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Corrective Action Plans

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Finding 1154960 (2025-002)
Material Weakness 2025
Miami-Cass County Rural Electric Membership Corporation
IN
Management of Miami-Cass REMC and Subsidiary will implement procedures to monitor and review accounts throughout the year. Management agrees with the findings.
Management of Miami-Cass REMC and Subsidiary will implement procedures to monitor and review accounts throughout the year. Management agrees with the findings.
View Audit 367301
Finding 1154959 (2025-001)
Material Weakness 2025
Miami-Cass County Rural Electric Membership Corporation
IN
Procurement, Suspension & Debarment Subrecipient Monitoring
Management of Miami-Cass REMC and Subsidiary will properly adhere to its written policy that governs the process for the procurement of materials and services in the future and add additional monitoring to prevent future error. Management agrees with the findings.
Management of Miami-Cass REMC and Subsidiary will properly adhere to its written policy that governs the process for the procurement of materials and services in the future and add additional monitoring to prevent future error. Management agrees with the findings.
View Audit 367301
Finding 1153882 (2025-003)
Material Weakness 2025
Housing Authority of the City of Trinidad
CO
HUD Housing Programs Matching / Level of Effort / Earmarking
2025-002. HUD Project loan made to other HUD Programs Corrective action planned: Trinidad Housing Authority is searching for other Accounting Services for the Housing Authority. We are currently working on a payment plan with payroll for Corazon Square and have started processing payments to Low Ren...
2025-002. HUD Project loan made to other HUD Programs Corrective action planned: Trinidad Housing Authority is searching for other Accounting Services for the Housing Authority. We are currently working on a payment plan with payroll for Corazon Square and have started processing payments to Low Rent. As we are moving forward in our search for accounting services, we will continue to pay equal amounts monthly to Low Rent. Contact person: Kathee Gutierrez Adams, Interim Executive Director. Anticipated completion date: Our goal is to be completely in compliance by end of fiscal year March 31, 2026.
View Audit 366945
Finding 1153768 (2025-003)
Material Weakness 2025
Housing Authority of the City of Meadville
PA
HUD Housing Programs Allowable Costs / Cost Principles Cash Management
HACM Management will sign all Capital Fund vouchers going forward.
HACM Management will sign all Capital Fund vouchers going forward.
View Audit 366863
Finding 1153764 (2025-001)
Material Weakness 2025
Foothills Community Health Care, Inc.
SC
Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties
In Finding 2025-001, it was reported that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing. In addition, one patient ...
In Finding 2025-001, it was reported that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing. In addition, one patient who qualified for a discount did not receive a discount. Management recognizes the importance of complying with federal sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, procedures will be established to ensure employees are trained to maintain the required documentation, including sliding fee applications, for sliding fee discounts provided. The Organization will establish procedures to ensure that selected patient records are reviewed by a supervisor on a periodic basis to ensure that the required documentation is properly maintained and that the patients receive the proper discount in accordance with the Organization’s policies.
View Audit 366861
Finding 1153703 (2025-001)
Material Weakness 2025
Gardner Commons Development Corporation
ME
Reporting § 200.512
View of Responsible Official and Corrective Action The delay in the submission of the Data Collection Form was a direct result of the audit team moving to a new accounting firm and a miscommunication as to which firm was going to assist with the completion of the Data Collection Form. Management has...
View of Responsible Official and Corrective Action The delay in the submission of the Data Collection Form was a direct result of the audit team moving to a new accounting firm and a miscommunication as to which firm was going to assist with the completion of the Data Collection Form. Management has taken steps to ensure that the Data Collection Form for the year-ended June 30, 2025 will be submitted timely. Upon identifying the late submission, management immediately completed the submission of the 2024 Data Collection Form and reporting package on August 12, 2025.
View Audit 366840
Finding 1153477 (2025-002)
Material Weakness 2025
The Corporation of Gonzaga University
WA
Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking
FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported wit...
FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported within the federally required timeframe. Strengthening this process will support the timeliness of federal compliance. Response: There is no disagreement with this audit finding. Action taken in response to finding: Some of the corrective actions noted in our response to finding 2025-001 also apply here. For example, quality assurance reports to identify students who withdraw from all classes in a part of term and the upcoming joint training and process mapping session with Student Financial Services and the Registrar’s Office will strengthen understanding of how enrollment status updates drive downstream compliance, including R2T4 processing. These steps will also ensure exceptions are addressed consistently and that communication channels between offices are clear. To address immediate gaps specific to R2T4 compliance, the Registrar’s Office has enhanced training regarding R2T4 compliance requirements related to recording withdrawals and enrollment changes in a timely, accurate and consistent manner. Additional quality checks are being implemented to confirm that withdrawal dates and status changes are entered accurately into the student information system so that R2T4 calculations are completed within federal timeframes. Together, these interventions are designed to ensure the timeliness and accuracy of R2T4 processing and compliance with federal requirements. We expect to have these corrective actions completed by September 12, 2025. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research
View Audit 366726
Finding 1153470 (2025-001)
Material Weakness 2025
The Corporation of Gonzaga University
WA
Student Financial Aid Special Tests & Provisions Reporting
FINDING 2025‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a reconciliation between the system of record and the reporting system to ensure all student changes (enrollment status an...
FINDING 2025‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a reconciliation between the system of record and the reporting system to ensure all student changes (enrollment status and address changes) are reported on a timely basis. Response: There is no disagreement with this audit finding. Action taken in response to finding: Gonzaga has already taken action and implemented quality assurance reports and monitoring to ensure all student changes (enrollment status and address changes) are reported timely. Additionally, to strengthen compliance going forward, Student Financial Services and the Registrar’s Office are partnering to conduct a joint annual training and process mapping session for key personnel. This session will provide an overview of enrollment reporting requirements, outline the steps needed when exceptions to normal policies occur, and evaluate processes to improve understanding of how decisions affect both upstream and downstream functions. The session will also focus on building a shared understanding of reporting processes, identifying gaps in procedures and knowledge, and establishing communication channels so that exceptions are addressed timely, consistently and appropriately. These actions are designed to enhance internal controls and ensure compliance of timely reporting between the system of record and the reporting system, and we expect to complete this training by September 12, 2025. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research
View Audit 366726
Finding 1153460 (2025-003)
Material Weakness 2025
Cheboygan Housing Commission
MI
Internal Control / Segregation of Duties
The current Occupancy Specialist is developing a training and implementation plan to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that HQS inspections are pe...
The current Occupancy Specialist is developing a training and implementation plan to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements.
View Audit 366709
Finding 1153459 (2025-002)
Material Weakness 2025
Cheboygan Housing Commission
MI
HUD Housing Programs Internal Control / Segregation of Duties
The current Occupancy Specialist is developing a training and implementation plan to ensure that rent reasonableness calculations are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenan...
The current Occupancy Specialist is developing a training and implementation plan to ensure that rent reasonableness calculations are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of rent reasonableness calculations and other required paperwork is included in the tenant files.
View Audit 366709
Finding 1153458 (2025-001)
Material Weakness 2025
Cheboygan Housing Commission
MI
HUD Housing Programs Internal Control / Segregation of Duties
The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant ...
The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of income from tenants and other required paperwork is included in the tenant files.
View Audit 366709
Finding 1153433 (2025-001)
Material Weakness 2025
Blue Ridge Rural Water CO INC
SC
HUD Housing Programs
The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.
The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.
View Audit 366673
Finding 1153310 (2025-002)
Material Weakness 2025
Mountain Famly Health Centers
CO
Questioned Costs Subrecipient Monitoring Eligibility
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.
View Audit 366550 Questioned Costs: $1
Finding 1153268 (2025-001)
Material Weakness 2025
B.r.l Housing Corporation
OH
HUD Housing Programs Reporting Special Tests & Provisions
Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the f...
Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the full amount was deposited, the delay constituted noncompliance with HUD's timing rules. To address this, management will implement procedures to ensure surplus cash deposits are made within 60 days based on unaudited computations, track and schedule deposits in advance, formally request HUD approval if deferrals are necessary, and maintain documentation of all related communications and approvals for compliance purposes. Actions Taken or Planned on the Findings: This was paid on check # 9841 Working on an implementation program for the future. Completion Date: August 25, 2025 Finding Resolution Status: In-Process Contact Person: Controller: Don Trigg Accountant: Charley Hinkle
View Audit 366462
Finding 1153168 (2025-005)
Material Weakness 2025
Outpatient Medical Center, Inc.
LA
Procurement, Suspension & Debarment § 200.214
2025-005 Suspension and Debarment Corrective action planned: OMC currently has a policy and procedure for vendor exclusion checks prior to executing contracts. This finding appears to be an incidental omission that resulted in no excluded vendors being identified. In one case, the vendor was an exis...
2025-005 Suspension and Debarment Corrective action planned: OMC currently has a policy and procedure for vendor exclusion checks prior to executing contracts. This finding appears to be an incidental omission that resulted in no excluded vendors being identified. In one case, the vendor was an existing one for many years. The CFO/Designee will monitor to assure exclusion checks prior to CEO signing any contracts or purchase orders with any vendor over $25,000 per year and will update policy as necessary in accordance with regulations. OMC will seek HRSA guidance on periodic review of existing vendors Anticipated completion date: September 30, 2025 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393
Finding 1153166 (2025-004)
Material Weakness 2025
Outpatient Medical Center, Inc.
LA
Cash Management Subrecipient Monitoring Material Weakness § 200.305
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures...
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures claimed for reimbursement and retains this documentation along with supporting invoices. A qualified, knowledgeable CFO will continue to ensure compliance with these requirements. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393
Finding 1153164 (2025-003)
Material Weakness 2025
Outpatient Medical Center, Inc.
LA
Questioned Costs Allowable Costs / Cost Principles § 200.403
2025-003 Period of Performance (repeat of finding 2024-005) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will monitor expenses, and a separate prepaid schedule ha...
2025-003 Period of Performance (repeat of finding 2024-005) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will monitor expenses, and a separate prepaid schedule has been developed to track future period expenses. OMC’s current CFO/Designee has a basic understanding of GAAP. All coding will be reviewed and approved by an authorized, knowledgeable CFO/Designee. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393 Questioned Costs: $1
Finding 1153162 (2025-002)
Material Weakness 2025
Outpatient Medical Center, Inc.
LA
Questioned Costs Allowable Costs / Cost Principles
2025-002 Allowable Costs/Cost Principles (repeat of finding 2024-004) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will continue to monitor to assure compliance w...
2025-002 Allowable Costs/Cost Principles (repeat of finding 2024-004) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective actions. The CFO/Designee will continue to monitor to assure compliance with documentation for all federal expenditures, whether payroll or procurement transactions. All supporting documentation is currently being retained electronically and linked to the corresponding transaction in the financial system. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
View Audit 366393 Questioned Costs: $1
Finding 1152940 (2025-001)
Material Weakness 2025
Community Workshop Residentials, INC G / Fha Project No. 072-Hd057
IL
Internal Control / Segregation of Duties HUD Housing Programs
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.
View Audit 366276
Finding 1152930 (2025-002)
Material Weakness 2025
Village of Shepherd
MI
Procurement, Suspension & Debarment
Management is in the process of drafting an updated procurement policy to comply with the new requirements of the Uniform Guidance.
Management is in the process of drafting an updated procurement policy to comply with the new requirements of the Uniform Guidance.
View Audit 366266
Finding 576208 (2025-001)
Material Weakness 2025
Freedom First Federal Credit Union
VA
Material Weakness Period of Performance Reporting
Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.
Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.
View Audit 366124
Finding 576159 (2025-001)
Material Weakness 2025
Sunrise Community Health
CO
Subrecipient Monitoring Internal Control / Segregation of Duties
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fe...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Management meetings will be scheduled with the COO, Director of Operations, and Dental Billing Supervisor(s) to provide updates on progress. Periodic internal auditing of sliding fee scale dental files will be completed. Quarterly management review of sliding fee scale program progress until Athena Dental is fully integrated with Athena Medical, where electronic health record issues were not detected regarding sliding fee scale adjustments. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kevin Maddox, CFO, at 636-236-5180
View Audit 366069
Finding 576151 (2025-006)
Significant Deficiency 2025
Community Action of Southern Indiana
IN
Reporting
The Agency acknowledges this error and agrees with the recommendations. With the completion of this audit, the Agency will be caught up after completing four audits in an 18 month time period. This current audit will be submitted by the required deadline and the next regular audit is scheduled to be...
The Agency acknowledges this error and agrees with the recommendations. With the completion of this audit, the Agency will be caught up after completing four audits in an 18 month time period. This current audit will be submitted by the required deadline and the next regular audit is scheduled to begin shortly after the close of FY 25-26.
View Audit 366061
Finding 576149 (2025-005)
Material Weakness 2025
Community Action of Southern Indiana
IN
Reporting
The Agency acknowledges this error and agrees with the recommendations. It is the Agency's opinion that this finding is a direct outcome of the reconciliation issues outlined in Findings 001-003. As those deficiencies are addressed systemically, the accuracy of SF-425 reports will be restored and ma...
The Agency acknowledges this error and agrees with the recommendations. It is the Agency's opinion that this finding is a direct outcome of the reconciliation issues outlined in Findings 001-003. As those deficiencies are addressed systemically, the accuracy of SF-425 reports will be restored and maintained.
View Audit 366061
Finding 576147 (2025-004)
Material Weakness 2025
Community Action of Southern Indiana
IN
Internal Control / Segregation of Duties Equipment & Real Property Management Procurement, Suspension & Debarment
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that the referenced actions took place in 2020, more than four years before the current audit period. This issue is not reflective of CASI's current internal control environment and doe...
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that the referenced actions took place in 2020, more than four years before the current audit period. This issue is not reflective of CASI's current internal control environment and does not represent an active or ongoing failure. This was an isolated instance resulting from the actions of a previous administration, whose financial and compliance oversight practices have since been fully overhauled.Since then, CASI has undergone significant changes in staff and Board leadership, financial controls, and Head Start compliance procedures, which directly mitigate any recurrence of this issue. The current leadership bas self-disclosed the issue and is actively working to resolve it. This matter was voluntarily identified and disclosed by current leadership to both the auditors and the Head Start Regional Office. Efforts are ongoing to correct the SF-429 and properly record a Notice of Federal Interest in collaboration with OHS, despite delays resulting from the broader federal restructuring of the Head Start regional offices.
View Audit 366061
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