Corrective Action Plans

Finding 1216735 (2024-001)

Material Weakness 2024

STEPS to Recovery Homes

AZ

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

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

View Audit 403178

Finding 1216689 (2024-001)

Material Weakness 2024

Casa Esperanza, Inc. and Affiliates

MA

Subrecipient Monitoring Reporting

Finding 2024-001: Timeliness of Reporting During a recent compliance review, it was identified that the organization did not have a formalized process to ensure consistent compliance with the reporting requirements under the Federal Funding Accountability and Transparency Act (FFATA). While the orga...

Finding 2024-001: Timeliness of Reporting During a recent compliance review, it was identified that the organization did not have a formalized process to ensure consistent compliance with the reporting requirements under the Federal Funding Accountability and Transparency Act (FFATA). While the organization maintains strong financial management and grant oversight practices, FFATA-specific procedures had not been explicitly incorporated into written policies, subrecipient agreements, or monitoring tools. Name of Contact Person: Emily Stewart, Chief Executive Officer Applicable Requirement FFATA requires prime recipients of federal funding to report certain subaward and executive compensation information to the federal government to promote transparency in the use of federal funds. These requirements are implemented through federal grant regulations including 2 CFR Part 170 and applicable provisions within 45 CFR Part 75. Corrective Actions Plan: To address this issue and strengthen compliance controls, the organization has implemented the following corrective actions: 1. Retroactive Reporting Completion The organization conducted a comprehensive review of all applicable federal awards. All required FFATA subaward reports from FY19 through the present have been entered into SAM.gov to ensure full compliance with federal reporting requirements. 2. Policy Updates Financial policies and procedures are being updated to include specific guidance regarding FFATA reporting requirements and internal responsibilities for ensuring compliance. 3. Contract Amendments Existing subrecipient agreements have been amended to include an attestation that they are compliant with FFATA requirements and 2 CFR 200. Amended contracts were distributed to all applicable subrecipients to ensure compliance with federal reporting obligations. 4. Subrecipient Monitoring Enhancements The organization has updated its subrecipient monitoring checklist to include verification of FFATA-related compliance requirements as part of ongoing oversight activities. 5. Training and Capacity Building Development staff and the Grants Accountant have registered for a training sponsored by the Department of Justice titled “Pass-through Entity’s Oversight Responsibilities for Subrecipients.” They attended the training online on Wednesday, March 25 2026. We are actively seeking additional compliance training to ensure staff fully understand FFATA requirements and any related compliance obligations. This step is intended to supplement existing financial compliance training and confirm that no additional requirements have been overlooked. Ongoing Monitoring The organization will monitor implementation of these corrective actions and incorporate FFATA compliance into routine grant management and subrecipient monitoring processes moving forward. Conclusion These corrective measures are intended to strengthen internal controls, improve transparency, and ensure full compliance with federal grant reporting requirements going forward. Anticipated Completion Date: Immediately

View Audit 403122

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 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 1216677 (2024-001)

Material Weakness 2024

Community Beyond Violence

CA

Reporting Internal Control / Segregation of Duties § 200.512

The Organization has hired new staff, changed accounting systems and is developing a strict month-end and year-end close procedure to ensure timely financial reporting and future compliance.

View Audit 403114

Finding 1216603 (2024-011)

Material Weakness 2024

Trimble Local School District

OH

Subrecipient Monitoring Material Weakness Reporting § 200.328

Finding Number: 2024-011 Planned Corrective Action: The district will strengthen procedures for preparing and reviewing Final Expenditure Reports to ensure all reported expenditures agree to the underlying accounting records and supporting documentation. The Treasurer will reconcile grant expenditur...

Finding Number: 2024-011 Planned Corrective Action: The district will strengthen procedures for preparing and reviewing Final Expenditure Reports to ensure all reported expenditures agree to the underlying accounting records and supporting documentation. The Treasurer will reconcile grant expenditures to system reports prior to submission and implement additional review procedures to ensure accurate and compliant federal reporting. Anticipated Completion Date: 05/31/2026 Responsible Contact Person: Ashley Miller

View Audit 403068

Finding 1216601 (2024-009)

Material Weakness 2024

Trimble Local School District

OH

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.403

Finding Number: 2024-009 Planned Corrective Action: The district will implement enhanced procedures for monitoring and tracking federal grant expenditures to ensure expenditures do not exceed awarded grant amounts and are properly reported. The Treasurer will review grant agreements, monitor availab...

Finding Number: 2024-009 Planned Corrective Action: The district will implement enhanced procedures for monitoring and tracking federal grant expenditures to ensure expenditures do not exceed awarded grant amounts and are properly reported. The Treasurer will review grant agreements, monitor available grant balances on a regular basis, and maintain supporting documentation for all federal expenditures and reporting to ensure compliance with federal requirements and accurate reporting on the Schedule of Expenditures of Federal Awards. At the time of the creation of this corrective action plan all COVID-19 related grants have been totally expended. The district is required to provide the board, ODEW, and the Financial Planning Commission with monthly monitoring documents. Within these documents is contained a worksheet that requires the treasurer to list each fund balance for all accounts and explain any negative balances and whether a PCR has been created to eliminate negative balances. This policy forces the district to pay close attention to any grant funds that are carrying negative balances. Anticipated Completion Date: 05/31/2026 Responsible Contact Person: Ashley Miller

View Audit 403068

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 1216520 (2024-003)

Material Weakness 2024

Easton Area School District

PA

Reporting

Management Corrective Action Plan: The District acknowledges the finding regarding the untimely submission of required reports to the Pennsylvania Department of Education related to federal grant programs. Management recognizes the importance of timely and accurate reporting to ensure compliance wit...

Management Corrective Action Plan: The District acknowledges the finding regarding the untimely submission of required reports to the Pennsylvania Department of Education related to federal grant programs. Management recognizes the importance of timely and accurate reporting to ensure compliance with grant requirements and maintain effective oversight of federal funding. The delays in submission were primarily the result of staffing transitions within the Business Office and challenges associated with completing prior year financial information needed for reporting purposes. The District has worked cooperatively with the Pennsylvania Department of Education throughout this process and has taken steps to address outstanding reporting requirements. To address this matter, the District has begun implementing corrective actions which include: Establishing internal reporting calendars and compliance deadlines for all required state and federal submissions; Assigning specific staff responsibilities for grant reporting and monitoring; Implementing supervisory review procedures to ensure reports are completed accurately and submitted timely; and Providing additional oversight and coordination related to federal grant compliance and reporting requirements. Individual(s) Responsible: CFO, Finance Officer Anticipated Completion Date: Prior to issuance of the Fiscal Year 2025 Financial Statements

View Audit 403014

Finding 1216467 (2024-001)

Material Weakness 2024

Bais Yaakov Elementary of Rockland County

NY

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before t...

The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight.

View Audit 402966

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 1216368 (2024-001)

Material Weakness 2024

First Person Care Clinic, Inc.

NV

Reporting

Parties responsible for all action items: CEO First Person Care Clinic – Harsh Chhawchharia, harsh@firstpersonclinic.org, phone 702-572-3500 Controller First Person Care Clinic – Demetrio Ordas, dordas@firstpersonclinic.org, phone 702-572-3500 Finding 2024- 001 Reporting (L) Significant Deficiency i...

Parties responsible for all action items: CEO First Person Care Clinic – Harsh Chhawchharia, harsh@firstpersonclinic.org, phone 702-572-3500 Controller First Person Care Clinic – Demetrio Ordas, dordas@firstpersonclinic.org, phone 702-572-3500 Finding 2024- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. Throughout 2024, our organization struggled to overcome ongoing obstacles due to a lack of personnel. Despite our efforts to hire additional administrative support, the process proved arduous, and we encountered difficulties in finding suitable candidates. In our quest for solutions, we proactively engaged with other FQHCs and NV PCA, exploring the potential for collaborative personnel arrangements. Moreover, our existing staff members underwent periods of illness, as did their families, further straining our capacity to fulfill our responsibilities effectively. As a result, the burden on our small team, consisting of just one additional staff member alongside myself and the CFO, became overwhelming. Juggling multiple roles and responsibilities amid personal and familial health challenges made it exceedingly difficult to keep up with the demanding workload. These circumstances underscored the urgent need for additional support and highlighted the critical importance of finding viable solutions to address our staffing limitations. CEO and CFO Timeframe: 2-4 months a. Staff Augmentation: We are actively working on hiring dedicated administrative support staff who will be responsible for assisting with routine tasks. This strategic addition to our team will allow the CEO and CFO to focus more effectively on their core responsibilities. b. Streamlined Processes: We are in the process of reviewing and optimizing our internal processes. This critical step will help enhance the overall efficiency of managing tasks related to federal reporting and grants management. c. Task Delegation: With the inclusion of additional staff members, we will delegate specific responsibilities to ensure that FFR quarterly reports are not only prepared but also submitted promptly. d. Reporting Calendar: We will be implementing a comprehensive reporting calendar that clearly outlines deadlines and assigns responsibilities. This organized approach will assist us in staying on track and meeting our reporting obligations consistently. e. Training and Development: Our team is committed to continuous improvement. To this end, we will be providing training and development opportunities for our staff to enhance their skills and knowledge in grants management and federal reporting. This investment in their professional development will result in greater accuracy and efficiency. In addition to these measures, we are exploring the possibility of engaging a third-party company if we encounter challenges in hiring employees directly. We are actively in discussions with other hiring companies and Locum tenants companies as needed to ensure that we have all the resources required to address this issue effectively. By implementing these measures, we aim to overcome historical challenges related to understaffing and limited access to essential resources. The collaborative efforts of the FPCC finance team, combined with streamlined processes and improved technology, will position us to submit FFR quarterly reports and the annual submission to the federal clearinghouse promptly and efficiently.

View Audit 402908

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 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 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 1216230 (2024-008)

Material Weakness 2024

Barclay College

KS

Student Financial Aid Reporting Subrecipient Monitoring

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lori Larsh, Vice Pr...

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026

View Audit 402736

Finding 1216227 (2024-006)

Material Weakness 2024

Barclay College

KS

Student Financial Aid Reporting

Enrollment Reporting to NSLDS Planned Corrective Action: A system will be put into place to ensure that enrollment is reported in a timely and accurate manner. Additionally, the College will complete a series of spot checks of NSLDS enrollment statuses throughout the year. Person Responsible for Cor...

Enrollment Reporting to NSLDS Planned Corrective Action: A system will be put into place to ensure that enrollment is reported in a timely and accurate manner. Additionally, the College will complete a series of spot checks of NSLDS enrollment statuses throughout the year. 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 1215999 (2024-003)

Material Weakness 2024

The Enola Group, Inc.

NC

Allowable Costs / Cost Principles Reporting

NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding. The delayed submission of the Data Collection Form and reporting package was primarily the result of an extended audit timeline caused by the transition to a new audit firm. In addition, delays ...

NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding. The delayed submission of the Data Collection Form and reporting package was primarily the result of an extended audit timeline caused by the transition to a new audit firm. In addition, delays associated with the completion of prior audit matters and the new auditor's initial review process contributed to the timing of the final audit report and subsequent FAC submission. Since that time, the Organization has hired a new auditor, improved internal closing procedures, and implemented enhanced monitoring of audit and federal reporting deadlines. Management is committed to timely compliance with all Uniform Guidance reporting requirements and believes these improvements will help prevent future delays. PROPOSED COMPLETION DATE: May 30, 2026

View Audit 402547

Finding 1215998 (2024-002)

Material Weakness 2024

The Enola Group, Inc.

NC

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

NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding; however, it is important to clarify that the circumstances leading to the deficiency were significantly impacted by delated and unresponsive actions from the federal agency. Specifically, the Or...

NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding; however, it is important to clarify that the circumstances leading to the deficiency were significantly impacted by delated and unresponsive actions from the federal agency. Specifically, the Organization submitted required reports and sought timely guidance and approvals from the federal agency, but responses were not received within the federal deadlines. These delays were outside of the Organization’s control and directly affected the timely reconciliation and finalization of reported amounts. Notably, the federal government has acknowledged delayed reports and there were no findings in their FY24 audit. Management will continue to improve internal controls and documentation practices while also documenting all federal communications and follow-up efforts to document the impact of future federal delays. PROPOSED COMPLETION DATE: Implemented and Ongoing

View Audit 402547

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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