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Corrective Action Plans

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Finding 1156382 (2024-002)
Material Weakness 2024
Minot Housing Authority
ND
HUD Housing Programs
Contact Person Tom Alexander, Executive Director Corrective Action Plan The Authority will be more diligent in completing HAP contracts when required, as well as all other required information. Completion Date Effective immediately
Contact Person Tom Alexander, Executive Director Corrective Action Plan The Authority will be more diligent in completing HAP contracts when required, as well as all other required information. Completion Date Effective immediately
View Audit 368699
Finding 1156380 (2024-005)
Material Weakness 2024
9/11 Day
CA
Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303 § 200.332
The subgrantees in question were Boys & Girls Clubs of America, National Youth Service League, Young Men’s Service League, and Boise State. 9/11 Day researched all subgrantees, required each to provide MOUs, program details, and budgets, and verified organizational status using resources such as Can...
The subgrantees in question were Boys & Girls Clubs of America, National Youth Service League, Young Men’s Service League, and Boise State. 9/11 Day researched all subgrantees, required each to provide MOUs, program details, and budgets, and verified organizational status using resources such as Candid and Charity Navigator. Financial statements were also reviewed, but documentation of these reviews and verifications was not consistently retained, and certain federal requirements were not fully incorporated into the process. 9/11 Day has now adopted a written policy that ensures that, in its role as a pass-through entity, all subgrants will be made in full compliance with the minimum required elements found under 2 CFR 200.332(b). This shall include implementing a comprehensive tracking and monitoring system for all subgrantees, regardless of funding level, with enhanced verification requirements for those receiving over $30,000. All subaward agreements will be updated to include the minimum required elements under 2 CFR 200.332(b), and the evaluation of subgrantee risk will incorporate all suggested elements under 2 CFR 200.332(c), including consideration of fraud risk and risk of noncompliance. The system will record the time and date of all eligibility verifications and retain supporting documentation, including MOUs, SAM.gov confirmation of suspension and debarment status, IRS Form 990s, financial statements, and audit confirmations. In compliance with 2 CFR 200.332(e)(1), subgrantees will now be required to submit both performance and financial reports, which will be reviewed and compared against project budgets. In addition, 9/11 Day will evaluate subgrantees’ Single Audits, if filed, in accordance with 2 CFR 200.332(e)(2)–(4) and will review any reported deficiencies. All monitoring activities will be documented and logged throughout the life of each project to ensure stronger oversight, complete documentation, and compliance with federal requirements.
View Audit 368692
Finding 1156379 (2024-004)
Material Weakness 2024
9/11 Day
CA
Questioned Costs Subrecipient Monitoring Reporting § 200.303 § 200.328 § 200.329
In 2024, 9/11 Day was unaware of this regulation, but agrees with this finding. 9/11 Day has adopted a written policy that shall ensure that all subgrants made are properly compliant with the Federal Funding Accountability and Transparency Act of 2006 (FFATA). All subgrantees will be entered into a ...
In 2024, 9/11 Day was unaware of this regulation, but agrees with this finding. 9/11 Day has adopted a written policy that shall ensure that all subgrants made are properly compliant with the Federal Funding Accountability and Transparency Act of 2006 (FFATA). All subgrantees will be entered into a centralized tracking log, and for those receiving pass-through funds exceeding $30,000, the required reporting will be completed directly in SAM.gov, which now includes the Federal Subaward Reporting System (FSRS). Each subgrantee’s eligibility will be verified in SAM.gov, with the date and results of the verification recorded, and all supporting documentation retained on file. This corrective action ensures that all subawards are properly logged, reported, and compliant with FFATA requirements.
View Audit 368692 Questioned Costs: $1
Finding 1156378 (2024-003)
Material Weakness 2024
9/11 Day
CA
Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.318 § 200.327
Following the close of the 2023 audit in October 2024, 9/11 Day implemented a strengthened procurement process for all large vendors, including the adoption of a formal procurement policy that complies with federal guidelines. A vendor log and checklist system has been established to document the re...
Following the close of the 2023 audit in October 2024, 9/11 Day implemented a strengthened procurement process for all large vendors, including the adoption of a formal procurement policy that complies with federal guidelines. A vendor log and checklist system has been established to document the receipt of RFPs, the rationale and method of procurement, and decisions on whether to move forward with a vendor. Although 9/11 Day has, and does verify whether vendors and subgrantees are permitted to receive federal funds, we have now updated our policy to retain printed verification of each vendor’s/subgrantee’s eligibility to receive federal funds, including confirmation that these organizations are not suspended or debarred. These documents will be retained in the procurement file for each vendor/subgrantee. These steps ensure compliance with 2 CFR 200.318 and provide clear documentation and oversight for all procurement activities.
View Audit 368692
Finding 1156376 (2024-002)
Material Weakness 2024
Soundview Senior Hdfc
NY
HUD Housing Programs
The above finding is the result of two missed rent schedules not being processed. It will be corrected with the execution of an approved repayment plan with HUD.
The above finding is the result of two missed rent schedules not being processed. It will be corrected with the execution of an approved repayment plan with HUD.
View Audit 368685
Finding 1156375 (2024-001)
Material Weakness 2024
Soundview Senior Hdfc
NY
HUD Housing Programs
As suggested, HUD will be approached for approval to apply the 2022 excess payment of 6K to the 2023 underpayment of 6K. in the unlikely event approval is denied, the shortage will be satisfied within 30 days from denial.
As suggested, HUD will be approached for approval to apply the 2022 excess payment of 6K to the 2023 underpayment of 6K. in the unlikely event approval is denied, the shortage will be satisfied within 30 days from denial.
View Audit 368685
Finding 1156372 (2024-002)
Material Weakness 2024
Trempealeau County
WI
Reporting Significant Deficiency
Trempealeau County, being a small county, has limited resources in personnel to accomplish a multi-verification in the reporting process. We will use additional current employees in house to do the verification to make sure the reporting is accurate before submitting. Responsible Person: Mary Martin...
Trempealeau County, being a small county, has limited resources in personnel to accomplish a multi-verification in the reporting process. We will use additional current employees in house to do the verification to make sure the reporting is accurate before submitting. Responsible Person: Mary Martin, County Clerk Anticipated Completion Date: We will attempt to begin the multiple verification process for the 2025 calendar year
View Audit 368678
Finding 1156370 (2024-001)
Material Weakness 2024
Ucc Xxiii, Inc. D/b/a Boardtown Village
OH
HUD Housing Programs Procurement, Suspension & Debarment Reporting
The security deposit was refunded to the tenant on the 78th day subsequent to their move-out. Management has taken measures to improve internal controls over compliance related to tenant security deposit refunds.
The security deposit was refunded to the tenant on the 78th day subsequent to their move-out. Management has taken measures to improve internal controls over compliance related to tenant security deposit refunds.
View Audit 368672
Finding 1156369 (2024-001)
Material Weakness 2024
Dallas County
MO
The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.
The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.
View Audit 368662
Finding 1156359 (2024-001)
Material Weakness 2024
City of Seattle
WA
Subrecipient Monitoring
Human Services Department (HSD) HSD acknowledges this finding. While the Department successfully tracked, collected, reviewed, and issued management decision letters to its subrecipients as a standard practice. In this instance a formal management decision was missed for this specific sub-recipient ...
Human Services Department (HSD) HSD acknowledges this finding. While the Department successfully tracked, collected, reviewed, and issued management decision letters to its subrecipients as a standard practice. In this instance a formal management decision was missed for this specific sub-recipient during the review period. The Department has taken corrective measures to strengthen its compliance process, clarify roles and responsibilities to ensure timely completion of this requirement. Office of Economic Development (OED) OED acknowledges this finding. OED intends to take corrective measures through strengthening internal controls over subrecipient single audit monitoring: • Including a step in our internal monitoring processes to document when Program Managers pull and review single audits with federally funded partners • Retaining a monitoring workbook to track and date collection of single audit reports Office of Housing (OH) • OH acknowledges that neither a review of applicable audits nor management decision was sent to subrecipients who had audit findings. OH staff will evaluate its current policies to determine the best way to identify, review and follow-up on any subrecipient audits that may include findings. This review will include appropriate written follow up on actions OH recommends the subrecipient to take to correct the finding(s).
View Audit 368642
Finding 1156356 (2024-002)
Material Weakness 2024
City of Seattle
WA
Subrecipient Monitoring Reporting
The Human Services Department (HSD) acknowledges this finding regarding the late submission of five FFATA reports and inaccuracies in CAPER reporting. These issues arose during a period of prolonged vacancies and while staff were in the process of being trained on reporting requirements, which reduc...
The Human Services Department (HSD) acknowledges this finding regarding the late submission of five FFATA reports and inaccuracies in CAPER reporting. These issues arose during a period of prolonged vacancies and while staff were in the process of being trained on reporting requirements, which reduced oversight capacity and contributed to delays and errors. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) Manager to provide consistent leadership and supervision. HSD updated department-wide FFATA Reporting Policies and Procedures following the federal transition to SAM.gov. Staff completed federal training, and prior reports were reviewed and corrected. The Department implemented controls to close workflow gaps to ensure obligations and data corrections are captured before submission. Additionally, ongoing training is being provided to reinforce compliance. These actions strengthen internal controls and are intended to ensure FFATA and CAPER reports are accurate, complete, and submitted in a timely manner moving forward.
View Audit 368642
Finding 1156352 (2024-003)
Material Weakness 2024
City of Seattle
WA
Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs
The City acknowledges that it did not close out or document the HQS deficiencies discovered as part of this audit. In recognition of continued growth of the OH housing portfolio, including HOME Program assisted projects, and OH’s capacity to maintain its inspection compliance, OH is in process of co...
The City acknowledges that it did not close out or document the HQS deficiencies discovered as part of this audit. In recognition of continued growth of the OH housing portfolio, including HOME Program assisted projects, and OH’s capacity to maintain its inspection compliance, OH is in process of contracting with a third-party vendor to complete its annual inspections, including HOME inspections for 2025. The contractor will inspect HUD’s NSPIRE level. With this additional support, OH anticipates it will have the capacity to see that corrections have been completed and documented consistent with the HOME program requirements.
View Audit 368642
Finding 1156346 (2024-004)
Material Weakness 2024
City of Seattle
WA
Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
The Department acknowledges this finding. The overage occurred following a period of prolonged vacancy in the contract specialist position and while newly assigned staff were still receiving training. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) M...
The Department acknowledges this finding. The overage occurred following a period of prolonged vacancy in the contract specialist position and while newly assigned staff were still receiving training. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) Manager to provide consistent leadership and supervision. The contract specialist receives structured management oversight and ongoing training to strengthen capacity for accurate budget monitoring. In July 2025, the FGMU updated its ESG policies and procedures to incorporate improved controls for earmarking. In addition, the Department has instituted regular training sessions for all staff responsible for federal grant management to reinforce compliance with earmarking and other federal requirements. These corrective actions are designed to strengthen internal controls, provide clearer oversight, and ensure that future expenditures remain within established budget and earmarking limits.
View Audit 368642
Finding 1156342 (2024-004)
Material Weakness 2024
Housing Authority of Racine County
WI
HUD Housing Programs Significant Deficiency
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
View Audit 368641
Finding 1156341 (2024-003)
Material Weakness 2024
Housing Authority of Racine County
WI
HUD Housing Programs Significant Deficiency
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
View Audit 368641
Finding 1156340 (2024-002)
Material Weakness 2024
Housing Authority of Racine County
WI
HUD Housing Programs Significant Deficiency
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the ...
Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been updated along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
View Audit 368641
Finding 1156339 (2024-001)
Material Weakness 2024
Housing Authority of Racine County
WI
HUD Housing Programs Eligibility Significant Deficiency
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanat...
Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review its system of internal control related to the policies and procedures in place to mitigate the risk of noncompliance with the requirements of the stated criteria. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PHA identified weaknesses in a new operating model, and has continued to fine-tune tracking and transparencies towards improved compliance. SEMAP reports are pulled monthly, and internal file audits are being conducted. Standard operating procedures have been created along with file checklists to ensure files are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Katie Kasprzak, Executive Director Planned completion date for corrective action plan: 12/31/2025
View Audit 368641
Finding 1156338 (2024-001)
Material Weakness 2024
Walden Oaks Apartments Preservation 071-11262
ID
HUD Housing Programs
The financial statements shall be submitted to HUD once finalized.
The financial statements shall be submitted to HUD once finalized.
View Audit 368639
Finding 1156336 (2024-002)
Material Weakness 2024
Colorado Village Collaborative
CO
Questioned Costs Allowable Costs / Cost Principles Material Weakness
Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Cont...
Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Control over Compliance Criteria and Condition: According to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), section 200.430, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that the system for establishing the estimates produces reasonable approximations of the activity actually performed; significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges based on budget estimates. Proof of these employees' approved compensation and job title is required to ensure their roles are allowable under the grant. Timesheets provided to support payroll charges did not accurately support the payroll expenses charged to the grants. Also, approval of the timesheets was not evident by the documentation provided. Finally, documentation supporting approval of each employee’s compensation was not maintained and provided to support the accuracy of employee compensation. Cause: During 2024, CVC’s management team underwent significant turnover, including the top finance officer, who represents the entire accounting department, as well as the HR director. Documentation was not maintained or could not be located to support payroll expenses allocated to the federal program. Effect and Context: When adequate support is not obtained and used to support the amount charged to the federal program, there is a risk that unsupported or inaccurate costs are being charged to the federal program. Questioned Costs: Payroll costs charged to the awards total $2,570,558. Recommendation: We recommend proper control activities should be implemented to allow for a consistent, accurate, and allowable method to support distribution of personnel charges to federal programs. Documentation should be properly maintained in the organization’s records. Views of responsible officials and planned corrective actions: CVC management will implement a process to perform timely review of salary expenses charged to federal awards, and retain records by pay period, and any pay rate and title changes, as support for expenditures charged to federal awards. Name of Contact Person: Gil Catbagan, Director of Finance Proposed Completion Date: December 31, 2025
View Audit 368632 Questioned Costs: $1
Finding 1156332 (2024-002)
Material Weakness 2024
Rural Development Finance Corporation
ND
Internal Control / Segregation of Duties § 200.303
Contact Person Brenna Ohman, Finance Director Corrective Action Plan Management acknowledges that due to limited personnel there is not always proper segregation of duties. Starting in October 2025, Management will begin having another review and approve grant reimbursement requests and grant report...
Contact Person Brenna Ohman, Finance Director Corrective Action Plan Management acknowledges that due to limited personnel there is not always proper segregation of duties. Starting in October 2025, Management will begin having another review and approve grant reimbursement requests and grant reporting prior to submission. Completion Date Rural Development Finance Corporation will implement the plan in 2025.
View Audit 368624
Finding 1156331 (2024-002)
Material Weakness 2024
Rensselaer Housing Authority
NY
HUD Housing Programs Special Tests & Provisions
The Rensselaer Housing Authority (RHA) has already implemented a check list to ensure tenant files are organized and reviewed by another employee and signed off as completed. Planned implementation Date of Corrective Action: Already in effect Person Responsible for Corrective Action:: Stacey Sabiani...
The Rensselaer Housing Authority (RHA) has already implemented a check list to ensure tenant files are organized and reviewed by another employee and signed off as completed. Planned implementation Date of Corrective Action: Already in effect Person Responsible for Corrective Action:: Stacey Sabiani, Executive Director
View Audit 368623
Finding 1156330 (2024-010)
Material Weakness 2024
McR Health, Inc.
FL
Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. This revised process will be put in place on October 1, 2025.
View Audit 368617 Questioned Costs: $1
Finding 1156316 (2024-004)
Material Weakness 2024
Henry Ford Health System
MI
Subrecipient Monitoring
Finding 2024-004 Significant Deficiency in Controls over Compliance and Noncompliance - Reporting Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition - A total of $910,157 of costs was passed through to se...
Finding 2024-004 Significant Deficiency in Controls over Compliance and Noncompliance - Reporting Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition - A total of $910,157 of costs was passed through to selected sub recipients during the year and the subawards were not reported in the FSRS. Corrective Action Plan – Henry Ford Health agrees with this finding and has created a workgroup to ensure that current information on FSRS is accurate and to also to clarify responsibility for ongoing reporting and review of subrecipient disclosure requirements to ensure timeliness and accuracy. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.
View Audit 368602
Finding 1156314 (2024-003)
Material Weakness 2024
Henry Ford Health System
MI
Questioned Costs Cash Management § 200.305
Finding 2024-003 Material Weakness in Controls over Compliance and Material Noncompliance – Cash Management Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – There were four drawdowns made in relation ...
Finding 2024-003 Material Weakness in Controls over Compliance and Material Noncompliance – Cash Management Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – There were four drawdowns made in relation to the fiscal year 2024 expenses for the grant. For two out of the four drawdowns, management erroneously drew down in excess of the expenses incurred. Corrective Action Plan – Henry Ford Health agrees with this finding. As of August 31, 2025, the grant is in a net receivable position, so no adjustment is required. An additional level of review is being added to the drawdown process to improve the control environment and reduce the associated risk of error. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.
View Audit 368602 Questioned Costs: $1
Finding 1156312 (2024-002)
Material Weakness 2024
Henry Ford Health System
MI
Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.403
Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inad...
Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inadvertently recorded twice for the fiscal year, resulting in an overstatement of personnel costs charged to the federal award. Further, indirect costs were charged in excess of the budgeted and approved amount under the grant agreement. Corrective Action Plan – Henry Ford Health agrees with this finding. The payroll expense was corrected in the Schedule of Expenditures of Federal Awards and will be corrected in September 30, 2025, Federal Financial Report. Prospectively the payroll for the employee in question will be processed through our automated payroll time and effort process, rather than through manual journal entries, thus reducing the risk of error. Additionally, set up and review procedures have been enhanced to improve the controls related to recovery of indirect costs. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.
View Audit 368602 Questioned Costs: $1
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