures to track grant matching and ensure that there is a monthly review of matching requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will review each agreement to confirm the matching requirements that must be followed. A designated team member will be responsible for tracking compliance with the required match. Name(s) of the contact person(s) responsible for corrective action: George Margoles Planned completion date for corrective action plan: December 31, 2026

View Audit 414949

Finding 1240316 (2024-005)

Material Weakness 2024

COUNTY OF SAC

IA

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

The County will develop a formal process for tracking all federal expenditures and take steps to learn when those expenditures trigger additional audit requirements.

View Audit 414856

Finding 1240312 (2024-004)

Material Weakness 2024

COUNTY OF SAC

IA

Reporting Matching / Level of Effort / Earmarking

The County will develop a formal process for tracking all federal expenditures and take steps to learn when those expenditures trigger additional audit requirements.

View Audit 414856

Finding 1240209 (2024-004)

Material Weakness 2024

Ekentucky Advanced Manufacturing Institute INC

KY

Subrecipient Monitoring Reporting Significant Deficiency § 200.208 § 200.339 § 200.501 § 200.512 § 200.520

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit an...

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit and submit the reporting package within nine months after year end. Anticipated completion date: December 31, 2026. Responsible contact person: Kathy Walker, Executive Director.

View Audit 414799

Finding 1240073 (2024-001)

Material Weakness 2024

Family Planning of South Central New York, Inc.

NY

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.512

Name of auditee: Family Planning of South Central New York, Inc. TIN: 16-1005972 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: Thomas Artale Thomas.Artale@FSPCNY.org Finding 2024-001 Corrective Action Plan The Organization ac...

Name of auditee: Family Planning of South Central New York, Inc. TIN: 16-1005972 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: Thomas Artale Thomas.Artale@FSPCNY.org Finding 2024-001 Corrective Action Plan The Organization acknowledges and is aware of this finding. Management will confirm their subrecipient status with all funding sources.

View Audit 414690

Finding 1240054 (2024-009)

Material Weakness 2024

COUNTY OF MCCURTAIN

OK

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

The current Board of County Commissioners acknowledges the finding. The Board will continue strengthening grant administration procedures and compliance monitoring related to federal programs. Additional review procedures Will be utilized to ensure federal expenditures and reporting requirements are...

The current Board of County Commissioners acknowledges the finding. The Board will continue strengthening grant administration procedures and compliance monitoring related to federal programs. Additional review procedures Will be utilized to ensure federal expenditures and reporting requirements are adequately documented and reviewed.

View Audit 414665

Finding 1239901 (2024-001)

Material Weakness 2024

County of Shelby, Illinois

IL

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

SECTION 5 - CORRECTIVE ACTION PLAN Finding 2024 - 001: Grant Administration Condition: During our current year-end audit procedures, we noted that the County did not have adequate centralized procedures to track, monitor, and aggregate grant activity across grant departments to ensure compliance wit...

SECTION 5 - CORRECTIVE ACTION PLAN Finding 2024 - 001: Grant Administration Condition: During our current year-end audit procedures, we noted that the County did not have adequate centralized procedures to track, monitor, and aggregate grant activity across grant departments to ensure compliance with grant requirements and to identify when the Single Audit threshold was met. Plan: The County will designate a central function, such as the Treasurer's Office, to maintain a comprehensive list of all grants awards received by County Departments. Departments will be required to notify the central function upon application for and receipt of grant funding and to provide periodic expenditure and compliance information. Standardized procedures will be implemented to monitor grant activity, track cumulative federal expenditures, and assess Single Audit applicability. Anticipated Date of Completion: Fiscal Year 2025 Name of Contact Person: Tad A. Mayhall, County Board Chairman Management Response: The county is working on establishing policies in response to the findings in the FY23 and FY24 audits. As a part of the corrective action plan for tracking grant revenues and expenses, we have been working in committee and with guidance from the incoming treasurer to establish the county treasures office as the central point of contact for all grant recording, to include application, receipt, and expense tracking for all grants in Shelby County.

View Audit 414535

Finding 1239820 (2024-007)

Material Weakness 2024

VILLAGE OF MENDON

MI

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Cash Management § 200.305

Finding 2024-007 – Lack of Separate Bank Account for Restricted Federal Cash Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will establish a separate bank account for restricted federal loan proceeds or implement a general ledger mechanism to ensure proper t...

Finding 2024-007 – Lack of Separate Bank Account for Restricted Federal Cash Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will establish a separate bank account for restricted federal loan proceeds or implement a general ledger mechanism to ensure proper tracking and reconciliation. Anticipated Completion Date: March 31, 2026

View Audit 414503

Finding 1239818 (2024-006)

Material Weakness 2024

VILLAGE OF MENDON

MI

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.334 § 200.403

Finding 2024-006 – Deficiencies in Disbursement Procedures and Documentation Retention Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will implement formal procedures for disbursement review, approval, and documentation. Staff will be trained on federal docu...

Finding 2024-006 – Deficiencies in Disbursement Procedures and Documentation Retention Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will implement formal procedures for disbursement review, approval, and documentation. Staff will be trained on federal documentation and record retention requirements. Anticipated Completion Date: March 31, 2026

View Audit 414503

Finding 1239638 (2024-005)

Material Weakness 2024

Arizona Immigrant and Refugee Services, INC

AZ

Procurement, Suspension & Debarment Material Weakness Matching / Level of Effort / Earmarking § 200.318 § 200.327

AIRS management has started the process of creating new and updated policies and procedures related to financial reporting activities, including written procurement standards, written standards of conflict of interest, and others as required under Uniform Guidance.

View Audit 414293

Finding 1239064 (2024-004)

Material Weakness 2024

Upmc

PA

Matching / Level of Effort / Earmarking Reporting

Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) Condition: For the period under audit, UPMC did not retain sufficient evidence to support the design ...

Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) Condition: For the period under audit, UPMC did not retain sufficient evidence to support the design and operation of internal controls over the applicable compliance requirements, including allowability; cash management; matching, level of effort and earmarking, program income, and reporting. Corrective action plan: UPMC has remediated this deficiency. Effective January 1, 2025, management revised the internal control policies and procedures for Ryan White, Part C to appropriately maintain evidence of controls performed. Completion: May 2025

View Audit 413918

Finding 1238734 (2024-002)

Material Weakness 2024

Schertz Housing Authority

TX

HUD Housing Programs Material Weakness Reporting § 200.303

We are working with our HUD field office to correct our VMS reporting.

View Audit 413657

Finding 1238369 (2024-004)

Material Weakness 2024

American Indian Council on Alcoholism Inc.

WI

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.318

Management agrees with the finding. Management has downloaded 2 CFR Part 200, section 200.318(i) for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly.

View Audit 413211

Finding 1238365 (2024-002)

Material Weakness 2024

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

2024-002: For the year ended December 31, 2024, $4,485,028 of FEMA expenditures were omitted from the 2024 Schedule. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Management has enhanced the process for prepar...

2024-002: For the year ended December 31, 2024, $4,485,028 of FEMA expenditures were omitted from the 2024 Schedule. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Management has enhanced the process for preparing the Schedule of Expenditures of Federal Awards (SEFA) to improve the completeness and accuracy offederal award reporting. The process includes reconciliation of federal expenditures reported in the SEFA to the District's underlying accounting records and supporting grant information. Management will also perform a documented secondary review of the SEFA prior to issuance to verify the completeness and accuracy of federal awards and expenditures reported. Differences identified through the reconciliation and review process will be investigated and resolved prior to finalization of the SEFA These procedures will be incorporated into the District's annual financial reporting process and applied to all applicable federal awards. Anticipated Completion Date: August 2026 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-002.

View Audit 413201

Finding 1238364 (2024-001)

Material Weakness 2024

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

Allowable Costs / Cost Principles Cash Management Period of Performance § 200.303 § 200.403

AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures...

AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.

View Audit 413201

Corrective Action Plans

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