Corrective Action Plans

Finding 572357 (2024-001)

None 2024

MA

Questioned Costs HUD Housing Programs Period of Performance

One of the four CMF funded projects, Barry Farm, is a two-phase project. The construction start was delayed due to local permitting challenges and COVID-related issues which resulted in the project not being completed by the original Project Completion date of March 27, 2024. Management informed C...

One of the four CMF funded projects, Barry Farm, is a two-phase project. The construction start was delayed due to local permitting challenges and COVID-related issues which resulted in the project not being completed by the original Project Completion date of March 27, 2024. Management informed CDFI Fund of the delays in the project and on May 16, 2024, CDFI Fund provided a one-year cure period to March 31, 2025. At that time, Management informed CDFI Fund that the second phase of the Barry Farm project would require a longer cure period due to a 30-month delivery schedule, driven by the incorporation of a large geothermal system, with delivery set for late 2026. CDFI Fund directed Management to report on the second phase’s progress with a new cure period request annually until project completion. During the cure period, Barry Farm’s first phase was completed, and is now leased up and operating. In March 2025, Management informed CDFI of the project status for phase two which is now 24% complete and remains on schedule for completion in November 2026. CDFI Fund provided a one-year cure period until March 31, 2026. Management has otherwise significantly exceeded the grant’s performance targets and will request cure period extensions until project completion.

View Audit 363432

Finding 572350 (2024-001)

Significant Deficiency 2024

Metropolitan Transportation Authority

NY

Questioned Costs Allowable Costs / Cost Principles Cash Management

FEDERAL AWARDS—CORRECTIVE ACTION PLAN REFERENCE # 2024-001 Federal Transit Cluster - ALN Number: 20.507; 20.525; and 20.526 Contract Number: C40261TECHINSP; C33941EFA-MTAB; C40265TECH-MTAB; U3NY-2023-101-02 and U9NY-2018-059-01 Significant Deficiency-Non-Compliance Agen...

FEDERAL AWARDS—CORRECTIVE ACTION PLAN REFERENCE # 2024-001 Federal Transit Cluster - ALN Number: 20.507; 20.525; and 20.526 Contract Number: C40261TECHINSP; C33941EFA-MTAB; C40265TECH-MTAB; U3NY-2023-101-02 and U9NY-2018-059-01 Significant Deficiency-Non-Compliance Agency: U.S. Department of Transportation Criteria: Activities Allowed/Allowable Costs/Cost Principles including Indirect Costs––Direct - As stated in Uniform Grant Guidance - §200 Requirements for Allowable Costs: a. Costs did not consist of improper payments, including (1) payments that should not have been made or that were made in incorrect amounts (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements; (2) payments that do not account for credit for applicable discounts; (3) duplicate payments; (4) payments that were made to an ineligible party or for an ineligible good or service; and (5) payments for goods or services not received (except for such payments where authorized by law). Condition/Context: The MTA has Activities Allowed/Allowable Costs/Cost Principles including Indirect Costs procedures in place. MTA has corporate policies and procedures regarding Activities Allowed/Allowable Costs. We tested the Federal Transit Cluster’s Allowable Costs compliance. Based on our review of sixty samples related to Personnel Services and Other than Personnel Services for this cluster, we noted that four samples related to an MTA Bus Company personnel’s hourly rate were charged at higher rate. We noted that the rate per personnel file and employee payroll register differs from the actual rate used by the agency to charge labor costs. The agency calculated labor cost using the annual earnings that is divided by 52 weeks because there are 52 weeks a year, but MTA payroll department used 52.1428 weeks based upon 365/7 days a week, which created variances in labor costs billed and actual recorded labor costs. For Contract # - U3NY-2023-101-02 and U9NY-2018-059-01 – We noted two instances of sixty samples reviewed where the agency used 2023 approved overhead rate of 98.18% instead of the 2024 approved overhead rate of 98.98%. Recommendation: We recommend that MTA ensure that all personnel are reviewed and should be charged at the correct hourly rates as required by §200 CFR Subpart E – Allowable Costs. We also recommend that approved indirect rate applied to direct costs. Corrective Action Plan: MTA Bus will work with the project team to implement the correct rate and calculate the variance. MTA Bus will return the credit to the FTA as needed. Going forward, MTA Bus will review the employee wage rates from the official data sources to ensure that the correct rates are applied. SIR Finance will ensure that the overhead rates on the labor sheets are reflecting the correct percentage by adding a "verification measure" to a checklist while performing internal audits and approvals of the invoices prior to submission. Additionally, SIR-Finance will adjust the formatting within the invoice spreadsheets for easier visibility to a potential error in the calculated overhead percentage. Action Date: MTABUS – 1ST QUARTER 2026 SIRTOA - Effective Immediately - on July 2025 Invoices Final Implementation Date: MTABUS – 2ND QUARTER 2026 SIRTOA – July 2025 Name And Phone Number of Person Responsible For Implementation: MTABUS Marixsa Rivera Assistant Budget Chief • Project Development 718-927-8056 SIRTOA Marissa Rand Assistant Director, Finance & Timekeeping - SIR 347-694-6448

View Audit 363411 Questioned Costs: $1

Finding 572347 (2024-002)

Material Weakness 2024

Sinai Health System and Affiliates

IL

HUD Housing Programs Reporting Questioned Costs

Finding Number: 2024-002 Condition The Corporation did not submit the financial statements to HUD within 180 days of their fiscal year. Planned Corrective Action: Sinai Health System has developed an action plan to ensure that financial statements and other materials are submitted in a timely fa...

Finding Number: 2024-002 Condition The Corporation did not submit the financial statements to HUD within 180 days of their fiscal year. Planned Corrective Action: Sinai Health System has developed an action plan to ensure that financial statements and other materials are submitted in a timely fashion to lenders and are compliant with the HUD Regulatory Agreements. The action plan consists of the following components: o Development of a policy that outlines HUD requirements and identifies individuals responsible for meeting the requirements; the Senior Finance Team and Compliance team should be educated on this annually. o Regular communication (no less than quarterly) between Finance and the Compliance Officer regarding HUD deadlines and deviation from these deadlines. o Development of a checklist that will be utilized by the Compliance and Finance departments regarding HUD requirements and deadlines. o Reporting to the Audit and Compliance Committee of the Board that the checklist has been completed/deadlines have been met. This will be a regular agenda item. Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025

View Audit 363396

Finding 572231 (2024-003)

Material Weakness 2024

Nash Edgecombe Wilson Community Action, Inc.

NC

Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs

Corrective Action: The Agency has purchased a software package to track and file inspections. The staff has been trained on the software, and it has been implemented in fiscal year 2025. The Agency is in the process of performing inspections on all units in fiscal year 2025. Once inspections are ...

Corrective Action: The Agency has purchased a software package to track and file inspections. The staff has been trained on the software, and it has been implemented in fiscal year 2025. The Agency is in the process of performing inspections on all units in fiscal year 2025. Once inspections are completed, Agency will be in compliance with HUD.

View Audit 363358 Questioned Costs: $1

Finding 572230 (2024-002)

Material Weakness 2024

Nash Edgecombe Wilson Community Action, Inc.

NC

Questioned Costs HUD Housing Programs

Corrective Action: The Agency has implemented procedures to evaluate the Utility rate data every year. The Agency has already evaluated fiscal year 2025.

View Audit 363358

Finding 572229 (2024-001)

Material Weakness 2024

Nash Edgecombe Wilson Community Action, Inc.

NC

Questioned Costs HUD Housing Programs

Corrective Action: The Agency is working with a CPA to catch up on missed filings, and has noted future deadlines for going forward.

View Audit 363358

Finding 572210 (2024-005)

Significant Deficiency 2024

Municipality of Cabo Rojo

PR

Questioned Costs Reporting Significant Deficiency

We will improve our internal control procedures related to record keeping and adjustments in order to ensure compliance with the March 31st federal requirement. Implementation Date: During the 2025-2026 fiscal year. Responsible Person: Warynex Carlo Hernández, Finance Department Director

View Audit 363351

Finding 572207 (2024-003)

Material Weakness 2024

Keokuk Housing Authority

IA

Questioned Costs Cash Management

Finding 2024-003 See response to finding 2024-002.

View Audit 363328 Questioned Costs: $1

Finding 572202 (2024-001)

Significant Deficiency 2024

National Church Residences

OH

Reporting Questioned Costs Period of Performance § 200.502 § 200.510

Finding Number: 2024-001 Condition: The expenditures were reported for the Capital Magnet Fund throughout the award period from the year ended June 30, 2019 to the year ended June 30, 2024 on the schedule of expenditures of federal awards (SEFA) but did not accurately report the amount of administr...

Finding Number: 2024-001 Condition: The expenditures were reported for the Capital Magnet Fund throughout the award period from the year ended June 30, 2019 to the year ended June 30, 2024 on the schedule of expenditures of federal awards (SEFA) but did not accurately report the amount of administrative expenditures incurred during the performance period, and, therefore, the SEFA was not complete and accurate for the year ended June 30, 2019 to the year ended June 30, 2024. Planned Corrective Action: Management has implemented procedures and controls to ensure reports are reviewed prior to submission and distributed funds are reported properly and in the correct period. Contact person responsible for corrective action: Lindsey Dehring, Vice President of Financial Planning & Analysis Anticipated Completion Date: July 31, 2025

View Audit 363317

Finding 572191 (2024-003)

Significant Deficiency 2024

Legacy Community Health Services, Inc.

TX

Questioned Costs Procurement, Suspension & Debarment Eligibility

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to a lack of verification of whether the patient had active eligibility or not. Steps have already been taken to begin addressing the issue. Additional training and communication will be provided to...

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to a lack of verification of whether the patient had active eligibility or not. Steps have already been taken to begin addressing the issue. Additional training and communication will be provided to the Financial Services team to reinforce understanding of eligibility and documentation requirements. Also, the Data Analyst in the Financial Services team will generate a bi-weekly report in Pioneer to identify all medications being billed to Ryan White and current status of eligibility. Implementation of this planned corrective action is the responsibility of Financial Services-IAT reporting.

View Audit 363301

Finding 572179 (2024-002)

Material Weakness 2024

Legacy Community Health Services, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to personnel costs for certain employees being allocated based on a budgeted full-time equivalent basis without subsequent reconciliation to time and effort records. All costs have been determined a...

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to personnel costs for certain employees being allocated based on a budgeted full-time equivalent basis without subsequent reconciliation to time and effort records. All costs have been determined as allowable costs, and the finding is a result of administrative challenges. Steps have already been taken to begin addressing the issue. Grant Accounting and Human Resources will implement a time and effort certification process signed by employee and supervisor. This new process will be rolled out during the first quarter of Fiscal Year 2026 with training provided to relevant personnel. The indirect cost employees working on various grants will certify their time allocation on a periodic basis and provide revised allocations for the upcoming period. These updates processes, communication and training will provide a demonstration of the remediation of this finding during fiscal year 2026.

View Audit 363301 Questioned Costs: $1

Finding 572177 (2024-002)

Material Weakness 2024

Deerfield Valley Communications Union District

VT

Reporting Questioned Costs § 200.328

The District acknowledges the continuing issue of receiving material vendor invoices many months after performance of contracted work. One set of late invoices entered into QuickBooks accounts payable with retroactive dates was not recognized as grant revenue earned. As recommended by the auditors, ...

The District acknowledges the continuing issue of receiving material vendor invoices many months after performance of contracted work. One set of late invoices entered into QuickBooks accounts payable with retroactive dates was not recognized as grant revenue earned. As recommended by the auditors, the District will begin tracking grant expenditures on an accrual basis beginning with the period ending July 31, 2025. In addition to the monthly recognition of cash accounts by the Finance Coordinator, all balance sheet accounts with material balances will be reconciled each month by the Treasurer with review by the Executive Director beginning with the period ending July 31, 2025. We anticipate both audit findings will be fully resolved by these actions. Responsible party: Patrick Moreland Date: Ongoing

View Audit 363299

Finding 572169 (2024-002)

None 2024

Opportunities Industrialization Centers of America, INC

PA

Questioned Costs Reporting

OICA has instituted a new policy and procedure whereby all grant-related expenditures shall be reviewed by both the Finance Team and the Grant Administration team to ensure that spend is both appropriate and in line with budgeted expectations. This includes documenting that labor expenditures aresu...

OICA has instituted a new policy and procedure whereby all grant-related expenditures shall be reviewed by both the Finance Team and the Grant Administration team to ensure that spend is both appropriate and in line with budgeted expectations. This includes documenting that labor expenditures aresupported by actual hours and pay rate.

View Audit 363281 Questioned Costs: $1

Finding 572168 (2024-001)

Material Weakness 2024

Opportunities Industrialization Centers of America, INC

PA

Questioned Costs Reporting Internal Control / Segregation of Duties

OICA has instituted a new policy and procedure whereby all grant-related expenditures shall be reviewed by both the Finance Team and the Grant Administration team to ensure that spend is both appropriate and in line with budgeted expectations. Budget exceptions will be similarly reviewed and approv...

OICA has instituted a new policy and procedure whereby all grant-related expenditures shall be reviewed by both the Finance Team and the Grant Administration team to ensure that spend is both appropriate and in line with budgeted expectations. Budget exceptions will be similarly reviewed and approved by responsible members of both departments. All expenditure decisions shall be documented and retained. Annual training shall be implemented to ensure that all relevant employees are familiar with the requirements for compliant documentation and retention.

View Audit 363281 Questioned Costs: $1

Finding 572097 (2024-003)

Material Weakness 2024

Youth & Shelter Services, INC

IA

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The Organization should ensure proper review and approval over expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to ...

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The Organization should ensure proper review and approval over expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: YSS engaged a project manager in September 2023 to provide oversight on the two major construction projects taking place, Rooftop Gardens and Ember Campus. The project manager reviews the work being performed to ensure alignment with the progress billing on the monthly AIA pay applications. The project manager submits the invoice for approval to the CFO who, with the CEO, approves payment and the invoice is sent YSS accounts payable to processes payment. Name of the contact person responsible for corrective action: Mark VanderLinden Planned completion date for corrective action plan: June 30, 2025

View Audit 363253

Finding 572087 (2024-001)

Significant Deficiency 2024

Summit Community Care Clinic, Inc.

CO

Period of Performance Questioned Costs Allowable Costs / Cost Principles § 200.1 § 200.303

Recommendation We recommend the Organization update their method of allocating expenditures to federal awards based on the incurred date, rather than paid date.

View Audit 363221 Questioned Costs: $1

Finding 572070 (2024-002)

Material Weakness 2024

Psa Behavioral Health Agency

AZ

Questioned Costs Material Weakness Reporting

Item: 2024-002 Assistance Listing Number: 93.958 Programs: Block Grants for Community Mental Health Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Mercy Care Pass-Through Grantor Identifying Number: Unknown Award Year: October 1, 2023 to September 30, 20...

Item: 2024-002 Assistance Listing Number: 93.958 Programs: Block Grants for Community Mental Health Services Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: Mercy Care Pass-Through Grantor Identifying Number: Unknown Award Year: October 1, 2023 to September 30, 2024 Compliance Requirement: Reporting Criteria or Specific Requirement: In accordance with the grant agreements the Organization is required to submit quarterly funding and expense reports to the grantor within 30 days after quarter end. Condition: For all 4 quarterly reports, the reports were submitted to the grantor subsequent to 30 days after quarter end. Name of Contact Person: Connie Svaleng, CFO Phone Number: (602) 995-1767 Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Actions: The Organization will enhance its existing controls to ensure the completion and submission of all required reporting in a timely manner.

View Audit 363188

Finding 572064 (2024-004)

None 2024

Southern Iowa Regional Housing Authority

IA

Matching / Level of Effort / Earmarking Questioned Costs

See response to finding 2024-002.

View Audit 363177

Finding 572063 (2024-003)

None 2024

Southern Iowa Regional Housing Authority

IA

Cash Management Questioned Costs

See response to finding 2024-001.

View Audit 363177 Questioned Costs: $1

Finding 572055 (2024-005)

Significant Deficiency 2024

City of Chicago

IL

Questioned Costs

The finding was a result of a 2022 original inspection that occurred for one rental property. The property was placed in temporary non-compliance status as a follow-up inspection was scheduled. The property did not correct all the non-compliant issues, and it did not receive a final non-compliant d...

The finding was a result of a 2022 original inspection that occurred for one rental property. The property was placed in temporary non-compliance status as a follow-up inspection was scheduled. The property did not correct all the non-compliant issues, and it did not receive a final non-compliant determination letter. The non-issuance of the final non-compliant letter was a mistake made by a Rehabilitation Construction Specialist (RCS) staff person. The RCS staff person should have followed up with the non-compliant determination letter within 12 months of the original inspection as described in Department of Housing’s policies and procedures. The property was inspected in June per the tri-annual inspection schedule and was issued a non-compliant letter. This oversight was a mistake made by the Rehabilitation Construction Specialist by not following up with the final non-compliant determination letter, which did not comply with the normal practice of Department of Housing’s policies and procedures. Deputy Commissioner of DOH’s Construction and Compliance (CAC) Division, Smith, will ensure all managers within CAC properly train their RCS staff on current policies and procedures. The managers’ specific tasks will include: 1. Review all temporary non-compliant and non-compliant projects with the RCS staff on a monthly basis to ensure follow-up notices are sent and reinspection(s) are scheduled within the timeframe given for that particular violation. 2. Track correspondences to owners and property managers informing them of reinspection dates and time for all non-compliant projects. 3. Collect final compliance determination for all non-compliant projects within the 12-month period. Deputy Commissioner Smith at Department of Housing’s Construction and Compliance Division will be responsible for ensuring the corrective action plan is implemented by December 31, 2025.

View Audit 363171

Finding 572054 (2024-004)

Significant Deficiency 2024

City of Chicago

IL

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

The Department of Family and Support Services (DFSS) will document its annual process regarding the calculation of Emergency Solutions Grant (ESG) matching and level of effort requirements to ensure it is accurately performed and reviewed by the appropriate DFSS Finance management personnel, Supervi...

The Department of Family and Support Services (DFSS) will document its annual process regarding the calculation of Emergency Solutions Grant (ESG) matching and level of effort requirements to ensure it is accurately performed and reviewed by the appropriate DFSS Finance management personnel, Supervisor of Accounting and Director of Finance. The completed match will be sent for final review to DFSS’ Deputy Commissioner of Finance for confirmation and required financial grant reporting. Deputy Commissioner of Finance Ciezczak at the Department of Family and Support Services will be responsible for providing oversight and monitoring this process. The defined process will be documented and implemented by December 31, 2025.

View Audit 363171

Finding 572052 (2024-002)

Material Weakness 2024

City of Chicago

IL

Questioned Costs HUD Housing Programs

The Chicago Department of Public Housing (CDPH) will continue working through its corrective action plan (CAP) for U.S. Department of Housing and Urban Development (HUD) which involves completing an assessment of all client-files for individuals receiving HOPWA services in the Chicago Eligible Metro...

The Chicago Department of Public Housing (CDPH) will continue working through its corrective action plan (CAP) for U.S. Department of Housing and Urban Development (HUD) which involves completing an assessment of all client-files for individuals receiving HOPWA services in the Chicago Eligible Metropolitan Statistical Area. CDPH staff developed the Client-file assessment tool in collaboration with HUD, and all HOPWA Project Sponsors in the Eligible Metropolitan Statistical Area have submitted, through Secure File Transfer, client files for every single individual receiving HOPWA services through their organization. CDPH staff are currently conducting a comprehensive assessment of the completeness of these files including documentation of the inspection of units resided in by individuals and households. This assessment is being conducted through REDCap secure survey to capture the assessment results for every single individual receiving HOPWA services. CDPH anticipates completion of this assessment by August 31, 2025. The results of the assessment will be submitted to HUD as a formal completion of the HUD-issued Corrective Action Plan. Following this submission, CDPH will engage with HUD in designing ongoing monitoring of HOPWA Project Sponsors in the jurisdiction. Director of Program Operations Stonehouse at the Chicago Department of Public Health for the Community Health Services Division of the Syndemic Infectious Disease Bureau will be responsible for overseeing the completion of the client file assessment, analysis of the results of the assessment and communication of these results with the HUD HOPWA Project Officer and HOPWA Project Sponsors, and working with HUD and other interest holders to design and implement ongoing monitoring standards.

View Audit 363171

Finding 572006 (2024-004)

Material Weakness 2024

Community Partnership, Inc.

PA

Questioned Costs Special Tests & Provisions Internal Control / Segregation of Duties

FINDING: 2024-004 Internal Control and Compliance over Special Tests and Provisions Recommendation: We recommend the Partnership establish policies and procedures to ensure that the Tri-Partite board requirements are followed. Action taken: CP staff continue to work with our state technical assist...

FINDING: 2024-004 Internal Control and Compliance over Special Tests and Provisions Recommendation: We recommend the Partnership establish policies and procedures to ensure that the Tri-Partite board requirements are followed. Action taken: CP staff continue to work with our state technical assistance provider and the Board of Directors to ensure that tri-partite requirements are met. The board recently updated its bylaws to reflect changes in the required number of board members, and CP has increased its visibility in the community. CP acknowledges that the elected official component of the board remains difficult to fill.

View Audit 363115 Questioned Costs: $1

Finding 572005 (2024-003)

Material Weakness 2024

United Community Center, Inc.

WI

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

The Organization acknowledges the finding. This was an isolated clerical error made by the staff responsible for preparing the reimbursement documentation. Although an employee already fully allocated to other programs was mistakenly included in the claim, the Organization had sufficient allowable p...

The Organization acknowledges the finding. This was an isolated clerical error made by the staff responsible for preparing the reimbursement documentation. Although an employee already fully allocated to other programs was mistakenly included in the claim, the Organization had sufficient allowable personnel expenses from other staff who were not fully allocated to federal programs. These resources could have been properly used to support the claim. Program operations continued without disruption and were not affected in any way, as there were adequate personnel costs available to sustain the program throughout the period. To prevent recurrence, the Organization is reviewing and strengthening its internal review procedures related to grant allocations and payroll backup. Additional training and oversight will be provided to ensure that future claims are accurately supported by allowable personnel costs.

View Audit 363112 Questioned Costs: $1

Finding 571982 (2024-003)

Significant Deficiency 2024

City of Coral Gables, Florida

FL

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.512

Management acknowledges that the City’s audit package and Data Collection Form were not submitted timely to the Federal Audit Clearinghouse within the required timeframe in accordance with Uniform Guidance (2 CFR 200.512). We understand the importance of timely submission in maintaining compliance w...

Management acknowledges that the City’s audit package and Data Collection Form were not submitted timely to the Federal Audit Clearinghouse within the required timeframe in accordance with Uniform Guidance (2 CFR 200.512). We understand the importance of timely submission in maintaining compliance with federal grant requirements and ensuring continued eligibility for federal funding. The delay was due to new ERP system conversion and staffing shortages. We will re-evaluate our current processes and ensure that all deadlines associated with the Single Audit process are clearly documented and monitored. We will conduct internal reviews after each year-end closing to ensure audit-related deadlines are met and updates will be provided to senior leadership as needed. We will strengthen internal controls and improve communication with our auditors to avoid future delays in submission to the Federal Audit Clearinghouse. Anticipated Completion Date: 7/31/2025 Person Responsible: Diana Gomez, Finance Director

View Audit 363084

Corrective Action Plans

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