Corrective Action Plans

Finding 555487 (2024-015)

Significant Deficiency 2024

Grant County

NM

Reporting Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action This is completed and will be completed again in June 2025. Finding resolution timeline: No later than June 2025. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager

View Audit 354003

Finding 555362 (2024-004)

Significant Deficiency 2024

Micro Entrerprise Services of Oregon

OR

Eligibility Significant Deficiency

Finding # 2024-004 Type: Significant deficiency over eligibility A.L. 14.218 U.S. Department of Housing and Urban Development Significant Deficiency Case file intake forms reviewed did not have documentation of required eligibility requirements for 7 of 35 case files selected. Corrective Action...

Finding # 2024-004 Type: Significant deficiency over eligibility A.L. 14.218 U.S. Department of Housing and Urban Development Significant Deficiency Case file intake forms reviewed did not have documentation of required eligibility requirements for 7 of 35 case files selected. Corrective Action: We were able to substantiate the eligibility of all participants however we agree improvement is needed in providing additional training for onboarding staff on eligibility criteria as well as ensuring onboarding forms are complete and accurate. We will also implement a formal manager review and approval of intake forms which includes validating eligibility criteria have been met. Anticipated Completion Date May 30, 2025

View Audit 353993

Finding 555327 (2024-002)

Significant Deficiency 2024

Serenity House Counseling Services, Inc.

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Procedures for maintaining accurate accounts receivable records will be reinforced, including periodic review. Beginning June 1, 2025, we will implement steps and procedures to eliminate the tardiness of Data Collection in Federal Audit Clearinghouse.

View Audit 353974

Finding 555300 (2024-001)

Significant Deficiency 2024

Zero to Five Montana

MT

Subrecipient Monitoring Procurement, Suspension & Debarment Significant Deficiency

Finding Number 2024-001: Monitoring of Funds Passed to Subrecipient Federal Program ALN: 93.575 Corrective Action Plan: Zero to Five Montana has implemented updated policies and procedures to ensure proper execution and documentation of subrecipient contracts and payments. All contracts are now proc...

Finding Number 2024-001: Monitoring of Funds Passed to Subrecipient Federal Program ALN: 93.575 Corrective Action Plan: Zero to Five Montana has implemented updated policies and procedures to ensure proper execution and documentation of subrecipient contracts and payments. All contracts are now processed and signed via an electronic signing service (e.g., DocuSign) by the Executive Director, with copies securely retained. Prior to disbursing funds, subrecipients with executed contracts are set up as vendors in the expense management system. The subrecipient must complete their vendor profiles and submit tax documentation. Payments are supported by an invoice that includes payment details, expense codes, and grant assignments (if applicable), and must be reviewed and approved by the Program and Operations Directors to confirm all documentation and compliance steps are met. Staff will be trained on these procedures by April 14, 2025, and quarterly audits will be conducted to monitor adherence, with findings reported to leadership and the governing board. Contact Person Responsible for Corrective Action: Caitlin Jensen, Executive Director Anticipated Completion Date: April 14, 2025

View Audit 353940

Finding 555214 (2024-001)

Significant Deficiency 2024

Spartanburg County First Steps to School Readiness Partnership

SC

Reporting Significant Deficiency

Spartanburg County First Steps (SCFS) management acknowledges its responsibility for complying with all applicable state and federal reporting requirements. SCFS maintains a comprehensive fiscal policies and procedures manual that outlines the responsibilities and processes necessary to ensure compl...

Spartanburg County First Steps (SCFS) management acknowledges its responsibility for complying with all applicable state and federal reporting requirements. SCFS maintains a comprehensive fiscal policies and procedures manual that outlines the responsibilities and processes necessary to ensure compliance with all reporting obligations. The late submission of certain federal reports for the 2023-2024 program year was primarily due to challenges associated with the agency's financial management system, Blackbaud. Specifically, the system generated extended wait times for necessary reports, significantly impacting the agency's ability to meet required deadlines. Over the past six months, SCFS has conducted an extensive evaluation of the Blackbaud system and determined that it does not adequately meet the operational needs of SC First Steps offices across the state. As a result, an emergency procurement process has been initiated to procure a new financial management system that will better support timely and accurate reporting. Spartanburg County First Steps is committed to ensuring all future state and federal reporting requirements are completed and submitted accurately and within required deadlines.

View Audit 353836

Finding 555196 (2024-002)

Significant Deficiency 2024

Gratz College

PA

Special Tests & Provisions Subrecipient Monitoring Cash Management

Finding 2024-002 Corrective Action Plan The College reassigned the duties within its business office to ensure remittances to students or parent borrowers of credit balances are executed in accordance with the timeline mandated by the U.S. Department of Education. Gratz College notes that this was ...

Finding 2024-002 Corrective Action Plan The College reassigned the duties within its business office to ensure remittances to students or parent borrowers of credit balances are executed in accordance with the timeline mandated by the U.S. Department of Education. Gratz College notes that this was the only instance of noncompliance and resulted from turnover in Gratz College’s business office staff. Anticipated Completion Date The corrective action plan was completed June 1, 2024 Names of Contact People Responsible for Corrective Action Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Ross Holgado – Manager of Financial Reporting Karen West – Senior Accounting Associate and Coordinator of Student Billing

View Audit 353822

Finding 555176 (2024-002)

Significant Deficiency 2024

Mary Baldwin University

VA

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required ...

2024-002 – Enrollment Reporting (Significant Deficiency) Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: The University did not report student enrollment data to the National Student Clearinghouse accurately and within minimum required timeframe. Criteria: Based on requirements set forth by 34 CFR 685.309(b)(2), the University is responsible for notifying the National Student Loan Data System (NSLDS) to changes to student’s enrollment data within minimum required timeframes. Cause: The University does not have adequate procedures in place to ensure changes in students’ enrollment statuses are identified and reported in a timely manner. Effect: Enrollment data was not reported timely or accurately to the Department of Education thus, the Department could not properly service the student’s loans. The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely enrollment reporting in NSLDS, the enrollment status for one student was not updated after the student was no longer enrolled on at least a half-time basis, and one student’s enrollment status date reported to NSLDS did not agree to date of withdraw reported on the R2T4 form. Repeat Finding: No. Recommendation: We recommend that the University put procedures in place to ensure that student enrollment statuses are updated in a timely manner. Management Response: The University has modified its withdrawal procedures and instructions related to the requirements set forth by 34 CFR 685.309(b)(2). Related to the findings above, due to staffing turnover, the appropriate test of controls needed to identify changes in a student’s enrollment status was not run in a timely manner. Going forward, the University has informed related staff that the aforementioned test of controls needs to be run at the end of each semester, and upon completion, staff must notify the NSLDS within the required timeframe. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285

View Audit 353780

Finding 555175 (2024-001)

Significant Deficiency 2024

Mary Baldwin University

VA

Special Tests & Provisions Student Financial Aid Reporting

2024-001 – Return of Title IV Funds (Significant Deficiency)Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: Return of Title IV funds occurred untimely for three students, exceeding 45 days as required, when considering the University’s ...

2024-001 – Return of Title IV Funds (Significant Deficiency)Department of Education, SFA Cluster; Compliance Requirement Affected – Special Tests and Provisions Condition: Return of Title IV funds occurred untimely for three students, exceeding 45 days as required, when considering the University’s date of determination as reported on R2T4 forms. Criteria: Returns of Title IV funds are required to be deposited or transferred into the SFA account or electronic funds transfers initiated to the Department of Education as soon as possible, but no later than 45 days after the date the institution determines that the student withdrew in accordance with 34 CFR 668.173(b). Cause: The University does not have adequate procedures in place to ensure students’ Title IV funds are returned timely. R2T4 forms improperly reported the date of determination the same as the student withdraw date. Effect: The University failed to return Title IV funds to the Department of Education within 45 days of the students’ date of determination as reported on the R2T4 forms. Context: A sample of nine official and unofficial student withdrawals was selected for audit from a population of 63. The test found three student withdrawals that were not in compliance with timely return of funds. Repeat Finding: No. Recommendation: We recommend that the University implement procedures to ensure that R2T4 forms are filed timely and properly reflect the University’s date of determination for all student withdrawals. Management Response: The University concedes that the R2T4 forms improperly reported the date of determination as the same date reported for the student’s date of withdrawal and the University has modified its withdrawal procedures and processes to reflect separate dates when necessary for date of determination and date of withdrawal. Instructions related to R2T4 requirements and timeliness of return of funds will be triggered from the appropriate date of determination. Related to the findings above, the University failed to accurately report the date of determination on R2T4 documentation, causing the return of funds to be out of the window for timely return. Although the funds were returned in a timely manner, the recordkeeping of the determination date was not documented properly. The University has since clarified for staff the importance of this documentation and change in process. Additionally, the university has identified the appropriate test of controls needed to accurately identify the student withdrawal date. This test of controls will be run at the end of each semester, and upon completion, the date the report is run will be used as the correct date of determination. If the Federal Audit Clearinghouse has questions regarding this plan, please call Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer at (540) 887-7285. Brad Sheriff, PhD, MBA, CMA, Interim Chief Financial Officer, Mary Baldwin University, 540-887-7285

View Audit 353780

Finding 555117 (2024-002)

Significant Deficiency 2024

Maine Guaranteed Access Reinsurance Association

ME

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.328

Finding: 2024-002 Federal Agency Name: U.S. Department of Health and Human Services Assistance Listing Number(s): 93.423 Program Name: 1332 State Innovation Waivers Finding Summary: Recipients of federal funds must submit financial reports as required by the Federal award. Reports submitted annually...

Finding: 2024-002 Federal Agency Name: U.S. Department of Health and Human Services Assistance Listing Number(s): 93.423 Program Name: 1332 State Innovation Waivers Finding Summary: Recipients of federal funds must submit financial reports as required by the Federal award. Reports submitted annually by the recipient must be due no later than 90 calendar days after the reporting period. Reports submitted quarterly or semiannually must be due no later than 30 calendar days after the reporting period, in accordance with CFR § 200.328(c). The Association’s existing controls over their reporting processes, to ensure reports were submitted timely, were not functioning in such a way that ensured reports were submitted on time. Responsible Individuals: Christopher E Howard, General Counsel and Secretary Corrective Action Plan: Management has established a multi-tier calendar control to notify them when reports are due in order to ensure timely filing of all reports. Anticipated Completion Date: Completed April 9, 2025.

View Audit 353712

Finding 554986 (2024-003)

Significant Deficiency 2024

Baptist Health Deaconess Madisonville, Inc.

KY

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding 2024-003 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities All...

Finding 2024-003 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: BHD, LLC calculated their indirect cost rate based on the total grant budget and claimed an equal amount of indirect costs per month instead of calculating the indirect cost rate per direct expenditures for each month. Responsible Individuals: Valarie Howard, Chief Financial Officer Corrective Action Plan: Historically, the indirect cost received by this grant has not been dependent of the direct expenditures. Based on verbal conversations with the HRSA grant project manager, requesting reimbursement for the indirect costs evenly over the year based on the budget submitted was acceptable. Therefore, the accounting treatment has been reflective of that. However, management agrees that recording the indirect cost based on the direct cost expenditures monthly is reasonable and appropriate and will make the change accordingly. Anticipated Completion Date: March 31, 2025.

View Audit 353595

Finding 554967 (2024-004)

Material Weakness 2024

Herron High School, Inc.

IN

Allowable Costs / Cost Principles Significant Deficiency § 200.430

Education Stabilization Fund – AL #84.425 2024-004 Noncompliance – Payroll Allocation Support Significant Deficiency Recommendation: The Auditor recommended the Organization develop internal controls to ensure proper documentation to support the allocation of payroll is maintained. Planned Correctiv...

Education Stabilization Fund – AL #84.425 2024-004 Noncompliance – Payroll Allocation Support Significant Deficiency Recommendation: The Auditor recommended the Organization develop internal controls to ensure proper documentation to support the allocation of payroll is maintained. Planned Corrective Action: Due to personnel changes, the necessary documentation of payroll allocations was not properly maintained. Clear records, with support regarding how amounts were determined for each payroll, shall be documented and matched to accounting files. Michelle Krauter, VP, Chief Financial Officer, will ensure the work performed and corresponding wages applicable to the grant programs is not only within budget but easily identifiable as a proper calculation. www.herronclassical.org Diverse. Tuition-Free. College Prep. If the U.S. Department of Education has questions regarding this plan, please call Michelle Krauter, Vice President, Chief Financial Officer at 317.231.0010

View Audit 353584

Finding 554962 (2024-005)

Significant Deficiency 2024

Thomas More University

KY

Reporting Student Financial Aid Significant Deficiency

Finding 2024-005 Enrollment Reporting: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans, Pell Grants AL #: 84.268, 84.063 Award Year: 2023-2024 Condition: Nine out of eighteen Enrollment Reporting rosters received were returned back after 15 days...

Finding 2024-005 Enrollment Reporting: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans, Pell Grants AL #: 84.268, 84.063 Award Year: 2023-2024 Condition: Nine out of eighteen Enrollment Reporting rosters received were returned back after 15 days. Corrective Action Planned: The late Enrollment Reporting was a result of the significant turnover in the Registrar's office. The University formed an oversight committee outside of the Registrar's office that corrected inaccurate reporting and worked through the backlog to meet reporting requirements. The experienced oversight committee will train the Registrar's office in continuing this timely compliance process for Enrollment Reporting and can backstop if any future personnel turnover or other event could negatively impact timely reporting. Responsible Party: Mark Messingschlager, Director of Financial Aid Anticipated Completion Date: Immediately

View Audit 353567

Finding 554961 (2024-004)

Significant Deficiency 2024

Thomas More University

KY

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2024-004 Notices and Authorizations: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans AL #: 84.268 Award Year: 2023-2024 Condition: The written notifications were not provided to students for the periods October 2, 2023 through October 26...

Finding 2024-004 Notices and Authorizations: (Significant Deficiency) Federal Agency: Department of Education Program: Federal Direct Student Loans AL #: 84.268 Award Year: 2023-2024 Condition: The written notifications were not provided to students for the periods October 2, 2023 through October 26, 2023 and December 19, 2023 through February 9, 2024. Corrective Action Planned: Corrective actions were taken to resolve the automated notification process. Additional failures were discovered, which led to these deficiencies, and subsequent corrections were made to the system. Based on the possibility of future failures in the automatic process, an additional safeguard procedure has been added to the Financial Aid Office at two levels to verify that the required notices are communicated timely. Responsible Party: Mark Messingschlager, Director of Financial Aid Anticipated Completion Date: Immediately

View Audit 353567

Finding 554953 (2024-005)

Material Weakness 2024

Village of Richfield

WI

Questioned Costs Procurement, Suspension & Debarment Eligibility

2024-005 – Coronavirus State and Local Fiscal Recovery Funds – Procurement, Suspended, Debarred – The Village is aware it has not verified contractors eligibility to work on Federally funded projects and will create policies to ensure the Village is compliant going forward. Responsible Official – Ja...

2024-005 – Coronavirus State and Local Fiscal Recovery Funds – Procurement, Suspended, Debarred – The Village is aware it has not verified contractors eligibility to work on Federally funded projects and will create policies to ensure the Village is compliant going forward. Responsible Official – James Healy – Administrator Anticipated Completion Date – The Village intends to work towards resolving this finding in the following year.

View Audit 353554 Questioned Costs: $1

Finding 554946 (2024-002)

Significant Deficiency 2024

Ascentria Community Services, Inc.

MA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: It is recommended that the Organization design controls to ensure expenses are supported by source documentation and allowable...

U.S. Department of Health and Human Services Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: It is recommended that the Organization design controls to ensure expenses are supported by source documentation and allowable costs under the grant or contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is reviewing standard operating procedures with the program staff. All expenses will be supported with source documentation. Management will perform periodic reviews to ensure expenses are supported by source documentation and allowable expenses under the grant. Name(s) of the contact person(s) responsible for corrective action: Christopher Paris Planned completion date for corrective action plan: June 30, 2025

View Audit 353549 Questioned Costs: $1

Finding 554942 (2024-003)

Significant Deficiency 2024

Community Health & Wellness Partners of Logan County

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Reimbursement requests should be reviewed by the CFO for all grants before submission to the grantor ...

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Reimbursement requests should be reviewed by the CFO for all grants before submission to the grantor to ensure that employees charged to the grants are different, in addition, timesheets should be reviewed during the grant reimbursement process to ensure time supports the specific grant and allowable costs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The CFO will review all grant submissions based on personnel costs each month and ensure that there are no duplicate billings and that timesheets appropriately reflect staff involvement. Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025

View Audit 353547 Questioned Costs: $1

Finding 554941 (2024-002)

Significant Deficiency 2024

Community Health & Wellness Partners of Logan County

OH

Special Tests & Provisions Eligibility HUD Housing Programs

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: A test should be performed in the billing software annually when the updated Sliding Fee Discount Sch...

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: A test should be performed in the billing software annually when the updated Sliding Fee Discount Schedule is put into place to ensure that slides are being calculated properly at the effective date of the new schedule. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CHWP will test for irregularities periodically throughout the year Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025.

View Audit 353547

Finding 554940 (2024-001)

Significant Deficiency 2024

Community Health & Wellness Partners of Logan County

OH

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information...

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information is complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CHWP has made enhancements to its financial reporting structure and used this in calculating the UOS data for CY 2024. We believe that we documented the numbers appropriately but will make sure that we continue to comply with this requirement in future UOS reporting, Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025.

View Audit 353547

Finding 554890 (2024-001)

Significant Deficiency 2024

Asian and Pacific Islander Wellness Center, Inc. D/b/a San Francisco Community Health Center

CA

Reporting Subrecipient Monitoring Significant Deficiency

2024‐001 Compliance Over Reporting Asian and Pacific Islander Wellness Center Inc. dba San Francisco Community Health Center [SFCHC] accepts this finding. A new CFO is hired in November 2024 with over 30 years of high‐level nonprofit experience in reporting compliance and finance and business operat...

2024‐001 Compliance Over Reporting Asian and Pacific Islander Wellness Center Inc. dba San Francisco Community Health Center [SFCHC] accepts this finding. A new CFO is hired in November 2024 with over 30 years of high‐level nonprofit experience in reporting compliance and finance and business operations. The new CFO has over 10 years as CFO/COO for two federally qualified health centers and immediately reviewed existing policies and procedures with focus on federal grants and compliance reporting. The next single audit submission for fiscal year ended March 31, 2025, will be submitted to the Federal Audit Clearinghouse [FAC] without delay. We are now planning timeline to commence independent review starting mid‐July. The estimated field audit will be completed by October 15. We are anticipating submission to FAC and other regulatory agencies no later than December 15, 2025, within 9 months from fiscal year [March 31]. At SFCHC, we re‐enforced the centralization of documents and records and secured sensitive information, reviewing access and rights of users to avoid compromising data. We also enabled the ‘attachment’ feature at MIP Fund Accounting. Accounting transactions along with documentation lived in digital files. A compliance calendar is now disseminated quarterly and shared with programs. We will be posting the same to SFCHC intra‐net and will be renewed each quarter. Anticipated Completion Date: At this time, the condition noted by our auditor is now addressed and will be tracked for progress. We are hiring additional staff to support grants and contracts administration, monitoring and reporting compliance. Responsible party: Rosalia Aquino Chief Financial & Compliance Officer April 9, 2025

View Audit 353455

Finding 554818 (2024-002)

Significant Deficiency 2024

Chaska Manor Dba: Talheim

MN

HUD Housing Programs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Monitoring Deposits over FDIC Limits Recommendation: We recommend that management develop procedures to ensure requirements are monitored, documented, and reviewed to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with ...

Monitoring Deposits over FDIC Limits Recommendation: We recommend that management develop procedures to ensure requirements are monitored, documented, and reviewed to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has designed internal controls to ensure deposits held over FDIC limits are monitored quarterly to ensure consistency with the minimally acceptable ratings as established by the Government National Association. Name(s) of contact person(s) responsible for corrective action: Nicole Chwala.

View Audit 353384

Finding 554817 (2024-001)

Significant Deficiency 2024

Chaska Manor Dba: Talheim

MN

Questioned Costs HUD Housing Programs Procurement, Suspension & Debarment

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has developed processes to verify replacement reserve deposits are updated based on the regulatory agreement annually. Name(s) of contact person(s) responsible for corrective action: Nicole Chwala. Planned completion date for corrective action plan: Corrective action has been taken in March 2025.

View Audit 353384 Questioned Costs: $1

Finding 554816 (2024-001)

Significant Deficiency 2024

Trinity Terrace

WI

Questioned Costs HUD Housing Programs Procurement, Suspension & Debarment

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...

Replacement Reserve Deposits Recommendation: We recommend that management develop procedures to ensure replacement reserve deposits are updated timely to ensure compliance with the HUD regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has developed processes to verify replacement reserve deposits are updated based on the regulatory agreement annually. Name(s) of contact person(s) responsible for corrective action: Nicole Chwala. Planned completion date for corrective action plan: Corrective action has been taken in February 2025.

View Audit 353383 Questioned Costs: $1

Finding 554787 (2024-004)

Significant Deficiency 2024

Woodford County, Illinois

IL

Procurement, Suspension & Debarment Significant Deficiency

The County will ensure that businesses are registered and in good standing with SAM.gov prior to entering any contracts over $25,000.

View Audit 353363

Finding 554773 (2024-002)

Significant Deficiency 2024

Nevins Manor, Inc.

MA

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2024‐002 Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Auditors recommend that management implement internal controls to document the monitoring of the financ...

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2024‐002 Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Auditors recommend that management implement internal controls to document the monitoring of the financial institution's rating on a quarterly basis to ensure consistency with the minimally acceptable ratings as established by the Government National Mortgage Association (GNMA) and maintain documentation of the ratings for at least three years. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The management company will begin documenting the financial institutions ratings on a quarterly basis to ensure consistency with the minimally acceptable ratings as established by the Government National Mortgage Association (GNMA and maintain this documentation in the administrative record for three years, including the current year Name(s) of the contact person(s) responsible for corrective action: Alexa Ducote Planned completion date for corrective action plan: March 25, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Alexa Ducote at 857‐221‐8753.

View Audit 353354

Finding 554772 (2024-001)

Significant Deficiency 2024

Nevins Manor, Inc.

MA

Procurement, Suspension & Debarment HUD Housing Programs Significant Deficiency

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2024‐001 Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Auditors recommend that the Organization make the missed deposit to the replacement reserve escrow and ...

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2024‐001 Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Auditors recommend that the Organization make the missed deposit to the replacement reserve escrow and establish internal controls to ensure required replacement reserve deposits are made in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The missed June 2024 replacement reserve deposit was made on March 11, 2025 Name(s) of the contact person(s) responsible for corrective action: Mary Sugrue Planned completion date for corrective action plan: March 25, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Mary Sugrue at 857‐221‐8694.

View Audit 353354

Corrective Action Plans

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