Corrective Action Plans

Finding 1155987 (2025-001)

Material Weakness 2025

RI

Internal Control / Segregation of Duties

United States Department of Housing and Urban Development Saugatucket Springs, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025 Name of Audit Firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place Suite 109 Lincoln, RI 02865 Audit period covered:...

United States Department of Housing and Urban Development Saugatucket Springs, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025 Name of Audit Firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place Suite 109 Lincoln, RI 02865 Audit period covered: 7/1/2024-6/30/2025 The findings from the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: Section 202 Project Rental Assistance—Assistance Listing # 14.157 Recommendation: The Corporation should design and implement internal controls to ensure that all tenant files have proper documentation. Action Taken: Management is in agreement with the auditor’s findings. Management has instructed all accounting personnel to review all matters related to tenant compliance. If the United States Department of Housing and Urban Development has questions regarding this plan, please call Frank Shea at (401) 296-3761.

View Audit 368450

Finding 1155869 (2025-002)

Material Weakness 2025

Charter Township of Clinton

MI

Subrecipient Monitoring Material Weakness

Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made wi...

Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made without completed review of certified payrolls, staff acknowledges records kept did not provide adequate backup to verify these controls. Going forward, staff will not only be sure to keep copies of certified payrolls with related invoices, they will also maintain records that confirm invoices without certified payrolls did not include labor that is subject to Davis-Bacon wage requirements. These records will likely come in the form of detailed invoice cost breakdowns (showing absence of labor costs) or correspondence affirming no labor costs were included in the invoice. Contact person responsible for corrective action: Matthew Wallace Anticipated Completion Date: Immediately

View Audit 368245

Finding 1155864 (2025-001)

Material Weakness 2025

Charter Township of Clinton

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project complet...

Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project completion to ensure that work was carried out in accordance with contract specifications had been implemented effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at both the beginning and end of the project are in the file. Staff has already set up either bi-weekly or monthly meetings (depending on project activity levels) to report on the status of ongoing projects. These meetings were intended to help staff keep current projects in line with the overall project budget (i.e. not obligating funds beyond what’s available). Using these same meetings to check project files for all necessary records will be an adjustment of negligible effort. In instances where there is a sizable gap between portions of a project (e.g. part of the project can’t be completed until spring) staff will consider closing out the completed portion of the project and completing a final inspection on the balance of the job at a later date. Contact person responsible for corrective action: Edwin Manninen, Matthew Wallace Anticipated Completion Date: Immediately

View Audit 368245

Finding 1155838 (2025-003)

Material Weakness 2025

The Trustees of Reservations and Affiliates

MA

Procurement, Suspension & Debarment

Department of Interior Save Americas Treasures Assistance Listing No. 15.929 Recommendation: We recommend the procurement policy be amended to include language that would require compliance with Uniform Guidance suspension/debarment requirements. Explanation of disagreement with audit finding: There...

Department of Interior Save Americas Treasures Assistance Listing No. 15.929 Recommendation: We recommend the procurement policy be amended to include language that would require compliance with Uniform Guidance suspension/debarment requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Suspension/Debarment: We have enhanced our written policies and document retention procedures around suspension/debarment checks, including comprehensive grant kick-off staff training by the Grants and Restricted Funds Manager and a new pre-award check-list to ensure debarment checks are completed prior to procurement. We are also exploring a custom integration with NetSuite's SuiteScript and SAM.gov Exclusions API to continually monitor vendor eligibility. Name(s) of the contact person(s) responsible for corrective action: Brian Therrien, Chief Financial Officer, 617-456-5253

View Audit 368226

Finding 1155837 (2025-002)

Material Weakness 2025

The Trustees of Reservations and Affiliates

MA

Procurement, Suspension & Debarment

Department of Interior Boston Harbor Islands Partnership – World’s End Carriage Road Restoration Assistance Listing No. 15.947 Recommendation: We recommend the procurement policy be amended to include language that would require compliance with Uniform Guidance suspension/debarment requirements. Exp...

Department of Interior Boston Harbor Islands Partnership – World’s End Carriage Road Restoration Assistance Listing No. 15.947 Recommendation: We recommend the procurement policy be amended to include language that would require compliance with Uniform Guidance suspension/debarment requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Suspension/Debarment: We have enhanced our written policies and document retention procedures around suspension/debarment checks, including comprehensive grant kick-off staff training by the Grants and Restricted Funds Manager and a new pre-award check-list to ensure debarment checks are completed prior to procurement. We are also exploring a custom integration with NetSuite's SuiteScript and SAM.gov Exclusions API to continually monitor vendor eligibility. Name(s) of the contact person(s) responsible for corrective action: Brian Therrien, Chief Financial Officer, 617-456-5253

View Audit 368226

Finding 1155836 (2025-001)

Material Weakness 2025

The Trustees of Reservations and Affiliates

MA

Procurement, Suspension & Debarment § 200.320

Department of Interior Boston Harbor Islands Partnership – World’s End Carriage Road Restoration Assistance Listing No. 15.947 Recommendation: We recommend documentation over price or rate quotations be maintained for all vendors with procurements that could potentially exceed the micropurchase thre...

Department of Interior Boston Harbor Islands Partnership – World’s End Carriage Road Restoration Assistance Listing No. 15.947 Recommendation: We recommend documentation over price or rate quotations be maintained for all vendors with procurements that could potentially exceed the micropurchase threshold ($10,000), rather than only those with an original purchase price exceeding $10,000, as the procurement policy is currently written. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Small Purchase Procurement: We have enhanced document retention procedures around small purchase procurement including staff training by the Grants and Restricted Funds Manager and a new pre-award check-list to ensure a minimum of 3 bids/quotes are obtained on any grant-funded purchases or services greater than $10k. We will be utilizing NetSuite's Document Library to manage document retention for grant-related bids and quotes. Name(s) of the contact person(s) responsible for corrective action: Brian Therrien, Chief Financial Officer, 617-456-5253

View Audit 368226

Finding 1155823 (2025-003)

Material Weakness 2025

Gooding Senior Housing Association INC

ID

Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.318

Finding 2025-003 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Procurement Questioned Costs: None Name of contact person and title: Pat Bishop, President Condi...

Finding 2025-003 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Procurement Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The entity has not established or documented a formal procurement policy or procedures to guide the acquisition of goods and services. No written guidelines were provided during the review period. Management Response: Management intends to establish a procurement policy. Status: In progress Anticipated Completion Date: Estimated 2025

View Audit 368214

Finding 1155822 (2025-002)

Material Weakness 2025

Gooding Senior Housing Association INC

ID

Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2025-002 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Special Tests and Provisions Questioned Costs: None Name of contact person and title: Pat Bishop...

Finding 2025-002 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Special Tests and Provisions Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The management did not establish did not establish or maintain required tax and insurance reserve accounts during the fiscal year. These reserves are required under loan and regulatory agreements to ensure funds are available to meet property tax and insurance obligations when due. Management Response: The project will establish reserve accounts for taxes and insurance. Status: In progress Anticipated Completion Date: Estimated 2025

View Audit 368214

Finding 1155821 (2025-001)

Material Weakness 2025

Gooding Senior Housing Association INC

ID

Reporting Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.512

Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...

Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025

View Audit 368214

Finding 1155793 (2025-001)

Material Weakness 2025

Ocracoke Health Center, Inc.

NC

Reporting HUD Housing Programs Equipment & Real Property Management

Management will review its finance infrastructure and the related cost/benefit of hiring additional staff with the required expertise.

View Audit 368201

Finding 1155791 (2025-002)

Material Weakness 2025

Warren Village, Inc.

CO

HUD Housing Programs Internal Control / Segregation of Duties

Cognizant or Oversight Agency for Audit, Warren Village, Inc. respectfully submits the following corrective action plan for the year ended March 31 , 2025. Audit period: Ended March 31 , 2025 The findings from the 3/31/2025 schedule of findings and questioned costs are summarized below. The find ing...

Cognizant or Oversight Agency for Audit, Warren Village, Inc. respectfully submits the following corrective action plan for the year ended March 31 , 2025. Audit period: Ended March 31 , 2025 The findings from the 3/31/2025 schedule of findings and questioned costs are summarized below. The find ings are numbered consistently with the numbers assigned in the schedule. Financial Statement Audit Findings Material Weakness 2025-001: Adjusting Journal Entries Recommendation: Auditors recommend the Organization improve communication with the Partnership and the Partnership auditor to ensure all related Partnership transactions are recorded timely, accurately and within the appropriate period. Action Taken: Management will engage the Partnership auditor earlier in more thorough communication around audited financial statement details and reconciling entries in future years, beginning with the 2025 calendar year audit commencing March 2026. Management was challenged by the one-time, varying construction project and LIHTC partner deliverables, complex legal entity pieces, and shortage of review and financial integration time between audits. Responsible Party: Vice President of Strategy, Finance & Operations Anticipated Date of Completion: June 2026 Responsible Contact: Amy Fleming, 303-320-5050 or email afleming@warrenvillage.org . Federal Award Findings and Questioned Costs Elig ibility, Significant Deficiency 2025-002: U.S. Department of Housing and Urban Development - Section 8 - Housing Assistance Payments Program Assistance Listing No.14.195 Recommendation: Auditors recommend that the Organization confer with Property Management staff to examine selected tenant files from the transition of property management companies through the recertification period of all tenants up to July and August 2025 to ensure appropriate evidence is contained within all tenant files to support complete tenant certification and eligibility. Action Taken: We have discussed with property management a review of all tenant files fromJune 2024 to August 2025 and requested a third-party compliance company or equivalent experience be engaged. Corrections will be made where feasible along with ongoing process improvements, including the implementation of a new internal Housing Director position to provide greater oversight of files and property management accountability. The Housing Director was hired July 21, 2025, with a target date set of December 31, 2025, for completed file review. Responsible Party: Housing Director, Vice President of Strategy, Finance & Operations and Property Management (Rocky Mountain Communities) Anticipated Date of Completion: January 2026 Responsible Contact: Amy Fleming, 303-320-5050 or email afleming@warrenvillage.org If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Amy Fleming, Vice President of Strategy, Finance & Operations at 303-320-5050 or email at afleming@warrenvillage.org.

View Audit 368188

Finding 1155767 (2025-001)

Material Weakness 2025

Central Park Senior Residences, Inc.

KS

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the securi...

Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the security deposit cash account to the former tenant. Action(s) taken or planned on the finding: The management agent refunded $407 to the former tenant on August 25, 2025.

View Audit 368134 Questioned Costs: $1

Finding 1155765 (2025-001)

Material Weakness 2025

Southern Hills Senior Residences, Inc.

KS

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent will ...

Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent will reimburse $3,118 to the Corporation.

View Audit 368133 Questioned Costs: $1

Finding 1155715 (2025-001)

Material Weakness 2025

National Crime Victim Law Institute

OR

Cash Management Internal Control / Segregation of Duties

National Crime Victim Law Institute (NCVLI) recognizes and agrees with the recommendation to reconcile contract billings to the accounting records and a closer in time review of the reconciliation before invoicing the government agency. While NCVLI has historically done this type of reconciliation, ...

National Crime Victim Law Institute (NCVLI) recognizes and agrees with the recommendation to reconcile contract billings to the accounting records and a closer in time review of the reconciliation before invoicing the government agency. While NCVLI has historically done this type of reconciliation, during this particular year where a confluence of events made the year-end more challenging (e.g., quarterly contract billings that straddle two fiscal years, loss of staffing and accounting contractor due to budget cuts, delayed reconciliation with Lewis & Clark College due to Lewis & Clark’s processes which serves as a bank account for NCVLI), we agree the process becomes even more critical. NCVLI agrees that costs charged to federal awards should be supported by the accounting records and has historically ensured this happened. We will, however, further improve internal processes to enhance accuracy of tracking, comparing and reviewing billings and expenses to mitigate the chance of this happening in the future. Notably, this error was fixed immediately by adjusting the next monthly billing for June 2025.

View Audit 368000

Finding 1155657 (2025-006)

Material Weakness 2025

Charter Township of Redford

MI

Subrecipient Monitoring Reporting Material Weakness

Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contac...

Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026

View Audit 367921

Finding 1155654 (2025-005)

Material Weakness 2025

Charter Township of Redford

MI

Matching / Level of Effort / Earmarking Cash Management Material Weakness § 200.303

Finding Number: 2025-005 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corre...

Finding Number: 2025-005 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corrective Action: The Township will update the Grant Policy to include a requirement for dual review on all grant reporting. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026

View Audit 367921

Finding 1155653 (2025-004)

Material Weakness 2025

Charter Township of Redford

MI

Procurement, Suspension & Debarment

Finding Number: 2025-004 Condition: The Township did not have a control in place to retain evidence that it performed a check to verify the contractors used under these programs were not suspended or debarred. Planned Corrective Action: The Township will put controls in place around retaining suppor...

Finding Number: 2025-004 Condition: The Township did not have a control in place to retain evidence that it performed a check to verify the contractors used under these programs were not suspended or debarred. Planned Corrective Action: The Township will put controls in place around retaining support for suspension and debarment verifications. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026

View Audit 367921

Finding 1155472 (2025-002)

Material Weakness 2025

Village of Decatur

MI

Procurement, Suspension & Debarment Subrecipient Monitoring

Management drafted an updated procurement policy to comply with the requirements of the Uniform Guidance, which was approved by the Village Council at a special meeting on June 23, 2025.

View Audit 367758

Finding 1155379 (2025-001)

Material Weakness 2025

Pineview, Inc.

IN

Questioned Costs

The Project deposited $272 into the reserve for replacement account.

View Audit 367628 Questioned Costs: $1

Finding 1155378 (2025-001)

Material Weakness 2025

Mapleview, Inc.

IN

Questioned Costs

The Project deposited $3,150 into the reserve for replacement account.

View Audit 367626 Questioned Costs: $1

Finding 1155368 (2025-001)

Material Weakness 2025

Milwaukee Health Services, Inc.

WI

Special Tests & Provisions

Milwaukee Health Services, Inc. (the "Organization") submits the following corrective action plan for the identified finding and questioned costs for the year ending January 31, 2025. Finding 2025-001: Special Tests and Provisions - Sliding Fees Statement of Condition: External auditors reviewed 40 ...

Milwaukee Health Services, Inc. (the "Organization") submits the following corrective action plan for the identified finding and questioned costs for the year ending January 31, 2025. Finding 2025-001: Special Tests and Provisions - Sliding Fees Statement of Condition: External auditors reviewed 40 sliding fee transactions to verify if the amount charged under the Organization's sliding fee program was calculated properly based on the patient's income level and in compliance with the Organization's sliding fee policy. External auditors noted that two ofthe sampled transactions were not properly determined resulting in the patients being over or undercharged for services. Corrective Action: The Organization will review its sliding fee policies and monitor determinations. Staff responsible for sliding fee determinations will be trained on properly computing sliding fees. The Organization will also review the system controls and safeguards within OCHIN Epic (Electronic Health Record) for assisting in sliding fee calculation accuracy. Person Responsible for Corrective Action: Joyce Nwatuobi, Chief Financial Officer Anticipated Timing for Completion of Corrective Action: November 30, 2025.

View Audit 367610

Finding 1155343 (2025-002)

Material Weakness 2025

Pioneer Apartments INC

WY

Questioned Costs Cash Management Material Weakness

Finding 2025-002 See response to finding 2025-001.

View Audit 367580 Questioned Costs: $1

Finding 1154987 (2025-001)

Material Weakness 2025

Community Health Centers of Central Wyoming, Inc.

WY

Special Tests & Provisions Material Weakness Significant Deficiency

2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the sta...

2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the staff on the form, and process to review each application to ensure compliance with the approved policy. The following actions will be taken: 1. Develop a formal peer review form and process for reviewing sliding fee scale applications. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 11, 2025 2. Provide training to all billing staff for peer review process and forms. Implementation of the process after training. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 12, 2025 and September 1, 2025 3. Monitor for effectiveness. After completion of peer review, the two managers will review and provide feedback to each employee monthly. Billing staff will be responsible for completing reviews and feedback on process and form structure. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: September 18, 2025 4. Verify effectiveness. The CFO and Revenue Cycle Manager will conduct a random audit of the peer review forms and ensure compliance with the policy for slide applications and ensure the peer review forms are completed, signed and dated. Anticipated completion date: March 1, 2026 Contact person responsible for corrective action: Evan Condelario, CFO

View Audit 367336

Finding 1154962 (2025-004)

Material Weakness 2025

Miami-Cass County Rural Electric Membership Corporation

IN

Questioned Costs Eligibility

Management of Miami-Cass REMC and Subsidiary will implement procedures to prevent unallowable costs. In addition, the State of Indiana Office of Community and Rural Affairs will be alerted of the questioned costs. Management agrees with this finding.

View Audit 367301 Questioned Costs: $1

Finding 1154961 (2025-003)

Material Weakness 2025

Miami-Cass County Rural Electric Membership Corporation

IN

Management of Miami-Cass REMC and Subsidiary was aware of lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate duties at this time. Management Agrees with the findings.

View Audit 367301

Corrective Action Plans

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