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Corrective Action Plans

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Heights Towers Services Company
TX
HUD Housing Programs Reporting
Audit Finding 2025-001: During our testing of reserve for replacement account transactions, it was discovered that the Project had made deposits of an insufficient amount each month for 22 months through September 2024. -Response: The reserve for replacement account is controlled by the lender and ...
Audit Finding 2025-001: During our testing of reserve for replacement account transactions, it was discovered that the Project had made deposits of an insufficient amount each month for 22 months through September 2024. -Response: The reserve for replacement account is controlled by the lender and when the lender discovered the deficiency during the year ended May 31, 2025 a lumpsum amount was drafted from the Project's monthly payment to cover the shortfall. In future, Management will inform the lender of changes to the monthly required deposit to the reserve for replacement account made by HUD.
View Audit 365067
Casa Barranquitas, Inc. Hud Project No. 056-Eh-346-Wah-L8
PR
HUD Housing Programs Special Tests & Provisions Cash Management
Finding No. 2025-001 Residual receipts deposit We agree. Condition: The residual cash surplus of $49,570 for the fiscal year ended March 31, 2024, was deposited into the Residual Receipts account approximately 12 months after the fiscal year-end, exceeding the 90-day HUD requirement. Cause: The dela...
Finding No. 2025-001 Residual receipts deposit We agree. Condition: The residual cash surplus of $49,570 for the fiscal year ended March 31, 2024, was deposited into the Residual Receipts account approximately 12 months after the fiscal year-end, exceeding the 90-day HUD requirement. Cause: The delay was due to a discrepancy in the Employer Identification Number (EIN) on file with the financial institution, which prevented the timely opening of the required account. Planned Corrective Actions: A formal review will be conducted within 30 days after the fiscal year-end to assess surplus cash status and initiate the deposit process. All communications and actions related to the residual receipt deposit will be documented and retained for audit purposes.
View Audit 365028
Finding 574698 (2025-006)
Material Weakness 2025
Village of Marion
MI
Procurement, Suspension & Debarment
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer, Fleis & Vandenbrink, has searched the state procurement office webpage to check if any vendor f...
This finding is due to the Village not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Village’s engineer, Fleis & Vandenbrink, has searched the state procurement office webpage to check if any vendor for a federal project is on the debarment list, which they are not. In the future, the Village will have controls in place to ensure that vendors are not debarred or suspended from federal funding awards. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2026 fiscal year. The plan for adherence is the Council will review implement controls to ensure that vendors are not suspended, debarred, or otherwise excluded.
View Audit 364976
Village of Marion
MI
Procurement, Suspension & Debarment Allowable Costs / Cost Principles
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2026 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
View Audit 364976
Finding 574634 (2025-001)
Significant Deficiency 2025
Mainline Health Systems, INC
AR
Special Tests & Provisions
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2025 Estimated Completion Date: September 2025 Finding #2025-001 – Statement of Condition Patients did not receive the proper sliding f...
Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2025 Estimated Completion Date: September 2025 Finding #2025-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding and management has continued to implement procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. The Office Managers have continued reviewing all new sliding fee applications on a monthly basis to ensure accuracy. The Billing Manager have continued to conduct quarterly audits of sliding fee claims to ensure the adjustments are entered correctly by the billing department. The Organization has also launched additional training for all individuals involved in the sliding fee application process as well as automated sliding fee adjustments to reduce errors.
View Audit 364897
Finding 574591 (2025-001)
Significant Deficiency 2025
Beeville Housing Authority
TX
HUD Housing Programs Subrecipient Monitoring
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, an...
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, and if there is a balance that cannot be repaid, a payment plan will be established. Working with fee accountants during this process monthly will ensure there are no balances remaining at year end.
View Audit 364824
Finding 574407 (2025-001)
Material Weakness 2025
Housing Authority of the City of Cheyenne
WY
HUD Housing Programs Special Tests & Provisions Material Weakness
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 reg...
August 08, 2025 RE: FYE 2025 Audit Finding Contact Name: Brenda Wise, Director of Accounting Section III – Federal Award Findings and Questioned Costs: Finding 2025-001 The Authority agrees with finding 2025-001 • The Authority did not follow HUD’s published instructions in Notice PIH-2023-25 regarding required reference year for financial data used in preparing HUD Form 52723. o Each year prior to submission of HUD form 52723, the Authority will review all relevant PIH notices regarding calculation of the Public Housing Operating Subsidy, will adhere to the most current requirements, and will update its internal control documents and procedures to ensure consistency with current HUD guidance. Specifically, formula income, audit costs, and PILOT will be based on the Financial Data Schedule defined by HUD.
View Audit 364768
Finding 574031 (2025-001)
Significant Deficiency 2025
Lutheran Social Services of the South, Inc.
TX
Reporting
Grant accountants will review all new grant awards for reporting schedules at their inception to ensure that off-cycle reporting requirements are included in the calendar, and review that the reports are available in the Payment Management Services (PMS) system monthly and include all known reports ...
Grant accountants will review all new grant awards for reporting schedules at their inception to ensure that off-cycle reporting requirements are included in the calendar, and review that the reports are available in the Payment Management Services (PMS) system monthly and include all known reports due. Grants Manager will review the calendar monthly to ensure that it is maintained with accurate information and the reporting steps are being addressed.
View Audit 364616
Finding 574020 (2025-001)
Material Weakness 2025
Housing Authority of the City of Blakely
GA
HUD Housing Programs
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
2025-001 ALN 14.850 – Public Housing Operating Fund – Wage Rate Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Exception: Ms. Katherine Speight, Executive Director Projected Completion Date: March 31, 2026
View Audit 364608
Finding 573857 (2025-002)
Significant Deficiency 2025
Rannie Webster Foundation
NH
HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking
2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance cover...
2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance coverage is reviewed annually and adjusted as necessary to meet HUD requirements. Explanation of disagreement with audit finding: Management is in agreement with the finding. Prior to affiliating with Silverstone Living, the Foundation had a separate endorsement included in their Property Coverage policy that included increased crime coverage to comply with HUD requirements. After transferring coverage to Silverstone Living’s policies, the increased crime coverage did not get transferred over to keep the Foundation in compliance. Action taken in response to finding: The Foundation is actively working with its insurance provider to increase coverage to the required level. The revised policy is expected to be in place by July 31, 2025. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 31, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Janet Langlois at 603-589-4111.
View Audit 364508
Finding 573856 (2025-001)
Significant Deficiency 2025
Rannie Webster Foundation
NH
HUD Housing Programs Procurement, Suspension & Debarment Significant Deficiency
U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed bel...
U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings and Questioned Costs – Major Federal Programs U.S. Department of Housing and Urban Development 2025-001 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: CLA recommends that management ensures the regulatory agreement is being followed by all parties involved, unless otherwise instructed by a HUD representative. Any communication regarding changes to the regulatory agreement should come directly from HUD. Explanation of disagreement with audit finding: Management is in agreement with the finding. They received miscommunication from Lument. Since the Foundation goes through Lument for HUD requests and approvals, management thought the communication they received from Lument was approved by HUD. As a result, management was under the impression that the residual receipts account was fully funded, and the deposit of surplus cash was not required. Action taken in response to finding: On July 18, 2025, management submitted a formal request to HUD to suspend deposits to the residual receipts fund. On July 21, 2025, HUD approved a suspension of deposits to the reserve as long as a balance of $640,856.81 is maintained. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 21, 2025.
View Audit 364508
First Baptist Housing Development Corporation II 053-Ee035
NC
HUD Housing Programs
The Organization should keep track of the monthly payments required as set by the annual form HUD-9250.
The Organization should keep track of the monthly payments required as set by the annual form HUD-9250.
View Audit 364469
Finding 573701 (2025-001)
Significant Deficiency 2025
Green River Medical Center, Inc.
UT
Upon Management’s review of the finding it was decided that the Chief Operations Officer and the Chief Financial Officer will each audit 10 sliding fee scale patient profiles per month (totaling 20 per month) to determine if necessary documentation has been filed. This practice will help management ...
Upon Management’s review of the finding it was decided that the Chief Operations Officer and the Chief Financial Officer will each audit 10 sliding fee scale patient profiles per month (totaling 20 per month) to determine if necessary documentation has been filed. This practice will help management discover deficiencies in the execution of our sliding fee scale policies and to implement corrective practices accordingly.
View Audit 364344
Gsma Mobile for Development Foundation, Inc.
GA
The Finance and Compliance Team has an established comprehensive process for managing new grant awards. Upon receiving a new grant, the team meticulously reviews all relevant documents to ensure that all compliance requirements, including reporting deadlines, are accurately recorded in the HUB. A Fi...
The Finance and Compliance Team has an established comprehensive process for managing new grant awards. Upon receiving a new grant, the team meticulously reviews all relevant documents to ensure that all compliance requirements, including reporting deadlines, are accurately recorded in the HUB. A Finance and Compliance Business Partner (FCBP) is assigned to each grant and is responsible for preparing and submitting grant reports. These reports must be approved by the Head of Finance and Compliance before submission to ensure accuracy and compliance with grantor requirements. Regarding the quarterly report due on January 31, 2025 submitted three business days past the original deadline, the delay was due to the unprecedented crisis following the announcement of the stop order from President Trump. During this period, we were unable to reach our contacts at the United States Agency for International Development (USAID) and were in continuous discussions with our Legal team to determine the best course of action during that time. This situation required us to make critical decisions concerning the Women in the Digital Economy Fund (WIDEF) team in London and New Delhi. The Foundation was timely on all other quarterly and annual reporting requirements. We believe that our current process for managing grants and reporting to grantors is robust and effective. The delay in the submission of the quarterly report was an exceptional circumstance, and we do not anticipate any significant changes to our existing procedures. Further, based termination notice reference in footnote 6, the Foundation no longer has access to this grant.
View Audit 364304
Ridgebury Apartments, Inc.
PA
Questioned Costs HUD Housing Programs
The $4,945.78 has been transferred back into the reserve for replacement account. To ensure this will not happen again the Assistant Controller will review the Reserve for Replacement Request before sending to HUD.
The $4,945.78 has been transferred back into the reserve for replacement account. To ensure this will not happen again the Assistant Controller will review the Reserve for Replacement Request before sending to HUD.
View Audit 363992 Questioned Costs: $1
Finding 573134 (2025-003)
Significant Deficiency 2025
Northland Health Partners Community Health Center
ND
Significant Deficiency Internal Control / Segregation of Duties
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS appli...
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.
View Audit 363937
Finding 572937 (2025-002)
Significant Deficiency 2025
Csi Residential, Inc.
CT
Questioned Costs HUD Housing Programs Reporting
Deposits required by HUD were not made during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project enforce procedures that ensure deposits are made timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned i...
Deposits required by HUD were not made during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project enforce procedures that ensure deposits are made timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has made the missing deposit as of March 31, 2025. Name of the contact person responsible for corrective action: Laurie Rudman, Senior Vice President, CFO Planned completion date for corrective action plan: March 31, 2025
View Audit 363778 Questioned Costs: $1
Finding 572935 (2025-001)
Significant Deficiency 2025
Csi Residential, Inc.
CT
HUD Housing Programs Reporting Significant Deficiency
The Project had not timely reviewed the bank reconciliations for July 2024. Recommendation: CLA Recommends the Project review bank reconciliations timely and formerly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to fin...
The Project had not timely reviewed the bank reconciliations for July 2024. Recommendation: CLA Recommends the Project review bank reconciliations timely and formerly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has retroactively reviewed all bank reconciliations that were not reviewed by the former management team as of March 31, 2025. Name of the contact person responsible for corrective action: Laurie Rudman, Senior Vice President, CFO Planned completion date for corrective action plan: March 31, 2025
View Audit 363778
Asi Freeport, Inc.
MN
Questioned Costs HUD Housing Programs
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Freeport, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 A...
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Freeport, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: March 31, 2025. The finding from the March 31, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number 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 AUDIT - FINDING 2025-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 The Project overpaid management fees to the management company. Recommendation: The management company should reimburse the Project for the $755 overpayment. Action Taken: The Project agrees with the finding. The management company will repay the overpaid management fee as soon as possible. If the Department of Housing and Urban Development has questions regarding this plan, please call Les Russo at 847-424-5601.
View Audit 363740 Questioned Costs: $1
Finding 572429 (2025-001)
Significant Deficiency 2025
Regis University
CO
Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking
Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non...
Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2025, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.
View Audit 363564
Metairie Manor
LA
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT WILL ENSURE THAT THE REPLACEMENT RESERVE DEPOSITS ARE MADE ON A TIMELY BASIS IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. MANAGEMENT WILL ENSURE THAT THE REPLACEMENT RESERVE DEPOSITS ARE MADE ON A TIMELY BASIS IN THE FUTURE.
View Audit 363420
Friendship Manor Housing Development Fund Company, Inc.
NY
Procurement, Suspension & Debarment HUD Housing Programs Matching / Level of Effort / Earmarking
Name of auditee: Friendship Manor Housing Development Fund Company, Inc. Project No.: 01411252 TIN: 20-8665840 Name of audit firm: EFPR Group, CPA, PLLC Period covered by audit: March 31, 2025 CAP prepared by: Andrea D. Mays President of the Managing Agent ADM Management Group, Inc. (716) 892-1799 C...
Name of auditee: Friendship Manor Housing Development Fund Company, Inc. Project No.: 01411252 TIN: 20-8665840 Name of audit firm: EFPR Group, CPA, PLLC Period covered by audit: March 31, 2025 CAP prepared by: Andrea D. Mays President of the Managing Agent ADM Management Group, Inc. (716) 892-1799 Current Findings on the Schedule of Findings and Questioned Costs and Recommendations (1) Finding 2025-001 Management will use the $42,926 of funds withdrawn from the reserves for replacements to payoff the loan acquired for the vehicle as originally intended.
View Audit 363342
Finding 572208 (2025-003)
Significant Deficiency 2025
Young Women's Christian Association of Rochester and Monroe County
NY
Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.327
Management will update written procurement policy that conforms with the Uniform Guidance and implement procedures and control processes to retain documentation supporting compliance with major federal program compliance requirements regarding suspension and debarment. Our HUD program currently chec...
Management will update written procurement policy that conforms with the Uniform Guidance and implement procedures and control processes to retain documentation supporting compliance with major federal program compliance requirements regarding suspension and debarment. Our HUD program currently checks certificates of occupancy through the City of Rochester and Towns to ensure that the properties do not have violations. Moving forward, we will also check new landlords and or contractors through the central contractor registry to be following federal requirements regarding suspension and debarment.
View Audit 363333
Finding 572073 (2025-001)
Material Weakness 2025
Orlando Rehabilitation Group
FL
Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. The advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware...
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. The advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware that such an advance was not permitted to be made. Kane Financial Services was also unaware. The plan to correct it includes the following action steps: • Seeking approval from HUD for the $2.7M advance. • If the advance is not approved, then the repayment will occur by the organizations over an 18-month period beginning in October 2025. It is understood that such advances will not be made going forward without prior HUD approval. The contact information for oversight of the plan is: Susan Shain Executive Vice President of Finance, Kane Financial Services Email: Sshain@kanefs.com Phone: 561-223-4161 Sincerely, Susan Shain Executive Vice President of Finance Kane Financial Services
View Audit 363196 Questioned Costs: $1
Finding 572003 (2025-001)
Material Weakness 2025
Homes for Laurel, Inc.
MD
HUD Housing Programs
Recommendation Management should establish additional procedures and monitor compliance with those procedures to ensure proper dissemination of EIV information in accordance with guidelines specified by HUD. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with th...
Recommendation Management should establish additional procedures and monitor compliance with those procedures to ensure proper dissemination of EIV information in accordance with guidelines specified by HUD. Finding Resolution Status: Resolved Views of Responsible Officials Management agrees with the finding and recommendation and will remind staff of the proper procedures for dissemination of EIV information.
View Audit 363100
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