Corrective Action Plans

Finding 1216944 (2024-011)

Material Weakness 2024

CT

Questioned Costs Reporting

Audit Finding: Auditors noted that the current period expenditures amount reported by the City did not agree to the general ledger activity by approximately $1,611,000. The expenditures reported were lower than the general ledger. Corrective Action: The City will implement procedures to review the p...

Audit Finding: Auditors noted that the current period expenditures amount reported by the City did not agree to the general ledger activity by approximately $1,611,000. The expenditures reported were lower than the general ledger. Corrective Action: The City will implement procedures to review the project and expenditure report prior to submission to ensure reporting is properly reconciled to the general ledger expenditures in accordance with the grant requirements. Name of Contact Person and Completion Date: Teresa Viscariello, Controller, July 1, 2026 Anita Carpenter, Grants Officer, July 1, 2026

View Audit 403242

Finding 1216931 (2024-010)

Material Weakness 2024

City of Stamford, Connecticut

CT

Reporting Questioned Costs Eligibility § 200.512

Audit Finding: Late Issuance of the Single Audit Reporting Package. The Single Audit package for the City’s fiscal year ended June 30, 2024 was not submitted to the Federal Audit Clearinghouse by March 31, 2025. Corrective Action: Management agrees with the finding. The City is evaluating the proces...

Audit Finding: Late Issuance of the Single Audit Reporting Package. The Single Audit package for the City’s fiscal year ended June 30, 2024 was not submitted to the Federal Audit Clearinghouse by March 31, 2025. Corrective Action: Management agrees with the finding. The City is evaluating the process and design of internal controls, including the ongoing implementation of a new ERP system, in order to ensure readiness from the audit and to avoid late filing of the single audit reporting package and data collection form. Name of Contact Person and Completion Date: Leah Kagan, Interim Director of Administration, December 31, 2026 Anita Carpenter, Grants Officer, December 31, 2026

View Audit 403242

Finding 1216685 (2024-007)

Material Weakness 2024

American Thoracic Society, Inc.

NY

Questioned Costs Eligibility Reporting § 200.512

Views of Responsible Officials and Planned Corrective Actions: The Finance Department acknowledges the late submission for the 2023 fiscal year. To ensure future compliance with Uniform Guidance deadlines, year-end close and audit preparation timelines have been restructured as per the response for ...

Views of Responsible Officials and Planned Corrective Actions: The Finance Department acknowledges the late submission for the 2023 fiscal year. To ensure future compliance with Uniform Guidance deadlines, year-end close and audit preparation timelines have been restructured as per the response for Finding 2024-001.

View Audit 403116

Finding 1216684 (2024-006)

Material Weakness 2024

American Thoracic Society, Inc.

NY

Internal Control / Segregation of Duties Questioned Costs Procurement, Suspension & Debarment § 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 1216683 (2024-005)

Material Weakness 2024

American Thoracic Society, Inc.

NY

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.502 § 200.510

Views of Responsible Officials and Planned Corrective Actions: The Finance Department will ensure an accurate SEFA in conjunction with the response for Finding 2024-002.

View Audit 403116

Finding 1216578 (2024-002)

Material Weakness 2024

Townspeople

CA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Management has implemented the following corrective actions: 1. Established a monthly reserve funding schedule that identifies required deposits and due dates. 2. Included replacement reserve funding requirements in the annual budgeting process and monthly financial review procedures. 3. Assigned re...

Management has implemented the following corrective actions: 1. Established a monthly reserve funding schedule that identifies required deposits and due dates. 2. Included replacement reserve funding requirements in the annual budgeting process and monthly financial review procedures. 3. Assigned responsibility to the Executive Director and Finance Committee to monitor compliance with reserve funding requirements. 4. Developed a plan to fund any reserve shortfall through future operating surpluses and/or approved funding sources.

View Audit 403057

Finding 1216576 (2024-001)

Material Weakness 2024

Townspeople

CA

Reporting Internal Control / Segregation of Duties Questioned Costs § 200.512

Management has implemented the following corrective actions: 1. Established a formal year-end closing timeline that includes deadlines for completion of the trial balance, account reconciliations, and supporting schedules. 2. Assigned responsibility to the Executive Director to monitor progress towa...

Management has implemented the following corrective actions: 1. Established a formal year-end closing timeline that includes deadlines for completion of the trial balance, account reconciliations, and supporting schedules. 2. Assigned responsibility to the Executive Director to monitor progress toward year-end closing milestones and ensure information is provided to the auditors on a timely basis. 3. Developed a comprehensive audit preparation checklist identifying all schedules, reconciliations, and documentation required by the auditors. 4. Scheduled pre-audit planning meetings with the auditors to establish mutually agreed-upon deadlines and identify potential issues that could delay audit completion 5. Implemented periodic status reviews during the audit process to monitor progress and address outstanding auditor requests promptly.

View Audit 403057

Finding 1216554 (2024-006)

Material Weakness 2024

Glacierland Resource Conservation and Development Council, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles § 200.403

Finding 2023-006 ● Criteria or Specific Requirement: 2 CFR Section 200.403 states the factors that determine allowability of costs charged to federal awards and requires costs to be determined in accordance with generally accepted accounting principles. ● Condition: We identified costs incurred in 2...

Finding 2023-006 ● Criteria or Specific Requirement: 2 CFR Section 200.403 states the factors that determine allowability of costs charged to federal awards and requires costs to be determined in accordance with generally accepted accounting principles. ● Condition: We identified costs incurred in 2023 that were incorrectly recorded as 2024 costs and charged to federal awards. ● Corrective Action Plan: Management agrees with the finding and they will evaluate our findings to determine an appropriate corrective action. After evaluation, Glacierland will designate specific tasks to the ‘Bookkeeper’ and ‘Executive Assistant’. These tasks will be reviewed by one another and the Executive Director. Creation of these two roles and review procedures will allow for increased internal controls to ensure costs are recorded in accordance with GAAP. Contact Person: Kirsten Jurcek Anticipated Date of Completion: September 1, 2026

View Audit 403049

Finding 1216528 (2024-014)

Material Weakness 2024

Pottawatomie County

OK

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

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

View Audit 403025

Finding 1216383 (2024-003)

Material Weakness 2024

County of Carbon

PA

Questioned Costs Student Financial Aid Subrecipient Monitoring

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entit...

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity Identifying Number: not available; 14.228, Community Development Block Grants, Passed Through Pennsylvania Department of Community and Economic Development, U.S. Department of Housing and Urban Development; 93.558, Pass-Through Granter #'s C000073823, C000075969, C000082698, C000086225, and C000088719, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available, 21.023, Emergency Rental Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available. Prior Year Finding Number: 2023-005 Criteria: Pursuant to the provisions of the Uniform Guidance, under Section 200.512(a), the County is required to complete and submit its Single Audit and related Data Collection Form within nine months of the end of its fiscal period (September 30) of the following year. Condition/Context The County's Single Audit and reporting package was delayed for the year ended December 31, 2023 beyond the nine-month due date. Effect: The County is not in compliance with certain requirements of the Uniform Guidance, including the Single Audit reporting requirements. Questioned Costs: None. Cause: Reconciliations and reports were not completed on a timely basis, and therefore, the completion and filing of its December 31, 2023 Single Audit and reporting package was not prioritized. Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframes. Views of Responsible Officials and Planned Corrective Actions: The County plans to have information ready for the auditors to get 2024 done in a reasonable time frame. Between staffing and priorities, the County hopes to have cleared by the 2025 audit.

View Audit 402918

Finding 1216364 (2024-003)

Material Weakness 2024

City of Reading

PA

Questioned Costs Cash Management Reporting

Condition During the 2024 fiscal year, grant expenditures related to a Commonwealth of Pennsylvania grant (see finding 2024-001) for the public safety building were reported in the American Rescue Plan fund. Since they were reported in the American Rescue Plan fund they were then included in the rep...

Condition During the 2024 fiscal year, grant expenditures related to a Commonwealth of Pennsylvania grant (see finding 2024-001) for the public safety building were reported in the American Rescue Plan fund. Since they were reported in the American Rescue Plan fund they were then included in the report submitted for that time period. Cause The decentralized grant administration at the City lead to missing communication between the departments and the improper accounting for the public safety building grant. Recommendation The City should continue to refine its grant administration and accounting functions to allow for a seamless accounting for grant awards. The current decentralized structure for grant administration can allow for grants awarded to not be properly accounted for and grant reimbursement or expenditures not performed timely. Management Response City management agrees with this finding. Grants Manager is in training to use the automated tracking system within Tyler Munis. The system has much greater capability than what we have been using or leveraging to date. During the first 2 quarters of 2026 we are taking steps to use the Tyler Maturity Model to refine and make sure we fully built out and turned on all features, including those for grant activity and project management. We look forward to the opportunity to grow and professionally our operations and grant accounting. Anticipated Completion Date - June 2026 Sincerely, Michael R. Oppenheimer City Controller City of Reading

View Audit 402899

Finding 1216330 (2024-103)

Material Weakness 2024

The Village at Oasis Park - Phase I, Inc.

AZ

Questioned Costs HUD Housing Programs Reporting § 200.512

Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Hous...

Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: Part 1: Immediate corrective actions (to address immediate noncompliance). Submit all overdue Single Audit and REAC reporting packages immediately to resolve the current noncompliance. Task Responsible Party 1.1. Prepare and submit delinquent reports: 1.1.1. Assemble and finalize the overdue Single Audit Reporting Package for FY 2024 and submit it to the Federal Audit Clearinghouse (FAC). Chief Financial Officer (CFO) 1.1.2. Assemble and finalize all overdue REAC Annual Financial Statements (AFS) for FY 2024 and submit them to HUD's Financial Assessment Subsystem (FASS-MF) via the REAC Secure Systems. Property Manager 1.2. Notify HUD: 1.2.1. Immediately notify the local HUD Field Office and the assigned Account Executive of the finding and the plan for submission of all delinquent reports. Property Manager 1.3. Document and address penalties: 1.3.1. Address any penalties or noncompliance flags resulting from the late filings, which may include interaction with HUD's Departmental Enforcement Center (DEC). Property Manager / CFO Part 2: Systemic corrective actions (to prevent future noncompliance) Implement new policies and procedures to ensure all future HUD Single Audit and REAC submissions are filed on time. Task Responsible Party 2.1. Revise and implement internal policies: 2.1.1. Draft a written policy defining the timelines and responsibilities for all HUD financial and audit reporting, including Single Audit and REAC AFS submissions. This policy will be housed in the organization's Operations Manual. CEO / CFO 2.2. Develop a comprehensive compliance checklist: 2.2.1. Create and implement a calendar-based checklist for all HUD reporting requirements, with deadlines for every stage of the process, including financial data collection, auditor engagement, and submission. CFO / Property Manager 2.3. Enhance financial review and control procedures: 2.3.1. Implement a formal review and approval process for all financial statements and audit packages. Require a documented review by the CFO and sign-off by the CEO and Board of Directors before any submission. CFO 2.4. Improve communication and oversight: 2.4.1. Establish a quarterly meeting with all key staff involved in HUD reporting (CFO, Property Manager, accounting staff) to review deadlines and ensure all tasks are on schedule. CEO 2.4.2. Assign a designated staff member as the primary point of contact for external auditors and the HUD REAC Secure Systems. Property Manager 2.5. Provide staff training: 2.5.1. Schedule and conduct training for all relevant staff on the new policies, checklists, and the HUD reporting platforms (FAC and REAC Secure Systems). Third Party Training Professionals, HUD and Property Manager’s compliance officer 2.6. Address external auditor issues (if applicable): 2.6.1. Evaluate the relationship with the current external audit firm. If timeliness was a factor in the audit report delay, establish clear communication protocols and deadlines in the new engagement letter. Consider a different firm for future audits if necessary. CFO Part 3: Monitoring and future enforcement (to sustain compliance) Create a monitoring plan to ensure the corrective actions are working and that late filings do not recur. Task Responsible Party 3.1. Ongoing monitoring: 3.1.1. The CFO will provide a monthly report to the CEO on the status of all HUD reporting deadlines. The report will highlight upcoming deadlines and progress toward completion. CFO 3.2. Annual review: 3.2.1. Conduct an annual review of the HUD Reporting Policy and Compliance Checklist to ensure they are current and effective. CEO / CFO 3.3. Update internal audit program: 3.3.1. Incorporate the timely filing of HUD reports into the organization's internal audit or quality assurance program. CFO Anticipated Completion Date: December 2025

View Audit 402820

Finding 1216329 (2024-102)

Material Weakness 2024

The Village at Oasis Park - Phase I, Inc.

AZ

Questioned Costs HUD Housing Programs Reporting

Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing...

Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. The Sponsor shall immediately remedy all past errors by correcting and if applicable, resubmit all vouchers that were inaccurate, incomplete, or submitted late. The Sponsor shall work with the property manager to create a detailed checklist to ensure all required fields and steps are completed for each voucher before submission. From there, we shall provide HUD with a report showing all corrected vouchers and detailing how the current data was reconciled with the original incorrect submissions. 2. Systemic preventative measures: • Develop and implement a training program to create a formal training curriculum for all staff involved in voucher processing. • Update internal policies and procedures to ensure that the Sponsor’s policies and procedures to include a specific, standardized process for all Section 811 voucher submissions. • Establish a monitoring and oversight protocol to ensure regular, ongoing monitoring process to review voucher submissions for accuracy and timeliness. • Leverage HUD resources and technology to ensure that all staff involved in voucher processing are trained on and regularly use the latest guidance from the HUD Exchange and relevant HUD manuals, including the TRACS Manual Voucher Submission application. • The Chief Financial Officer will be responsible for ensuring all corrective actions are implemented and sustained. Anticipated Completion Date: December 2025

View Audit 402820

Finding 1216328 (2024-101)

Material Weakness 2024

The Village at Oasis Park - Phase I, Inc.

AZ

Questioned Costs Eligibility Material Weakness

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistanc...

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Eligibility Questioned Costs: Unknown Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. Complete all missed annual recertifications immediately. • Method: The property manager shall immediately Identify every tenant file where an annual income recertification was not performed. Collect and verify all required documentation from the affected tenants, using third-party verification as the preferred method. • Responsible Party: Property Manager. 2. Document all eligibility factors and discrepancies. • Method: For every affected tenant file, thoroughly document the process of verifying income, assets, and eligibility. Include explanations for any missing third-party verifications and document all follow-up attempts. • Responsible Party: Property Manager. 3. Retransmit corrected HUD Form 50059 filings to the TRACS system. • Method: Submit corrections for each tenant with a file deficiency by using the "Correction/Retransmittal" (R) code on a new Form HUD-50059A. • Responsible Party: Property Manager. 4. Address any rent-related issues arising from the missing recertifications. • Method: Calculate any potential back-rent owed by tenants due to misreporting or changes in income. Based on HUD guidelines and property policy, negotiate repayment plans if necessary, but carefully follow guidance regarding tenant culpability. • Responsible Party: Property Manager. 5. Revise and formalize resident file management policies and procedures. • Method: Update internal policy and procedural documents to establish clear, step-by-step instructions for completing annual recertifications, including all documentation requirements. Incorporate a standardized checklist for each tenant file to ensure consistent application. • Responsible Party: Controller and Property Manager. 6. Implement an improved tickler and tracking system. • Method: Use property management software to automatically generate alerts and reports for upcoming recertification deadlines. Implement a double-check process where a supervisor reviews and signs off on the list of upcoming deadlines each month to ensure no file is missed. • Responsible Party: Property Manager. 7. Provide comprehensive training for all staff involved in recertifications. • Method: Conduct mandatory training for all staff on Section 811 program requirements, focusing specifically on annual income recertifications and acceptable documentation. Include regular refresher training and create a central, accessible library of HUD guidance. • Responsible Party: Third Party Training Professionals, HUD and Property Manager’s compliance officer. 8. Establish a quality control review process. • Method: Implement a desk review process where a senior staff member or third-party consultant periodically audits a sample of completed recertification files. This internal monitoring should check for accuracy, completeness, and proper documentation. • Responsible Party: Property Manager. 9. Develop a monthly compliance monitoring report. • Method: The report will summarize the status of all recertifications for the month, listing upcoming deadlines and noting any files that required a correction. This will be presented to senior management. • Responsible Party: Property Manager. 10. Conduct a follow-up review. • Method: Engage an external auditor or consultant to perform a follow-up review of recertification files after the first year of the new procedures. This independent assessment will verify that the corrective actions are working effectively. • Responsible Party: Senior Management. 11. Provide status reports to HUD. • Method: As per the notice of noncompliance, submit regular reports to the relevant HUD Hub or Program Center detailing the progress on the CAP and any specific items requested. • Responsible Party: Property Manager and Chief Financial Officer of Sponsor. Anticipated Completion Date: December 2025

View Audit 402820

Finding 1216327 (2024-103)

Material Weakness 2024

The Village at Oasis Park - Phase Ii, Inc.

AZ

Questioned Costs HUD Housing Programs Reporting § 200.512

Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Hous...

Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD046; AZ20Q091002 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: Part 1: Immediate corrective actions (to address immediate noncompliance). Submit all overdue Single Audit and REAC reporting packages immediately to resolve the current noncompliance. Task Responsible Party 1.1. Prepare and submit delinquent reports: 1.1.1. Assemble and finalize the overdue Single Audit Reporting Package for FY 2024 and submit it to the Federal Audit Clearinghouse (FAC). Chief Financial Officer (CFO) 1.1.2. Assemble and finalize all overdue REAC Annual Financial Statements (AFS) for FY 2024 and submit them to HUD's Financial Assessment Subsystem (FASS-MF) via the REAC Secure Systems. Property Manager 1.2. Notify HUD: 1.2.1. Immediately notify the local HUD Field Office and the assigned Account Executive of the finding and the plan for submission of all delinquent reports. Property Manager 1.3. Document and address penalties: 1.3.1. Address any penalties or noncompliance flags resulting from the late filings, which may include interaction with HUD's Departmental Enforcement Center (DEC). Property Manager / CFO Part 2: Systemic corrective actions (to prevent future noncompliance) Implement new policies and procedures to ensure all future HUD Single Audit and REAC submissions are filed on time. Task Responsible Party 2.1. Revise and implement internal policies: 2.1.1. Draft a written policy defining the timelines and responsibilities for all HUD financial and audit reporting, including Single Audit and REAC AFS submissions. This policy will be housed in the organization's Operations Manual. CEO / CFO 2.2. Develop a comprehensive compliance checklist: 2.2.1. Create and implement a calendar-based checklist for all HUD reporting requirements, with deadlines for every stage of the process, including financial data collection, auditor engagement, and submission. CFO / Property Manager 2.3. Enhance financial review and control procedures: 2.3.1. Implement a formal review and approval process for all financial statements and audit packages. Require a documented review by the CFO and sign-off by the CEO and Board of Directors before any submission. CFO 2.4. Improve communication and oversight: 2.4.1. Establish a quarterly meeting with all key staff involved in HUD reporting (CFO, Property Manager, accounting staff) to review deadlines and ensure all tasks are on schedule. CEO 2.4.2. Assign a designated staff member as the primary point of contact for external auditors and the HUD REAC Secure Systems. Property Manager 2.5. Provide staff training: 2.5.1. Schedule and conduct training for all relevant staff on the new policies, checklists, and the HUD reporting platforms (FAC and REAC Secure Systems). Third Party Training Professionals, HUD and Property Manager’s compliance officer 2.6. Address external auditor issues (if applicable): 2.6.1. Evaluate the relationship with the current external audit firm. If timeliness was a factor in the audit report delay, establish clear communication protocols and deadlines in the new engagement letter. Consider a different firm for future audits if necessary. CFO Part 3: Monitoring and future enforcement (to sustain compliance) Create a monitoring plan to ensure the corrective actions are working and that late filings do not recur. Task Responsible Party 3.1. Ongoing monitoring: 3.1.1. The CFO will provide a monthly report to the CEO on the status of all HUD reporting deadlines. The report will highlight upcoming deadlines and progress toward completion. CFO 3.2. Annual review: 3.2.1. Conduct an annual review of the HUD Reporting Policy and Compliance Checklist to ensure they are current and effective. CEO / CFO 3.3. Update internal audit program: 3.3.1. Incorporate the timely filing of HUD reports into the organization's internal audit or quality assurance program. CFO Anticipated Completion Date: December 2025

View Audit 402819

Finding 1216326 (2024-102)

Material Weakness 2024

The Village at Oasis Park - Phase Ii, Inc.

AZ

Questioned Costs HUD Housing Programs Reporting

Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing...

Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD046; AZ20Q09100 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. The Sponsor shall immediately remedy all past errors by correcting and if applicable, resubmit all vouchers that were inaccurate, incomplete, or submitted late. The Sponsor shall work with the property manager to create a detailed checklist to ensure all required fields and steps are completed for each voucher before submission. From there, we shall provide HUD with a report showing all corrected vouchers and detailing how the current data was reconciled with the original incorrect submissions. 2. Systemic preventative measures: • Develop and implement a training program to create a formal training curriculum for all staff involved in voucher processing. • Update internal policies and procedures to ensure that the Sponsor’s policies and procedures to include a specific, standardized process for all Section 811 voucher submissions. • Establish a monitoring and oversight protocol to ensure regular, ongoing monitoring process to review voucher submissions for accuracy and timeliness. • Leverage HUD resources and technology to ensure that all staff involved in voucher processing are trained on and regularly use the latest guidance from the HUD Exchange and relevant HUD manuals, including the TRACS Manual Voucher Submission application. • The Chief Financial Officer will be responsible for ensuring all corrective actions are implemented and sustained. Anticipated Completion Date: December 2025

View Audit 402819

Finding 1216325 (2024-101)

Material Weakness 2024

The Village at Oasis Park - Phase Ii, Inc.

AZ

Questioned Costs Eligibility Material Weakness

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistanc...

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD046; AZ20Q09100 Pass-Through grantors: N/A Compliance Requirement: Eligibility Questioned Costs: Unknown Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. Complete all missed annual recertifications immediately. • Method: The property manager shall immediately Identify every tenant file where an annual income recertification was not performed. Collect and verify all required documentation from the affected tenants, using third-party verification as the preferred method. • Responsible Party: Property Manager. 2. Document all eligibility factors and discrepancies. • Method: For every affected tenant file, thoroughly document the process of verifying income, assets, and eligibility. Include explanations for any missing third-party verifications and document all follow-up attempts. • Responsible Party: Property Manager. 3. Retransmit corrected HUD Form 50059 filings to the TRACS system. • Method: Submit corrections for each tenant with a file deficiency by using the "Correction/Retransmittal" (R) code on a new Form HUD-50059A. • Responsible Party: Property Manager. 4. Address any rent-related issues arising from the missing recertifications. • Method: Calculate any potential back-rent owed by tenants due to misreporting or changes in income. Based on HUD guidelines and property policy, negotiate repayment plans if necessary, but carefully follow guidance regarding tenant culpability. • Responsible Party: Property Manager. 5. Revise and formalize resident file management policies and procedures. • Method: Update internal policy and procedural documents to establish clear, step-by-step instructions for completing annual recertifications, including all documentation requirements. Incorporate a standardized checklist for each tenant file to ensure consistent application. • Responsible Party: Controller and Property Manager. 6. Implement an improved tickler and tracking system. • Method: Use property management software to automatically generate alerts and reports for upcoming recertification deadlines. Implement a double-check process where a supervisor reviews and signs off on the list of upcoming deadlines each month to ensure no file is missed. • Responsible Party: Property Manager. 7. Provide comprehensive training for all staff involved in recertifications. • Method: Conduct mandatory training for all staff on Section 811 program requirements, focusing specifically on annual income recertifications and acceptable documentation. Include regular refresher training and create a central, accessible library of HUD guidance. • Responsible Party: Third Party Training Professionals, HUD and Property Manager’s compliance officer. 8. Establish a quality control review process. • Method: Implement a desk review process where a senior staff member or third-party consultant periodically audits a sample of completed recertification files. This internal monitoring should check for accuracy, completeness, and proper documentation. • Responsible Party: Property Manager. 9. Develop a monthly compliance monitoring report. • Method: The report will summarize the status of all recertifications for the month, listing upcoming deadlines and noting any files that required a correction. This will be presented to senior management. • Responsible Party: Property Manager. 10. Conduct a follow-up review. • Method: Engage an external auditor or consultant to perform a follow-up review of recertification files after the first year of the new procedures. This independent assessment will verify that the corrective actions are working effectively. • Responsible Party: Senior Management. 11. Provide status reports to HUD. • Method: As per the notice of noncompliance, submit regular reports to the relevant HUD Hub or Program Center detailing the progress on the CAP and any specific items requested. • Responsible Party: Property Manager and Chief Financial Officer of Sponsor. Anticipated Completion Date: December 2025

View Audit 402819

Finding 1216308 (2024-001)

Material Weakness 2024

Greene County

NY

Reporting Internal Control / Segregation of Duties Questioned Costs

CORRECTIVE ACTION PLAN Finding – 2024-001 Coronavirus State and Local Recovery Funds, ALN 21.027 Compliance Requirement - Reporting Criteria Recipients of SLFRF funds are required to submit complete, accurate and timely Project and Expenditure Reports in accordance with U.S. Department of Treasury g...

CORRECTIVE ACTION PLAN Finding – 2024-001 Coronavirus State and Local Recovery Funds, ALN 21.027 Compliance Requirement - Reporting Criteria Recipients of SLFRF funds are required to submit complete, accurate and timely Project and Expenditure Reports in accordance with U.S. Department of Treasury guidance and the Uniform Guidance. Reporting requirements include: • Accurate reporting of obligations and expenditures by project and expenditure category. • Submission of all required data elements prescribed by Treasury. • Retention of documentation is sufficient to support reported financial and programmatic information. Condition The County did not fully comply with U.S. Department of Treasury SLFRF reporting requirements for the period ended December 31, 2024. Specifically, the County’s Project and Expenditure Report submitted through the Treasury Reporting Portal was incomplete and/or inaccurate. Noted exception included: • Inaccurate reporting of obligated and expended amounts for one or more SLFRF projects. As a result, the SLFRF report submitted was not complete, accurate, or fully supported as required. Recommendation We recommend that the County: 1) Establish and document formal SLFRF reporting policies and procedures. 2) Implement a reconciliation process between accounting records and reported SLFRF data. 3) Require supervisory review and approval of all SLFRF submissions prior to reporting to Treasury. 4) Provide ongoing training to staff responsible for SLFRF compliance and reporting. 5) Maintain complete and organized documentation to support all reported obligations and expenditures. Response We are in agreement with the recommendation and management will take steps to strengthen internal controls over SLFRF reporting. These actions include enhancing reconciliation procedures between the accounting records and amounts reported to the Treasury reporting portal and implementing an additional level of supervisory review prior to report submission. Anticipated Completion Date This will be corrected for the December 31, 2025 audit. Person Responsible Deborah Gallo Deputy County Treasurer

View Audit 402796

Finding 1216303 (2024-003)

Material Weakness 2024

Connecticut Children's Medical Center and Subsidiaries

CT

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconcil...

Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconciliation Workflow and System Controls The State of Connecticut utilizes CT WiZ, a centralized vaccine ordering and supply management system. To maintain ordering privileges, the program enforces a strict regulatory safeguard: inventory must be fully reconciled every two weeks. Failure to complete this reconciliation triggers an automated, hard stop within CT WiZ, preventing any additional vaccine orders from being placed. To ensure absolute accuracy and data integrity, our practice executes a standardized, threepart reconciliation process that typically leverages a dual-provider verification model: • Part 1: Physical Count (Floor Staff): Clinical nurses on the floor conduct a manual, physical inventory of all vaccine doses, cross-referencing exact lot numbers and expiration dates. • Part 2: Electronic Health Record Alignment (Coordinator): The designated Vaccine Coordinator reviews the physical counts against the electronic Lot Manager log within Epic to identify and resolve any administrative discrepancies. • Part 3: State System Data Entry (Coordinator): The verified quantities are formally submitted into the CT WiZ portal to complete the biweekly cycle and clear the system for subsequent orders. Staffing Redundancy: While a single coordinator may occasionally manage all three steps if cross-covering the floor, the workflow is deliberately structured to divide tasks between floor nurses (physical counts) and site coordinators (via EMR reconciliation and CT WiZ entry). 2. Vaccine Oversight Team Vaccine operations are managed through a centralized leadership structure with site-specific accountability to ensure consistent oversight at clinic locations. Vaccine operations may be managed by a senior nurse practice manager, practice manager, lead nurse or a backup coordinator. This triad ensures continuous coverage, strict adherence to ordering schedules, and immediate troubleshooting for storage or inventory alerts. 3. Storage, Handling, and Annual Training Compliance In alignment with state oversight expectations and the strict guidelines governing CVP asset management, cold-chain integrity and proper handling are heavily protected. To mitigate risk and standardize knowledge across all care teams, the following educational requirements are mandated: • Mandatory Annual Training: All rostered nursing personnel - including core staff, float pool, and per diem nurses - are strictly required to complete annual training modules dedicated to CVP guidelines and CDC Storage and Handling. • Verification of Competency: Training must be completed through the official CDC TRAIN platform, and employees must submit their earned certificates of completion to clinical leadership to be maintained on file for audit readiness. Name(s) of Contact Person(s) Responsible for Corrective Action: Matthew Farr, VP Ambulatory Operations, Cynthia O’Brien, Senior Nurse Manager Practice Operations Anticipated Completion Date: 01/01/2026

View Audit 402778

Finding 1216228 (2024-007)

Material Weakness 2024

Barclay College

KS

Questioned Costs Student Financial Aid Material Weakness

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 Questioned Costs Student Financial Aid

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

Finding 1216017 (2024-001)

Material Weakness 2024

Southeast Chicago Chamber of Commerce

IL

Reporting Internal Control / Segregation of Duties Questioned Costs § 200.507 § 200.512

Management will implement enhanced year-end closing and audit coordination procedures, including earlier preparation timelines, improved tracking of audit deliverables and reporting deadlines, and increased coordination with outsourced accounting and audit partners to help ensure timely completion a...

Management will implement enhanced year-end closing and audit coordination procedures, including earlier preparation timelines, improved tracking of audit deliverables and reporting deadlines, and increased coordination with outsourced accounting and audit partners to help ensure timely completion and submission of future Single Audit reporting packages.

View Audit 402560

Finding 1215975 (2024-003)

Material Weakness 2024

JEWISH FAMILY SERVICES OF GREENWICH

CT

Questioned Costs Subrecipient Monitoring Eligibility § 200.300

Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and institut...

Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and instituted the following corrective actions: • Updated Internal Signature Policy: We have drafted a strict internal policy requiring the primary case manager-and any other staff actively working on a case-to sign and date all required enrollment documents. This explicitly includes signing intake forms and completing the interpreter sections, where applicable. This policy ensures there is never any ambiguity regarding who is handling the case. • Mandatory Supervisory Review: To enforce this new standard, our internal policy now requires Program Managers and Directors to systematically review each individual case file. Leadership must verify that all required staff signatures, interpreter sign-offs, and eligibility approvals are fully documented before a client's enrollment is considered complete. • Standardized Case Coversheet: To immediately resolve the issue of identifying case handlers, we are implementing a standardized enrollment coversheet for all new files. This document clearly assigns the primary case manager on day one and requires a final supervisory signature to formally authorize the eligibility review. • Targeted Training and Spot-Checks: We are conducting immediate refresher training for all program staff to clarify exactly which signatures are required on each document. Furthermore, leadership will conduct routine, random spot-checks of active case files each month to verify that staff are consistently adhering to this policy in real-time. By formalizing our signature requirements and mandating director-level reviews, we are confident this updated workflow establishes clear accountability and fully resolves the finding.

View Audit 402530

Finding 1215974 (2024-002)

Material Weakness 2024

JEWISH FAMILY SERVICES OF GREENWICH

CT

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. F...

Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. Furthermore, the delayed receipt of the FY23 audit-delivered post-FY24-precluded the implementation of procedural adjustments during the audited timeframe. To address our operational realities and ensure strict, ongoing adherence to 2 CFR § 200.430, the agency immediately instituted systemic enhancements for FY25. The Organization has transitioned all time tracking to a streamlined, system-driven process within our UKG platform: • Integrated UKG Time Tracking and Approvals: All employees are now required to punch in and out directly through the UKG system, efficiently assigning their actual hours worked to specific program and grant codes to generate functional, after-the-fact timesheets. To further streamline this documentation, the Organization is gradually transitioning our existing supervisory reviews into UKG’s electronic sign-off workflow, which will centralize our approval records and ensure accurate distribution across federal awards.

View Audit 402530

Finding 1215973 (2024-001)

Material Weakness 2024

JEWISH FAMILY SERVICES OF GREENWICH

CT

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302

Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorpor...

Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorporate the auditors' feedback during the FY24 audited period. However, the Organization took immediate, proactive steps to deploy enhanced internal controls for FY25 to ensure continuous alignment with federal standards. To ensure strict adherence to 2 CFR § 200.302(a), we are actively implementing a more regular reconciliation process between government grant revenue claimed and actual revenue earned. As a key part of this initiative, the Organization has developed and deployed new internal financial tools designed to incorporate automation into our daily workflows. By utilizing these automated tools-such as standardized templates for recording cash receipts and systematically clearing Accounts Receivable-we have significantly enhanced the accuracy of our data entries and reduced the risk of manual misstatements. Our ongoing objective is to leverage these tools to establish clear, standardized documentation procedures, ensuring that all financial reports and claims are consistently generated from a reconciled general ledger. Management remains fully committed to dedicating the necessary time and resources to mature these financial controls and ensure robust compliance with federal regulations.

View Audit 402530

Corrective Action Plans

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