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Corrective Action Plans

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Finding 1208311 (2025-001)
Material Weakness 2025
Prince Hall Plaza
IN
The Project will snsure that all information is received in a timely manner to complete the audit.
The Project will snsure that all information is received in a timely manner to complete the audit.
View Audit 399338
Finding 1208307 (2025-001)
Material Weakness 2025
Hartford Village
MI
HUD Housing Programs
Agree with the facts and circumstances described above. Subsequent to year end, the Organization will be opening a separate security deposit account to hold the cash.
Agree with the facts and circumstances described above. Subsequent to year end, the Organization will be opening a separate security deposit account to hold the cash.
View Audit 399329
Finding 1208306 (2025-001)
Material Weakness 2025
Benjamin Hershey Manor
IA
HUD Housing Programs Questioned Costs Procurement, Suspension & Debarment
Name of auditee: Benjamin Hershey Memorial Convalescent Home HUD auditee identification number: 074-11175 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Jessica Ward Position: Chief Financial Officer Telephone number: 402...
Name of auditee: Benjamin Hershey Memorial Convalescent Home HUD auditee identification number: 074-11175 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Jessica Ward Position: Chief Financial Officer Telephone number: 402-333-7373 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2025-001: Comments on the Finding and Each Recommendation: The Corporation did not provide HUD with a completed annual financial report by March 31, 2026, as required by HUD. Pursuant to the terms of the Regulatory Agreement, within ninety (90) days following the end of each fiscal year, the Corporation shall provide a complete annual financial report based upon an examination of the books and records of the Community prepared in accordance with the requirements of HUD and certified by a Certified Public Accountant or other person acceptable to the Commissioner. As a result, the Corporation was not in compliance with the Regulatory Agreement. The annual financial statements should be issued in a timely manner pursuant to the time frame set forth by HUD. Action(s) taken or planned on the finding: The audit report as of and for the year ended June 30, 2025 has been submitted to HUD. No further action is required.
View Audit 399327
Finding 1208305 (2025-005)
Material Weakness 2025
City of Cambridge Massachusetts
MA
Subrecipient Monitoring § 200.303 § 200.332
The City has established a well-designed internal control manual of policies and procedures over the ARPA grant’s full cycle grants management, as well as various templates to evaluate the subrecipients’ risks and monitor their performances. In FY 26, the City will implement its internal controls by...
The City has established a well-designed internal control manual of policies and procedures over the ARPA grant’s full cycle grants management, as well as various templates to evaluate the subrecipients’ risks and monitor their performances. In FY 26, the City will implement its internal controls by conducting timely subrecipient monitoring activities with signed documents.
View Audit 399326
Finding 1208302 (2025-004)
Material Weakness 2025
City of Cambridge Massachusetts
MA
Subrecipient Monitoring Questioned Costs Procurement, Suspension & Debarment § 200.303
Repeat finding 2024-005 The City will establish policies, procedures and internal controls to ensure that all subrecipient CAPER reports are reconciled to the IDIS system and submitted to HUD within 90 days of year end.
Repeat finding 2024-005 The City will establish policies, procedures and internal controls to ensure that all subrecipient CAPER reports are reconciled to the IDIS system and submitted to HUD within 90 days of year end.
View Audit 399326
Finding 1208301 (2025-003)
Material Weakness 2025
City of Cambridge Massachusetts
MA
Subrecipient Monitoring § 200.1 § 200.303
Repeat Finding 2024-004 The City will continue strengthening its policies, procedures, and internal controls to ensure that all subawards are reported in full compliance with FFATA. The City reported subawards using the subaward obligation date, which is the date the agreement is fully executed, rat...
Repeat Finding 2024-004 The City will continue strengthening its policies, procedures, and internal controls to ensure that all subawards are reported in full compliance with FFATA. The City reported subawards using the subaward obligation date, which is the date the agreement is fully executed, rather than the July 1st performance start date. As a result, obligation dates vary depending on when each agreement is signed.
View Audit 399326
Finding 1208300 (2025-002)
Material Weakness 2025
City of Cambridge Massachusetts
MA
Subrecipient Monitoring § 200.303 § 200.332
Repeat Finding 2024-003 The City has established a risk assessment tool that rates each HOPWA subrecipient across 9 factors: 1) award amount, 2) timeliness of reporting, 3) timeliness of invoicing, 4) quality of reporting, 5) program complexity, 6) staff capacity, 7) staff turnover, 8) management ch...
Repeat Finding 2024-003 The City has established a risk assessment tool that rates each HOPWA subrecipient across 9 factors: 1) award amount, 2) timeliness of reporting, 3) timeliness of invoicing, 4) quality of reporting, 5) program complexity, 6) staff capacity, 7) staff turnover, 8) management changes, and 9) grantee history. The City will use this tool to determine the appropriate level and frequency of monitoring for each subrecipient.
View Audit 399326
Finding 1208299 (2025-001)
Material Weakness 2025
City of Cambridge Massachusetts
MA
Subrecipient Monitoring § 200.1 § 200.303
Repeat Finding 2024-002 The City will continue strengthening its policies, procedures, and internal controls to ensure that all amounts passed through to subrecipients under subawards, as defined in 2 CFR 200.1 are reported in accordance with the FFATA federal regulations. In addition, the City will...
Repeat Finding 2024-002 The City will continue strengthening its policies, procedures, and internal controls to ensure that all amounts passed through to subrecipients under subawards, as defined in 2 CFR 200.1 are reported in accordance with the FFATA federal regulations. In addition, the City will use obligation date for FFATA reporting.
View Audit 399326
Finding 1208298 (2025-002)
Material Weakness 2025
Southwestern Oregon Community College
OR
Matching / Level of Effort / Earmarking Questioned Costs Student Financial Aid § 200.303
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its policies and procedures around reporting to COD to ensure that information is reported accurately and timely and to retain evidence of the key control having occurred. E...
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College evaluate its policies and procedures around reporting to COD to ensure that information is reported accurately and timely and to retain evidence of the key control having occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Additional staff member will review COD reports before they are submitted via EdConnect. Name(s) of the contact person(s) responsible for corrective action: Laura Sneddon Planned completion date for corrective action plan: April 2026
View Audit 399324
Finding 1208296 (2025-001)
Material Weakness 2025
Southwestern Oregon Community College
OR
Student Financial Aid Matching / Level of Effort / Earmarking Reporting § 200.303
Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College implement changes in process and procedures for NSLDS enrollment reporting and implement an internal control that ensures reporting is both timely and accurate. Expla...
Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College implement changes in process and procedures for NSLDS enrollment reporting and implement an internal control that ensures reporting is both timely and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Continue to review policies and procedures for accurate reporting. Investigate and identify discrepancies being exported by the Student Information System (Jenzabar). Have additional staff member review file and sign off before the data is submitted. Name(s) of the contact person(s) responsible for corrective action: Laura Sneddon Planned completion date for corrective action plan: June 2026
View Audit 399324
Finding 1208292 (2025-001)
Material Weakness 2025
Kids First Health Care
CO
Allowable Costs / Cost Principles § 200.430
Corrective Action Plan Audit Finding Reference Number: 2025-001 Federal Program: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Assistance Listing Number (ALN): 21.027 Federal Agency: U.S. Department of the Treasury Contact Person(s) Responsible for Corrective Action: Whitney Gustin Conno...
Corrective Action Plan Audit Finding Reference Number: 2025-001 Federal Program: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Assistance Listing Number (ALN): 21.027 Federal Agency: U.S. Department of the Treasury Contact Person(s) Responsible for Corrective Action: Whitney Gustin Connor, Executive Director Planned Corrective Action: Kid's First will implement the following procedures to address the lack of time and effort documentation and supervisory review for salary allocations charged to SLFRF grants: Require written supervisory review and approval of salary allocation percentages for all employees charged to federal grants. Develop and document procedures for periodic reconciliation of salary charges to actual time and effort records, in accordance with 2 CFR 200.430. Anticipated Completion Date: July 31, 2026
View Audit 399321
Finding 1208274 (2025-001)
Material Weakness 2025
Trilogy, Inc.
IL
Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.308 § 200.309 § 200.403
Period of Performance – Assistance Listing No. 93.958 Recommendation: Management should review and revise its process for allocating costs to federal grants to include additional layers of review and so that costs for which some or all are from outside of the period of performance, may be appropriat...
Period of Performance – Assistance Listing No. 93.958 Recommendation: Management should review and revise its process for allocating costs to federal grants to include additional layers of review and so that costs for which some or all are from outside of the period of performance, may be appropriately excluded from the federal grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will revise cost allocation procedures to add program and finance review steps to ensure that only costs incurred within the applicable period of performance are charged to federal grants. Costs identified as outside the allowable period will be excluded or reclassified. Updated procedures will be communicated to relevant staff and monitored for compliance. Name(s) of the contact person(s) responsible for corrective action: George Pepe Planned completion date for corrective action plan: 6/30/2026
View Audit 399300
Finding 1208273 (2025-004)
Material Weakness 2025
Trilogy, Inc.
IL
Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303
Special Tests and Provisions – Assistance Listing No. 14.267 Recommendation: We recommend program managers verify that rent reasonableness checklists and certifications are fully completed by HUD staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...
Special Tests and Provisions – Assistance Listing No. 14.267 Recommendation: We recommend program managers verify that rent reasonableness checklists and certifications are fully completed by HUD staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a supervisory review process requiring program managers to review and formally sign off on rent reasonableness checklists and certifications. Staff will receive refresher training on completion requirements, and management will periodically review files to ensure documentation is complete and properly approved. Name(s) of the contact person(s) responsible for corrective action: Jamie Rotter Planned completion date for corrective action plan: 6/30/2026
View Audit 399300
Finding 1208272 (2025-003)
Material Weakness 2025
Trilogy, Inc.
IL
Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency § 200.212 § 200.318
Suspension and Debarment – Assistance Listing No. 14.267 Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. To the extent pra...
Suspension and Debarment – Assistance Listing No. 14.267 Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. To the extent practicable, the organization can engage with a third party that will verify any new and existing vendors have not been suspended or debarred on a monthly basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will update procurement procedures to require documented SAM.gov verification for all new vendors prior to contract execution and periodically for existing vendors. Evidence of verification (e.g., screenshots or confirmation reports) will be retained in procurement files. Management will also evaluate engaging a third‑party service to perform monthly suspension and debarment screenings. Compliance will be reviewed as part of routine procurement oversight. Name(s) of the contact person(s) responsible for corrective action: Scott Russell Planned completion date for corrective action plan: 6/30/2026
View Audit 399300
Finding 1208271 (2025-002)
Material Weakness 2025
Trilogy, Inc.
IL
Procurement, Suspension & Debarment § 200.320
Procurement – Assistance Listing No. 14.267 Recommendation: We recommend the organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying mul...
Procurement – Assistance Listing No. 14.267 Recommendation: We recommend the organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/service and then utilizing an approved vendors list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will update its procurement policy to include a formal pre‑approved vendor list and documentation requirements for all procurement methods. Management will standardize procurement files to ensure inclusion of required support, such as vendor selection rationale, cost or price analysis, and approval documentation. Procurement staff will receive training on updated policy requirements, and compliance will be periodically reviewed by management. Name(s) of the contact person(s) responsible for corrective action: Scott Russell Planned completion date for corrective action plan: 6/30/2026
View Audit 399300
Finding 1208270 (2025-001)
Material Weakness 2025
Health Emergency Medical Services, Inc.
MI
Material Weakness
Condition: Several accounts were not properly reviewed such that multiple audit journal entries were required to be made to correct accidental miscoding of dates for transactions, not stopping recurring journal entries on a timely basis, and not adjusting year-end accrual balances. Planned Correctiv...
Condition: Several accounts were not properly reviewed such that multiple audit journal entries were required to be made to correct accidental miscoding of dates for transactions, not stopping recurring journal entries on a timely basis, and not adjusting year-end accrual balances. Planned Corrective Action: Management agrees with this finding. Management did not, as required, conduct a comprehensive review of the internal financial statements on both a monthly basis and at year-end on a combined basis resulting in inaccurate statements requiring auditor corrections. In the future, management will appropriately review the balance sheet and income statements monthly and on a combined basis at the end of the fiscal year to insure accurate account postings resulting is accurate financial report balances. Contact person responsible for corrective action: Robert Miljan, Jr., Executive Director Anticipated Completion Date: March 31, 2026
View Audit 399290
Finding 1208269 (2025-001)
Material Weakness 2025
Good Shepherd Homes Corporation
IL
Questioned Costs
The Organization agrees with the finding. The Project has begun and will continue to make monthly deposits back to the security deposit bank account to meet the outstanding security deposit obligations so that by year end, the security deposit bank account is equal to or greater than the aggregate o...
The Organization agrees with the finding. The Project has begun and will continue to make monthly deposits back to the security deposit bank account to meet the outstanding security deposit obligations so that by year end, the security deposit bank account is equal to or greater than the aggregate of all outstanding security deposit obligations owed to tenants. The Project will also begin a monthly check that the security deposit bank account is adequately funded to cover all outstanding security deposit obligations owed to tenants. Contact: Angela Pough, Site Property Manager Completion Date: December 31, 2026
View Audit 399283
Finding 1208268 (2025-001)
Material Weakness 2025
Good Shepherd Homes, Inc.
MN
HUD Housing Programs Questioned Costs Cash Management
United States Department of Housing and Urban Development Good Shepherd Homes, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: January 01, 2025 - December 31, 2025 The findings from the schedule of findings and questioned costs are d...
United States Department of Housing and Urban Development Good Shepherd Homes, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: January 01, 2025 - December 31, 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—FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development SIGNIFICANT DEFICIENCY 2025-001 Section 223(f) Mortgage Insurance for the Refinance of Existing Multifamily Housing Projects Federal Assistance Listing #14.155 Recommendation: We recommend that management deposit the remaining $770 to the residual receipts account as soon as possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management deposited the $770 into the residual receipts account on March 12, 2026. Management will ensure moving forward that if the Project has surplus cash, the correct amount will be deposited into the residual receipts account. Name(s) of the contact person(s) responsible for corrective action: Krista Martini, Chief Financial Officer Planned completion date for corrective action plan: March 12, 2026 If the United States Department of Housing and Urban Development has questions regarding this plan, please call Krista Martini at 320-259-3490.
View Audit 399272
Finding 1208267 (2025-009)
Material Weakness 2025
Polytechnic University of Puerto Rico, Inc.
PR
Cash Management § 200.302 § 200.305
The University will strengthen its cash management procedures to ensure that federal funds requests (drawdowns) are limited to immediate cash needs and that funds are disbursed within required timeframes. Enhancements will be made to the existing reconciliation process to ensure it provides sufficie...
The University will strengthen its cash management procedures to ensure that federal funds requests (drawdowns) are limited to immediate cash needs and that funds are disbursed within required timeframes. Enhancements will be made to the existing reconciliation process to ensure it provides sufficient detail to accurately link drawdowns to the corresponding disbursements and payroll charges, supported by adequate documentation. Additionally, Pre‑ and post‑disbursement reviews will be implemented to verify timing, accuracy, allowability, and prevent duplicate requests. Policies and procedures will be reinforced, and internal controls strengthened through segregation of duties, supervisory review, and documented approval processes. All records will be centrally maintained, and staff will receive targeted training to ensure consistent compliance. Furthermore, the University will also implement ongoing monitoring and periodic internal reviews to promote sustained compliance and address repeat findings. All corrective actions will be implemented within 30–60 days.
View Audit 399265
Finding 1208265 (2025-008)
Material Weakness 2025
Polytechnic University of Puerto Rico, Inc.
PR
Procurement, Suspension & Debarment § 200.318 § 200.319
The University will strengthen procurement policies and procedures to ensure full compliance with federal requirements, including clear guidelines for sole-source justifications and competitive procurement thresholds. A standardized procurement documentation checklist will be implemented to ensure a...
The University will strengthen procurement policies and procedures to ensure full compliance with federal requirements, including clear guidelines for sole-source justifications and competitive procurement thresholds. A standardized procurement documentation checklist will be implemented to ensure all purchases include required support, such as quotes, cost analysis, and written justification for noncompetitive procurements. Pre-procurement review and approval controls will be established to verify compliance prior to vendor selection. The University will enhance oversight and monitoring of procurement activities, including periodic internal reviews, and provide training to staff on federal procurement standards. All procurement records will be maintained in a centralized and organized system to ensure a complete audit trail. Corrective measures will be implemented within 30–60 days with ongoing monitoring.
View Audit 399265
Finding 1208264 (2025-007)
Material Weakness 2025
Polytechnic University of Puerto Rico, Inc.
PR
Eligibility Questioned Costs
As a resolution plan to ensure proper compliance with eligibility criteria required for student admission to the TRIO Program, specifically regarding disability, we will implement the following measures: Review and modify the program admission application to include a checklist format for the docume...
As a resolution plan to ensure proper compliance with eligibility criteria required for student admission to the TRIO Program, specifically regarding disability, we will implement the following measures: Review and modify the program admission application to include a checklist format for the documents submitted by the student to validate compliance with eligibility criteria during the program admission process. Create a form that a qualified professional or specialist can use to validate and document relevant information about the disability to determine eligibility and reasonable accommodations or modifications, as established and defined by the Americans with Disabilities Act (ADA). This form will be required when the medical certification provided by the qualified professional/specialist does not detail relevant information to determine the student’s eligibility based on disability or is more than one year old. Access and participate in training sessions, workshop, seminars, and webinars that focus on the ADA and its amendments, and on Title 42, Chapter 126, Section 1210, to gain greater knowledge and experience in meeting disability eligibility criteria in the Program.
View Audit 399265
Finding 1208263 (2025-006)
Material Weakness 2025
Polytechnic University of Puerto Rico, Inc.
PR
Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking
The Financial Aid Office, to ensure compliance with federal requirements, has implemented since the end of the 2024-2025 academic cycle a revised reconciliation procedure within the new system and established controls to ensure that Direct Loan reconciliations are completed monthly and that appropri...
The Financial Aid Office, to ensure compliance with federal requirements, has implemented since the end of the 2024-2025 academic cycle a revised reconciliation procedure within the new system and established controls to ensure that Direct Loan reconciliations are completed monthly and that appropriate documentation is retained.
View Audit 399265
Finding 1208262 (2025-005)
Material Weakness 2025
Polytechnic University of Puerto Rico, Inc.
PR
Student Financial Aid
Once identified, the population selection parameters in Ellucian Banner were corrected, ensuring that the files reflect the complete and appropriate data.
Once identified, the population selection parameters in Ellucian Banner were corrected, ensuring that the files reflect the complete and appropriate data.
View Audit 399265
Finding 1208261 (2025-004)
Material Weakness 2025
Polytechnic University of Puerto Rico, Inc.
PR
Questioned Costs Student Financial Aid Subrecipient Monitoring
Staffing Enhancement - Approval was granted for the hiring of an additional staff member dedicated to the refund process. This action increases operational capacity and strengthens segregation of duties, a key regulatory control to prevent delays in processing Title IV credit balance refunds. Staff ...
Staffing Enhancement - Approval was granted for the hiring of an additional staff member dedicated to the refund process. This action increases operational capacity and strengthens segregation of duties, a key regulatory control to prevent delays in processing Title IV credit balance refunds. Staff Training - Formal training was provided to personnel involved in the refund process to ensure compliance with updated procedures and strengthen internal controls. Technical consultations with Ellucian Banner were conducted to ensure that processes align with system best practices and institutional requirements. Completion of Procedures Manual - The procedures manual was finalized and includes standardized steps that streamline workflow, reduce operational risks, and ensure full traceability of each stage of the refund process. The manual is a mandatory reference for the personnel involved in refund process. Interdepartmental Work Schedule - A coordinated work schedule was established among Financial Aid, Bursar, and Accounting. The schedule outlines specific dates for financial aid disbursements, refund processing in student accounts, and issuance of payments to students. This measure strengthens interdepartmental coordination and supports compliance with required timelines. With the implementation of these corrective and preventive measures, the University reinforces its commitment to meeting all required timelines, improving administrative efficiency, and maintaining strong internal controls to ensure timely and compliant processing of Title IV credit balance refunds.
View Audit 399265
Finding 1208259 (2025-003)
Material Weakness 2025
Polytechnic University of Puerto Rico, Inc.
PR
Questioned Costs Student Financial Aid Subrecipient Monitoring
Upon identification of the issue, the Financial Aid Office conducted a comprehensive review of its internal procedures and implemented corrective measures to ensure full compliance with Title IV regulations. These measures included reinforcing staff training through targeted sessions, strengthening ...
Upon identification of the issue, the Financial Aid Office conducted a comprehensive review of its internal procedures and implemented corrective measures to ensure full compliance with Title IV regulations. These measures included reinforcing staff training through targeted sessions, strengthening internal monitoring controls, and confirming that the new system is properly configured to generate and track disbursement notifications. Additionally, the University is in the process of implementing the ISE system, with an expected full deployment date of April 2026, which will further enhance automation and tracking capabilities related to disbursement notifications. As part of the enhanced monitoring controls, the office has established periodic reviews of disbursement records, monthly reconciliation processes, and the routine generation and review of system reports to verify that notifications are sent timely and accurately. These steps are designed to prevent similar occurrences in the future and ensure that all students receiving Direct Loans are consistently provided with the required disbursement notifications in accordance with regulatory requirements.
View Audit 399265
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