Corrective Action Plans

Finding 1156605 (2024-002)

Material Weakness 2024

NY

Questioned Costs HUD Housing Programs Eligibility

Finding Number 2024-002 ELIGIBILITY – DEFICIENCY - COMPLIANCE Agency Name FEDERAL AGENCY: U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Program ALN 14.850 – PUBLIC AND INDIAN HOUSING Contract # N/A Criteria Eligibility for Individuals - Most PHAs devise their own application forms that are filled...

Finding Number 2024-002 ELIGIBILITY – DEFICIENCY - COMPLIANCE Agency Name FEDERAL AGENCY: U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Program ALN 14.850 – PUBLIC AND INDIAN HOUSING Contract # N/A Criteria Eligibility for Individuals - Most PHAs devise their own application forms that are filled out by the PHA staff during an interview with the tenant. The head of household signs (a) a certification that the information provided to the PHA is correct; (b) one or more release forms to allow the PHA to get information from third parties; (c) a federally prescribed general release form for employment information; and (d) a privacy notice. Under some circumstances, other members of the family may be required to sign these forms (24 CFR sections 5.212, 5.230, and 5.601 through 5.615). Condition/Context The Authority received funding from the HUD. The Public and Indian Housing Program is to provide and operate cost effective, decent, safe, and affordable dwellings for lower income families through an authorized local PHA. Of the sixty (60) case files selected for testing in which 540 pieces of audit evidence (eligibility forms as noted in the Criteria section above) were requested to be provided: • Ten eligibility forms were not provided (Three missing application forms, two missing Federally prescribed general release form for employment information; two missing verification of income; two missing calculation of rent forms and one missing reexamine family income). These forms are required documentation to be maintained in the case files to support eligibility for Public and Indian Housing Program. Therefore, we were not able to determine if the eligible participants met all the eligibility criteria. Recommendation We recommend the Authority strengthen its controls over the Public and Indian Housing Program case files to ensure that all eligibility forms are received, reviewed, and maintained in the case files to support the determination of eligibility. Corrective Action Plan In January 2011, NYCHA implemented the Siebel Customer Relationship Management (CRM) system, which included digital file storage and an online application process, which replaced our previous paper application process. Any applications in process from that date onward were subject to document scanning and documentation was stored digitally. Any applications processed prior to this date were kept in a paper format and stored at the development, where the applicant was certified or where the tenant resides. If a tenant family transferred to another development, the physical tenant folder and documents were sent to their new location. In June 2020, NYCHA sought to digitize all tenant folders; however, the cost of the project was determined to be prohibitive so the goal of digitizing the tenant folders was not realized. Any documents damaged or lost prior to 2011 cannot be recovered, including those impacted by Hurricane Sandy. Action Date September 12, 2025 Final Implementation September 12, 2025 Name And Phone Number Of Person Responsible for Implementation Sylvia Aude Senior Vice president Office of the Senior Vice President for Public Housing Operations Tenancy Administration +1-212-306-3921

View Audit 368960 Questioned Costs: $1

Finding 1156570 (2024-004)

Material Weakness 2024

Housing Authority of the City of Omaha

NJ

Questioned Costs HUD Housing Programs Significant Deficiency

U.S. Department of Housing and Urban Development 2024-004 Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 – Rent Reasonableness Recommendation: We recommend the Authority implement controls to ensure reasonable rent requirements are met. Explanation of disagreement with audit find...

U.S. Department of Housing and Urban Development 2024-004 Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 – Rent Reasonableness Recommendation: We recommend the Authority implement controls to ensure reasonable rent requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will increase oversight in the Section 8 Housing Choice Voucher program to ensure that established internal control policies are being followed. Increased effort with quality control and staff training will be focused in this area to ensure the HUD-50058 and rent determinations match and are clear on the comparable units. Name(s) of the contact person(s) responsible for corrective action: Philisa Smith, HCV Director Planned completion date for corrective action plan: December 31, 2026

View Audit 368905 Questioned Costs: $1

Finding 1156568 (2024-002)

Material Weakness 2024

Housing Authority of the City of Omaha

NJ

Questioned Costs HUD Housing Programs Special Tests & Provisions

U.S. Department of Housing and Urban Development 2024-002 Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 - Eligibility Recommendation: We recommend the Authority: - Review and revise its eligibility determination procedures to ensure full compliance with HUD regulations. - Train ...

U.S. Department of Housing and Urban Development 2024-002 Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 - Eligibility Recommendation: We recommend the Authority: - Review and revise its eligibility determination procedures to ensure full compliance with HUD regulations. - Train staff on proper documentation and verification protocols for tenant income, assets, expenses and overall eligibility. - Conduct a file audit to identify and correct any improperly admitted tenants. - Update its Administrative Plan to reflect accurate eligibility screening procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will increase oversight in the Section 8 Housing Choice Voucher program to ensure that established internal control policies are being followed. Additional Quality Control personnel have been added in 2025 to review files and confirm calculations. Electronic workflow processes are also being implemented to track regulatory compliance and flag files when not all required processes are completed. Name(s) of the contact person(s) responsible for corrective action: Philisa Smith, HCV Director Planned completion date for corrective action plan: December 31, 2026

View Audit 368905 Questioned Costs: $1

Finding 1156543 (2024-002)

Material Weakness 2024

Samaritas and Subsidiaries

MI

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising...

Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising intake and eligibility documentation protocols to require verification and supervisory sign-off that the individual meets the award’s eligibility definition and providing targeted staff training on eligibility requirements under the Refugee Admissions Program. Quarterly internal reviews of eligibility determinations will be conducted, with exceptions reported to management for corrective action. Anticipated Completion Date: December 31, 2025

View Audit 368884 Questioned Costs: $1

Finding 1156539 (2024-001)

Material Weakness 2024

Samaritas and Subsidiaries

MI

Questioned Costs Allowable Costs / Cost Principles Period of Performance

Contact Person(s): Bridgette Zappacosta, CFO Corrective Action Planned: Management concurs with the finding. We acknowledge that expenditures were charged outside of the applicable award period due to timing of invoice receipt and data entry errors. The Organization has reviewed its internal control...

Contact Person(s): Bridgette Zappacosta, CFO Corrective Action Planned: Management concurs with the finding. We acknowledge that expenditures were charged outside of the applicable award period due to timing of invoice receipt and data entry errors. The Organization has reviewed its internal controls and will strengthen procedures to ensure compliance with federal requirements. Specifically, we are revising our grant expenditure procedures, implementing new software which includes additional review controls and is specific to grant reporting, and providing targeted staff training on period of performance compliance. We will also perform quarterly monitoring of federal award expenditures to verify compliance. Anticipated Completion Date: December 31, 2025

View Audit 368884 Questioned Costs: $1

Finding 1156532 (2024-002)

Material Weakness 2024

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Questioned Costs Internal Control / Segregation of Duties § 200.303 § 200.334

Management agrees with the recommendation and will implement stronger review processes to ensure proper documentation is in place to support program activities and reports submitted to the grantor. All staff charged with maintaining client documentation will receive updated training on recordkeeping...

Management agrees with the recommendation and will implement stronger review processes to ensure proper documentation is in place to support program activities and reports submitted to the grantor. All staff charged with maintaining client documentation will receive updated training on recordkeeping requirements, supporting documents specifying such requirements, and supports throughout the year to ensure documents are properly maintained and verified. Documents will be reviewed regularly for completeness and specifically cross-checked with quarterly report and invoice information directly by program leadership prior to submission. This process will be led by the Vice President of Family Empowerment and Self Sufficiency with support from operational and compliance staff.

View Audit 368880 Questioned Costs: $1

Finding 1156514 (2024-002)

Material Weakness 2024

Texas Biomedical Research Institute

TX

Questioned Costs Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.317 § 200.318 § 200.319

Finding 2024-002 – Procurement and Suspension and Debarment Condition: Texas Biomed did not comply with procurement requirements per the Uniform Guidance. Specifically, Texas Biomed did not comply with informal procurement methods for small purchases and noncompetitive procurement requirements. Texa...

Finding 2024-002 – Procurement and Suspension and Debarment Condition: Texas Biomed did not comply with procurement requirements per the Uniform Guidance. Specifically, Texas Biomed did not comply with informal procurement methods for small purchases and noncompetitive procurement requirements. Texas Biomed also did not comply with its own procurement policy in relation to procurements of small purchases and noncompetitive procurements. Additionally, Texas Biomed did not maintain records for certain procurements sufficient to detail the history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, the basis for the contract price, and the performance of a cost or price analysis, when required. Three of the four procurements noted as findings were, in fact, sole source procurements but lacked timely documentation of sole source rationale. Corrective Action Plan: Texas Biomed made a change in management over the procurement function and hired an experienced and knowledgeable Assistant Director of Supply Chain Management on September 15, 2025 to oversee procurement and ensure compliance with the necessary requirements. To ensure compliance and adherence to purchasing policies and procedures, Texas Biomed will introduce a Purchasing Compliance Program. This program will include training and oversight procedures for the purchasing program. The training will include: new hire training, ongoing quarterly purchasing training for end users and purchasing staff. The purchasing team will maintain training documents and ensure new and existing employees have the most current policy, procedures, and requirements to guide them through the purchasing process. The oversight procedures will be performed by the Assistant Director of Supply Chain Management and shall include auditing purchase orders over the micro-purchase threshold to ensure proper documentation is present. The Assistant Director of Supply Chain Management will also lead efforts of continuous improvement to update and communicate the Purchasing Compliance Program to all Texas Biomed staff. Key dates shall include: • Enhanced new hire training October 2025 • Quarterly training session January 2026 • Oversight procedures developed November 2025 Responsible Parties: Eva Zepeda, Director, Finance; Eric McGowin, Assistant Director, Supply Chain Management Completion Date: October 31, 2025

View Audit 368866 Questioned Costs: $1

Finding 1156504 (2024-001)

Material Weakness 2024

Romulus Housing Commission

MI

Questioned Costs Subrecipient Monitoring Eligibility

Report period: 12/31/2024 Title of result and comment FY24 Audit Corrective Action Plan Contact person Responsible for Sabrina Bollinger Corrective Action: Contact's Phone Number 248-593-4611 Contact's Email Address: sbollinger@fourmidable,com Views of Responsible Official: Management agrees with th...

Report period: 12/31/2024 Title of result and comment FY24 Audit Corrective Action Plan Contact person Responsible for Sabrina Bollinger Corrective Action: Contact's Phone Number 248-593-4611 Contact's Email Address: sbollinger@fourmidable,com Views of Responsible Official: Management agrees with the auditor's finding and will implement the auditor's recommendations. Description of Corrective Action Plan The Commission should implement internal controls over tenant files to ensure accountability. Allcertifications and the required documentation should be maintained in the tenant's current file. Additionally,in order to ensure certifications are performed timely and tenant information is input correctly, theCommission should have a second party review files in a timely manner. Anticipated Completion Date: The plan is to implement the corrective action within six months of the audit date. If applicable: Document reason issue will NOT be corrected with 6 months: N/A

View Audit 368862 Questioned Costs: $1

Finding 1156495 (2024-001)

Material Weakness 2024

Serve Wyoming, Inc.

WY

Questioned Costs

Implemented corrective actions and updated internal procedures, as outlined in the financial management section of the handbook. Staff have received additional training on proper disbursement procedures, coaching and monitoring. In addition, a full review of all checks for FY25 have been completed a...

Implemented corrective actions and updated internal procedures, as outlined in the financial management section of the handbook. Staff have received additional training on proper disbursement procedures, coaching and monitoring. In addition, a full review of all checks for FY25 have been completed and noted. Going forward, checks will be prepared and submitted to the Executive Director in two expense batches prior to processing by the indepdendent bookkeeper. An additional control step has also been added to the Executive Director's review, requiring the indvidual mailing the checks to verify the presence of two signatures.

View Audit 368857 Questioned Costs: $1

Finding 1156484 (2024-001)

Material Weakness 2024

Northwest Youth Services

WA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Corrective Action:  Housing service leadership staff have developed a HUD‐compliant Rent Reasonableness Policy to ensure that each lease served through NWYS will have documentation supporting compliance with federal reasonable rental rates. NWYS housing service leadership staff will follow this pol...

Corrective Action:  Housing service leadership staff have developed a HUD‐compliant Rent Reasonableness Policy to ensure that each lease served through NWYS will have documentation supporting compliance with federal reasonable rental rates. NWYS housing service leadership staff will follow this policy and procedure to ensure rental rates fall within federal grant compliance requirements at the time of each lease signing or renewal. Documentation of rent reasonableness certification will be performed by NWYS housing staff, reviewed by NWYS housing service leadership, and maintained in the client’s permanent file, as defined in the NWYS Rent Reasonableness Policy. Name(s) of Responsible Party:  NWYS Housing leadership staff – Luis Reyna, Addison Ausley, Daniel Pry Anticipated Completion Date:  9/5/25

View Audit 368841 Questioned Costs: $1

Finding 1156481 (2024-006)

Material Weakness 2024

Mission Edge San Diego

CA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Condition Found During allowable cost testing, it was noted that one of the contracts with the vendors included a rate that exceeded the rate cap without prior approval. Upon inquiry no prior approval was obtained. Corrective Action Plan Before execution, route all vendor and subrecipient agreements...

Condition Found During allowable cost testing, it was noted that one of the contracts with the vendors included a rate that exceeded the rate cap without prior approval. Upon inquiry no prior approval was obtained. Corrective Action Plan Before execution, route all vendor and subrecipient agreements funded by federal awards to Controller/Accounting for verification of allowability, rate caps, prior approvals, and special terms. Additional review during the A/P process ensures compliance. Responsible Person for Corrective Action Plan The Controller for Mission Edge San Diego and Accounting personnel. Implementation of Corrective Action Plan Policy adoption within 30 days of report.

View Audit 368823 Questioned Costs: $1

Finding 1156480 (2024-005)

Material Weakness 2024

Mission Edge San Diego

CA

Questioned Costs Procurement, Suspension & Debarment

During procurement testing, it was noted that Mission Edge did not follow 2 CFR 200 required methods of procurement or its internal procurement policy for the purchase of goods or services using federal funds. Mission Edge did not obtain quotes or bids for certain expenditures as required by its pro...

During procurement testing, it was noted that Mission Edge did not follow 2 CFR 200 required methods of procurement or its internal procurement policy for the purchase of goods or services using federal funds. Mission Edge did not obtain quotes or bids for certain expenditures as required by its procurement policy. In addition, Mission Edge did not verify that vendors were not suspended, debarred, or otherwise excluded from participation in the program. Corrective Action Plan Review and confirm that each Project has Adopted a Uniform Procurement Policy. This policy will address: 1. Micro-purchases, small purchases, sealed bids, competitive proposals, noncompetitive proposals thresholds and methods. 2. Cost/price analysis for procurements above the Simplified Acquisition Threshold. 3. Ensure consistent applicability to fiscally sponsored projects. 4. Mandatory Debarment/Suspension Checks utilizing SAM.gov for all covered transactions and attached required verification to covered transactions. Responsible Person for Corrective Action Plan The Controller of Mission Edge San Diego (policy owner); Project Directors as applicable. Implementation of Corrective Action Plan Policy adoption within 30 days of report.

View Audit 368823 Questioned Costs: $1

Finding 1156471 (2024-001)

Material Weakness 2024

Emergency Food Network of Tacoma and Pierce County

WA

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

U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee sp...

U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by tracking and recording the actual hours each employee, regardless of position, spends working on each grant, on their time sheet or with a specific grant code, that specifies how many hours per day were spent on each federal and nonfederal activity. Alternatively, EFN can implement an after-the-fact review procedure to ensure the proper allocation of payroll expenditures to Federal and non-Federal awards, in accordance with 2 CFR 200.430. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Emergency Food Network (EFN) engaged a new audit firm for the 2024 audit. Before this year the EFN audit was administered by Johnson, Stone Pagano for 9 years. No deficiencies were previously reported or identified during those audits regarding time estimates for employees used for allocations including most of those specifically identified funding sources. In response to the 2024 audit finding by Clifton Larson Allen (CLA) in July of 2025, when the audit was conducted, EFN implemented an immediate individual employee time study that was approved by CLA to meet the recommendation. This time study methodology will be implemented twice per year on an ongoing basis with records retained and available for future audit verification. EFN has received written response from CLA that implementing this method meets all the requested requirements to be in compliance and mitigate future findings on this issue. Name of the contact person responsible for corrective action: Michelle Douglas, CEO Planned completion date for corrective action plan: August 2025 If anyone has questions regarding this plan, please call Michelle Douglas, CEO, at 253-208- 2962.

View Audit 368815 Questioned Costs: $1

Finding 1156466 (2024-001)

Material Weakness 2024

Council Towers Housing Development Fund Corporation

NY

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

We are planning to close the current policy. We are opening a separate policy for Council Towers II, Council Towers III and Council Towers IV that we covered by that policy.

View Audit 368800 Questioned Costs: $1

Finding 1156459 (2024-002)

Material Weakness 2024

Southwestern Christian College

TX

Questioned Costs Reporting Significant Deficiency § 200.328 § 200.329

Emergency Relief Fund (HEERF) Programs (significant deficiency) Condition (per audit): Non-compliance noted regarding untimely filing of quarterly and annual report. SwCC’s Explanation: The HEERF department and reporting systems were closed, and Grants personnel were unable to retrieve a copy of the...

Emergency Relief Fund (HEERF) Programs (significant deficiency) Condition (per audit): Non-compliance noted regarding untimely filing of quarterly and annual report. SwCC’s Explanation: The HEERF department and reporting systems were closed, and Grants personnel were unable to retrieve a copy of the required reports from the ESF Data Collection System by the suggested deadline of May 19, 2025. Corrective Actions (overseen by the President): 1. Grant Reporting Calendar o A compliance calendar with all DOE reporting deadlines was created in August 2025. o Internal deadlines are set two weeks before federal due dates. o Responsible Official: Director of Grants 2. Dual Review & Submission Tracking o All grant quarterly and annual reports must be reviewed and signed off by the Director of Grants, President, and Comptroller before submission. o Submission confirmations will be saved in the respective grants folder of the electronic filing system. o Responsible Officials: President, Director of Grants & Comptroller 3. Centralized Filing & Audit Readiness o Grant reports (quarterly, annual, and related correspondence) will be stored in the centralized electronic filing system for continuity and audit review. o Responsible Officials: Director of Grants & Business Office 4. Quarterly Compliance Checks o The President and Director of Grants will conduct quarterly compliance reviews to confirm all required reports are submitted timely. o Responsible Officials: President & Director of Grants 5. Time and Effort Reporting in Populi o Effective August 2025, time and effort reporting for all Title IV-funded student workers and grant-funded employees will be completed in Populi, capturing descriptions of duties and percentage of time worked, aligned with payroll and funding sources. o Responsible Officials: Director of Grants & Comptroller/Business Office Completion Date: Reporting calendar implemented August 2025; all future reports will be submitted timely under this protocol. Southwestern Christian College is committed to full compliance with federal regulations and the highest standards of financial accountability. The corrective actions outlined above address both Title IV and HEERF audit findings with immediate steps, ongoing monitoring, and strengthened internal controls. With the implementation of new reconciliation processes, expanded staffing in the Business Office, centralized electronic filing, enhanced verification and reporting protocols, and a structured compliance calendar, SwCC has established sustainable safeguards to prevent recurrence of deficiencies.

View Audit 368771 Questioned Costs: $1

Finding 1156458 (2024-001)

Material Weakness 2024

Southwestern Christian College

TX

Questioned Costs Student Financial Aid

Finding 2024-001: U.S. Department of Education (USDE), Title IV Student Financial Aid Programs (significant deficiency): Condition (per audit): Non-compliance with Title IV requirements, including missing reconciliations, inaccurate/untimely NSLDS reporting, incomplete Work-Study files, missing refu...

Finding 2024-001: U.S. Department of Education (USDE), Title IV Student Financial Aid Programs (significant deficiency): Condition (per audit): Non-compliance with Title IV requirements, including missing reconciliations, inaccurate/untimely NSLDS reporting, incomplete Work-Study files, missing refund documentation, incomplete FAFSA verification records, and unavailable FISAP reconciliation documentation. Questioned Costs: $29,087 Corrective Actions (overseen by the President): 1. Monthly Title IV Reconciliations o Beginning August 2025, monthly reconciliations between the Business Office and Financial Aid Office will be conducted and logged in the new centralized electronic filing system in Populi for audit readiness and continuity during staff transitions. o To further strengthen the process, two additional staff members, a new Accounts Payable Manager and Comptroller, with extensive audit and business office management and grants management/reconciliation experience, and has been added to the Business Office. o Reconciliation logs will be retained in the centralized electronic filing system in Populi. o Responsible Official: Comptroller/ Business Office Staff 2. Electronic Filing System o To address missing FISAP, refund, and Work-Study documentation, SwCC implemented an organized electronic filing system in Populi by funding stream, year, and document type. o Includes FISAP, Work-Study timesheets, NSLDS reports, and refund documentation. o Responsible Official: Financial Aid Director and Business Office. 3. Enrollment Reporting to NSLDS o To address untimely/incorrect reporting, weekly enrollment status reports will be submitted through Populi and verified with the Registrar. o SwCC is finalizing its agreement with the National Student Clearinghouse to further improve accuracy. o Responsible Official: Registrar. 4. Work-Study Documentation o To address missing student files, all Work-Study records (award letters, timesheets, disbursement records) will be scanned and retained in each student’s electronic file. o Responsible Official: Financial Aid Director. 5. Refund Documentation o To address missing refund testing documentation, all refund calculations will be cross-verified by the Business Office and Financial Aid Office, and approved by the President before posting. o Records will be stored in the filing system. o Responsible Official: Comptroller/ Business Office and Financial Aid Office 6. FAFSA Verification o To address incomplete verification documentation, SwCC uses a standardized verification checklist. The Populi system does not allow disbursement of student files selected for verification. A manual override is required, and these overrides will continue to be managed within the Office of Financial Aid for disbursement. o Responsible Official: Financial Aid Director. 7. FISAP Retention o To address unavailable FISAP records, annual FISAP submissions will be stored in the electronic filing system for future testing and audit review. o Responsible Official: Comptroller/ Business Office and Financial Aid Office Completion Date: Initial corrective actions completed by August 31, 2025. Ongoing monitoring monthly/quarterly as required.

View Audit 368771 Questioned Costs: $1

Finding 1156450 (2024-002)

Material Weakness 2024

Lincoln Senior Housing, INC

CT

Questioned Costs HUD Housing Programs Cash Management

Recommendation – The Project should ensure the surplus cash calculation is made in a manner that allows for a timely deposit of any required deposit to the residual receipts account. If there are cash flow issues preventing the deposit from taking place, the Project needs to contact HUD and request ...

Recommendation – The Project should ensure the surplus cash calculation is made in a manner that allows for a timely deposit of any required deposit to the residual receipts account. If there are cash flow issues preventing the deposit from taking place, the Project needs to contact HUD and request a waiver if allowed. Views of Responsible Officials and Planned Corrective Actions – Management will calculate an estimated surplus cash calculation amount and deposit them into the residual receipts account within the required time frame. Name and Title of Responsible Official – Sabine Cox, Comptroller Anticipated Completion Date – Once the funds are received.

View Audit 368750 Questioned Costs: $1

Finding 1156449 (2024-001)

Material Weakness 2024

Lincoln Senior Housing, INC

CT

Questioned Costs HUD Housing Programs Significant Deficiency

Recommendation – The reserve account was underfunded as of 12/31/24. We recommend that management discuss this issue with HUD and request approval retroactively to fund the reserve account at a lower amount until the funds due to the Project are paid in full by HUD. Views of Responsible Officials an...

Recommendation – The reserve account was underfunded as of 12/31/24. We recommend that management discuss this issue with HUD and request approval retroactively to fund the reserve account at a lower amount until the funds due to the Project are paid in full by HUD. Views of Responsible Officials and Planned Corrective Actions – Management will reach out to HUD and request approval retroactively to fund the reserve account at a lower amount. Once the approval has been granted and the remainder of the funds have been received, management will pay the reserve account in full. Name and Title of Responsible Official – Sabine Cox, Comptroller Anticipated Completion Date – unknown

View Audit 368750 Questioned Costs: $1

Finding 1156392 (2024-001)

Material Weakness 2024

Liberty Terrace Apartments

IN

Questioned Costs HUD Housing Programs Special Tests & Provisions

Finding 2024-001: The Corporation did not make all required reserve for replacements deposits during the year ended December 31, 2024. Comments on the Finding and Each Recommendation: The Corporation should make a deposit of $30,975 to the reserve for replacements fund. Action(s) Taken or Planned on...

Finding 2024-001: The Corporation did not make all required reserve for replacements deposits during the year ended December 31, 2024. Comments on the Finding and Each Recommendation: The Corporation should make a deposit of $30,975 to the reserve for replacements fund. Action(s) Taken or Planned on the Finding: The Corporation concurs with the recommendation and will make the deposit to fully fund the reserve for replacements fund.

View Audit 368702 Questioned Costs: $1

Finding 1156379 (2024-004)

Material Weakness 2024

9/11 Day

CA

Questioned Costs Subrecipient Monitoring Reporting § 200.303 § 200.328 § 200.329

In 2024, 9/11 Day was unaware of this regulation, but agrees with this finding. 9/11 Day has adopted a written policy that shall ensure that all subgrants made are properly compliant with the Federal Funding Accountability and Transparency Act of 2006 (FFATA). All subgrantees will be entered into a ...

In 2024, 9/11 Day was unaware of this regulation, but agrees with this finding. 9/11 Day has adopted a written policy that shall ensure that all subgrants made are properly compliant with the Federal Funding Accountability and Transparency Act of 2006 (FFATA). All subgrantees will be entered into a centralized tracking log, and for those receiving pass-through funds exceeding $30,000, the required reporting will be completed directly in SAM.gov, which now includes the Federal Subaward Reporting System (FSRS). Each subgrantee’s eligibility will be verified in SAM.gov, with the date and results of the verification recorded, and all supporting documentation retained on file. This corrective action ensures that all subawards are properly logged, reported, and compliant with FFATA requirements.

View Audit 368692 Questioned Costs: $1

Finding 1156336 (2024-002)

Material Weakness 2024

Colorado Village Collaborative

CO

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Cont...

Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Control over Compliance Criteria and Condition: According to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), section 200.430, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that the system for establishing the estimates produces reasonable approximations of the activity actually performed; significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges based on budget estimates. Proof of these employees' approved compensation and job title is required to ensure their roles are allowable under the grant. Timesheets provided to support payroll charges did not accurately support the payroll expenses charged to the grants. Also, approval of the timesheets was not evident by the documentation provided. Finally, documentation supporting approval of each employee’s compensation was not maintained and provided to support the accuracy of employee compensation. Cause: During 2024, CVC’s management team underwent significant turnover, including the top finance officer, who represents the entire accounting department, as well as the HR director. Documentation was not maintained or could not be located to support payroll expenses allocated to the federal program. Effect and Context: When adequate support is not obtained and used to support the amount charged to the federal program, there is a risk that unsupported or inaccurate costs are being charged to the federal program. Questioned Costs: Payroll costs charged to the awards total $2,570,558. Recommendation: We recommend proper control activities should be implemented to allow for a consistent, accurate, and allowable method to support distribution of personnel charges to federal programs. Documentation should be properly maintained in the organization’s records. Views of responsible officials and planned corrective actions: CVC management will implement a process to perform timely review of salary expenses charged to federal awards, and retain records by pay period, and any pay rate and title changes, as support for expenditures charged to federal awards. Name of Contact Person: Gil Catbagan, Director of Finance Proposed Completion Date: December 31, 2025

View Audit 368632 Questioned Costs: $1

Finding 1156330 (2024-010)

Material Weakness 2024

McR Health, Inc.

FL

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...

MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. This revised process will be put in place on October 1, 2025.

View Audit 368617 Questioned Costs: $1

Finding 1156314 (2024-003)

Material Weakness 2024

Henry Ford Health System

MI

Questioned Costs Cash Management § 200.305

Finding 2024-003 Material Weakness in Controls over Compliance and Material Noncompliance – Cash Management Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – There were four drawdowns made in relation ...

Finding 2024-003 Material Weakness in Controls over Compliance and Material Noncompliance – Cash Management Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – There were four drawdowns made in relation to the fiscal year 2024 expenses for the grant. For two out of the four drawdowns, management erroneously drew down in excess of the expenses incurred. Corrective Action Plan – Henry Ford Health agrees with this finding. As of August 31, 2025, the grant is in a net receivable position, so no adjustment is required. An additional level of review is being added to the drawdown process to improve the control environment and reduce the associated risk of error. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.

View Audit 368602 Questioned Costs: $1

Finding 1156312 (2024-002)

Material Weakness 2024

Henry Ford Health System

MI

Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.403

Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inad...

Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inadvertently recorded twice for the fiscal year, resulting in an overstatement of personnel costs charged to the federal award. Further, indirect costs were charged in excess of the budgeted and approved amount under the grant agreement. Corrective Action Plan – Henry Ford Health agrees with this finding. The payroll expense was corrected in the Schedule of Expenditures of Federal Awards and will be corrected in September 30, 2025, Federal Financial Report. Prospectively the payroll for the employee in question will be processed through our automated payroll time and effort process, rather than through manual journal entries, thus reducing the risk of error. Additionally, set up and review procedures have been enhanced to improve the controls related to recovery of indirect costs. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.

View Audit 368602 Questioned Costs: $1

Finding 1156139 (2024-004)

Material Weakness 2024

Sunray Communities, Inc.

TX

Questioned Costs HUD Housing Programs Cash Management

CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...

CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-004: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: The Company opened a residual receipt account and plans to deposit $3,633. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.

View Audit 368559 Questioned Costs: $1

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