Corrective Action Plans

Finding 1218927 (2025-002)

Material Weakness 2025

GU

Reporting

Finding NO. 2025-002 Reporting SF-425 View of the University of Guam and Corrective Action Plan: The University acknowledges the finding. The University notes that, for each SF-425 submission, it consults with the assigned Economic Development Administration (EDA) grant coordinator and provides supp...

Finding NO. 2025-002 Reporting SF-425 View of the University of Guam and Corrective Action Plan: The University acknowledges the finding. The University notes that, for each SF-425 submission, it consults with the assigned Economic Development Administration (EDA) grant coordinator and provides supporting documentation for the reported amounts. The amounts reported for “cash receipts” were reviewed and acknowledged by EDA and reconciled to the University’s reimbursement records. The University also consulted with EDA regarding whether revised reports were necessary. EDA informed the University that revised reports may be submitted but are not required. Accordingly, while the reporting basis selected on the form was not consistent with the basis used in preparing the supporting accounting records, the University believes the underlying amounts reported were supported, reconciled, and accepted by the federal grantor agency. To strengthen compliance going forward, the University will enhance its review procedures to ensure consistency between the reporting basis selected on the SF-425, supporting accounting records, and federal reporting instructions. Name of Contact Person: Abigail Martin, Comptroller Proposed Completion date: July 31, 2026

View Audit 404978

Finding 1218926 (2025-002)

Material Weakness 2025

Park City Communities, INC

CT

HUD Housing Programs Questioned Costs Eligibility

2025-002 - Eligibility: Public Housing Operating Fund (FALN #14.850) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the ...

2025-002 - Eligibility: Public Housing Operating Fund (FALN #14.850) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the collection and retention of certain tenant information to document the eligibility determination for each recipient. Condition The results of our testing indicated that certain items were not completed in a timely matter as follows: • In fifteen instances, the income verification form was not found in the file or not performed timely. Questioned Costs Not determinable. Context We selected a sample of 60 files for review. Our sample was a statistically valid sample. Effect or Possible Effect The tenant income verification form was not performed timely. Cause The cause is unknown. Identification as a Repeat Finding This finding is a repeat finding (see prior year finding number: 2024-002). Recommendation We recommend that Park City continue to improve its internal processes to ensure tenant income verification is performed timely. Park City's Response A Compliance Manager has been hired to randomly review resident files to make sure all documentation is maintained. An email reminder is sent monthly to managers to insure that EIV for move-ins is done on a timely basis. Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900

View Audit 404966

Finding 1218925 (2025-001)

Material Weakness 2025

Park City Communities, INC

CT

HUD Housing Programs Questioned Costs Special Tests & Provisions

2025-001 – Eligibility and Special Tests and Provisions: Housing Voucher Cluster (FALN #14.871) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (2...

2025-001 – Eligibility and Special Tests and Provisions: Housing Voucher Cluster (FALN #14.871) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the collection and retention of certain tenant information to document the eligibility determination for each recipient. Condition The results of our testing indicated that certain items were unable to be located in the file, as follows: • In five instances, supporting documentation (Form HUD-52580) was not available to verify that HQS inspections were completed and passed • In five instances, social security verification was missing from the tenant file. • In six instances, income verification form was missing from the tenant file or performed timely. • In fourteen instances, signed HAP contracts were not maintained in the tenant file for review. • In one instance, income was incorrectly calculated on Form HUD-50058. Questioned Costs Not determinable. Context We selected a sample of 60 files for review. Our sample was a statistically valid sample. Effect or Possible Effect The tenant file documentation was incomplete and tenant income verification was not performed timely. Cause The cause is unknown. Identification as a Repeat Finding This finding is a repeat finding (see prior year finding number: 2024-001). Recommendation We recommend that Park City continue to improve its internal processes to ensure tenant files contain the required documentation and tenant income verification is performed timely. Park City's Response Income verification: PCC has implemented software tracking of income verification attempts. Inspections: An SOP was issued to staff to review/compare lines 5I and 5H on the 50058 to inspection result history, to confirm dates populating are accurate. HAP Contracts and Social Security Card Documentation: Implemented internal tracking review of ongoing executions are in place and monitored. HAP payments are not released until HAP contract is executed by both parties. Automated process to perform a review of electronically indexed files will be put into place to identify active units that may not display an indexed document relevant to HAP contract. A request for submission of the documents will be made. Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900

View Audit 404966

Finding 1218923 (2025-002)

Material Weakness 2025

Danville School District

AR

Procurement, Suspension & Debarment § 200.320

The District will gather two qualified vendors for purchases of $10,000 to $25,000. The District will have Board approval for purchases exceeding $25,700. In addition, the Food Service Director will exercise care to order items on the bid list, but will not be limited to only items on the bid list a...

The District will gather two qualified vendors for purchases of $10,000 to $25,000. The District will have Board approval for purchases exceeding $25,700. In addition, the Food Service Director will exercise care to order items on the bid list, but will not be limited to only items on the bid list as new items become available.

View Audit 404952

Finding 1218920 (2025-001)

Material Weakness 2025

Danville School District

AR

Allowable Costs / Cost Principles Questioned Costs School Nutrition Programs

The District will implement proper control over program expenditures. Expenditures for other programs will be paid directly from those program funds, if possible.

View Audit 404952

Finding 1218917 (2025-001)

Material Weakness 2025

THE LIGHTHOUSE FOR THE BLIND IN NEW ORLEANS, INCORPORATED

LA

Procurement, Suspension & Debarment § 200.318 § 200.327

Going forward, Lighthouse Louisiana will ensure that its procurement policy reflects its commitment to purchases made in a manner that promotes full and open competition, supports price reasonableness, and maintains appropriate documentation based on the applicable procurement threshold. Management ...

Going forward, Lighthouse Louisiana will ensure that its procurement policy reflects its commitment to purchases made in a manner that promotes full and open competition, supports price reasonableness, and maintains appropriate documentation based on the applicable procurement threshold. Management confirms that the Organization will apply a $10,000 micro-purchase threshold, require price or rate quotations from an adequate number of qualified sources for small purchases between $10,000 and $250,000, and require a formal competitive process for procurements exceeding $250,000, unless a properly documented exception applies. Lighthouse Louisiana did not actively retain all SAM.gov search results in vendor files for each vendor included in the procurement testing; however, if a SAM.gov verification was performed but not retained in the file, management will document the issue, perform and retain an updated verification, and strengthen internal controls to require retention of SAM.gov evidence before agreement execution or renewal. As part of its corrective action, Lighthouse Louisiana will enhance its procurement file review process to ensure that each grant-funded procurement contains, as applicable, the procurement method determination, supporting quotes or price comparisons, price reasonableness analysis, vendor selection rationale, required approvals, contract or agreement, and SAM.gov verification. Management will also reinforce staff training on procurement documentation requirements and will implement a standardized procurement checklist for grant-funded purchases. The Chief Financial Officer, Chief Operations Officer, and Project Director will be responsible for ensuring that any requested documentation is gathered and submitted to the auditors and that procurement file improvements are implemented prospectively.

View Audit 404950

Finding 1218916 (2025-003)

Material Weakness 2025

Russell Rural Water District No. 3

KS

Procurement, Suspension & Debarment

SIGNIFICANT DEFICIENCY 2025-003 Water and Waste Disposal Systems for Rural Communities – Procurement, Suspension and Debarment Condition During inquiry of District management, it was determined that the District did not have the required written policies in place to be followed. Recommendation We re...

SIGNIFICANT DEFICIENCY 2025-003 Water and Waste Disposal Systems for Rural Communities – Procurement, Suspension and Debarment Condition During inquiry of District management, it was determined that the District did not have the required written policies in place to be followed. Recommendation We recommend that the District’s written policies be updated to properly reflect all requirements. Comments on the Finding Management is aware of the oversight and has begun the process of creating a written policy.

View Audit 404949

Finding 1218915 (2025-003)

Material Weakness 2025

The Salvation Army Golden State Division

CA

Material Weakness School Nutrition Programs Equipment & Real Property Management

The Division is in the process of designing and implementing a precise control to ensure that the inventory reports are reviewed prior to being submitted to the grantor and that the backup documentation is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielins...

The Division is in the process of designing and implementing a precise control to ensure that the inventory reports are reviewed prior to being submitted to the grantor and that the backup documentation is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.

View Audit 404948

Finding 1218896 (2025-002)

Material Weakness 2025

The Salvation Army Golden State Division

CA

Eligibility Questioned Costs Subrecipient Monitoring

The Division is in the process of designing and implementing a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and that such evidence is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major,...

The Division is in the process of designing and implementing a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and that such evidence is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.

View Audit 404948

Finding 1218877 (2025-001)

Material Weakness 2025

The Salvation Army Golden State Division

CA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.502

The Division is in the process of designing and implementing a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Com...

The Division is in the process of designing and implementing a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.

View Audit 404948

Finding 1218858 (2025-002)

Material Weakness 2025

Auburn University

AL

Subrecipient Monitoring § 200.332 § 200.501

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Various ...

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Various agencies Award Names: Southeast Region Cybersecurity Collaboration Center (SERC3), Establish, manage, and maintain a public-private partnership (PPP) additive manufacturing (AM) consortium for the Rapid Manufacturing Propulsion Technology (RAMPT), Developing effective adaptation strategies to enhance the resilience of farmers under changing climate, Towards a sustainable bioeconomy: Biotransformation of paper mill sludge for value-added chirally pure (R)-1,3-butanediol production, A systems approach to perennial forage management using plant growth-promoting rhizobacteria Award Numbers: 212514, 208409, 200987, 205258, and 205264 Assistance Listing Title: Cybersecurity, Energy Security & Emergency Response (CESER), Science, Integrative Activities, and Agriculture and Food Research Initiative (AFRI) Assistance Listing Number: 81.008, 43.RD, 47.083, and 10.310, Award Year: 2024 - 2025 Pass-through entity: UT-Batelle LLC, RPM Innovations, Inc., New Mexico State University, Regents of University of the University of California, and University of Tennessee Management notes 2025-002 is a repeat finding of 2024-002, but given the timing of the finding last year, our 2024 CAP was anticipated to be completed as of October 1, 2025. To ensure Auburn University is in compliance with 2CFR 200.332(f), Auburn University has implemented the following corrective action plan: Since the audit period, the University has completed a comprehensive review of its subrecipient monitoring framework and has been working to distribute workload more effectively with the goal of building consistency in subrecipient monitoring procedures. This includes efforts to clarify ownership of monitoring tasks, implementing a more centralized and standardized approach to documentation, and balancing the day-to-day operational duties across the subaward team to allow for appropriate focus on Uniform Guidance compliance. Brief internal training sessions or check-ins will be conducted to reinforce expectations and ensure that all staff are aligned with the updated documentation practices. Current procedures were revised to address risk assessments and annual monitoring. These improvements are designed to ensure consistency, accountability, and compliance with Uniform Guidance expectations moving forward. We will document when all reviews of sub-recipients’ financial statements/Uniform Guidance reports occur and who completes the reviews. These reviews will be entity-specific and conducted annually. The corrective actions noted herein have been implemented as of October 1, 2025. Contact: Tony Ventimiglia Asst. VP Research Administration Office of the Senior VP for Research & Economic Development Amy Douglas Associate VP Financial Services/Controller Completed Date: October 1, 2025

View Audit 404945

Finding 1218854 (2025-001)

Material Weakness 2025

Auburn University

AL

Procurement, Suspension & Debarment Questioned Costs Allowable Costs / Cost Principles § 200.324

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, and also applies to Expanded Food and Nutrition Education Programs, whic...

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, and also applies to Expanded Food and Nutrition Education Programs, which is not a cluster Sponsoring Agency: National Aeronautics and Space Administration and Department of Agriculture Award Names: NASA 90NSSC24K0999 and NI22eFNEPXXXG004-0003 Award Numbers: 208905 and 385076 Assistance Listing Title: Mission Support and Expanded Food and Nutrition Education Program Assistance Listing Number: 43.009 and 10.514 Award Year: 2024 – 2025 Management notes 2025-001 is a repeat finding of 2024-001, but given the timing of the finding last year, our 2024 CAP was anticipated to be completed as of October 1, 2025. To ensure Auburn University is in compliance with 2CFR 200.324, Auburn University has implemented the following corrective action plan: In addition to our current policies that required three quotes for purchases between $15,000-$75,000 and a formal competitive bid for purchases greater than $75,000, Auburn University revised our policies to require a cost or price analysis for items greater than $250,000, documenting that the purchase is reasonable. For items greater than $250,000, we will include a certification on the Professional Services Contracts and the Sole Source request forms indicating an analysis of cost or price has occurred and that the purchase is reasonable. As part of the cost or price analysis, we will utilize available data points. In addition to our analysis, we will ensure that our reviews have been appropriately documented and included in our files. Prior to the implementation date noted below, we will review any purchases greater than $250,000 in fiscal year 2026 and ensure proper cost or price analysis is completed and documented. The corrective actions noted herein have been implemented as of October 1, 2025. Contact: Missty Kennedy Chief Procurement Officer and Executive Director Procurement and Payment Services Amy Douglas Associate VP Financial Services/Controller Completed Date: October 1, 2025

View Audit 404945

Finding 1218852 (2025-005)

Material Weakness 2025

Proteus, Inc.

CA

Reporting

Proteus, Inc will implement a reconcilliation process for reconciling our two payroll systems through an automated program reducing manually time involved and data entry errors. Transitioning to a new integrated accounting system will significantly reduce errors and eliminate manual processes. We wi...

Proteus, Inc will implement a reconcilliation process for reconciling our two payroll systems through an automated program reducing manually time involved and data entry errors. Transitioning to a new integrated accounting system will significantly reduce errors and eliminate manual processes. We will also provide additional staff training to assure the accountability over timekeeping.

View Audit 404943

Finding 1218841 (2025-002)

Material Weakness 2025

Avoyelles Child Development Services, INC

LA

Internal Control / Segregation of Duties Reporting

Compliance Finding – Uniform Guidance Head Start Program Cluster #93.600 Material Noncompliance 2025-002 Federal Reporting and Grant Drawdown RECOMMENDATION: Management should implement procedures to ensure 1) all required federal reports are submitted timely, 2) federal reporting systems are adequa...

Compliance Finding – Uniform Guidance Head Start Program Cluster #93.600 Material Noncompliance 2025-002 Federal Reporting and Grant Drawdown RECOMMENDATION: Management should implement procedures to ensure 1) all required federal reports are submitted timely, 2) federal reporting systems are adequately monitored and supported, and 3) grant funds are not drawn down prior to obtaining all required federal approvals. VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION: Management believes that the organization maintains a comprehensive and effective system of internal controls over financial reporting, compliance, and grant administration. The findings relate to a specific control deficiency identified during the audit which were both impacted by a lack of communications from the funding agency and the 43-day Federal Government shutdown from October 1, 2025 to November 12, 2025, and do not, in management's view, reflect a systemic weakness in the overall control environment. Management acknowledges the circumstances that resulted in the findings and recognizes the opportunity to strengthen certain procedures and documentation practices. The conditions identified were limited in scope and occurred despite the existence of established policies, oversight processes, and monitoring activities designed to promote compliance with applicable federal requirements.

View Audit 404935

Finding 1218840 (2025-001)

Material Weakness 2025

Avoyelles Child Development Services, INC

LA

Reporting Internal Control / Segregation of Duties

Internal Control Over Compliance – Uniform Guidance Head Start Program Cluster #93.600 Significant Deficiency in Internal Control Over Compliance 2025-001 Federal Reporting and Grant Drawdown RECOMENDATION: Management should strengthen internal controls over federal reporting and grant administratio...

Internal Control Over Compliance – Uniform Guidance Head Start Program Cluster #93.600 Significant Deficiency in Internal Control Over Compliance 2025-001 Federal Reporting and Grant Drawdown RECOMENDATION: Management should strengthen internal controls over federal reporting and grant administration by 1) implementing procedures to ensure timely submission of all required federal reports, 2) establishing contingency procedures for system interruptions, and 3) requiring documented evidence of federal approval prior to drawing down grant funds associated with capital expenditures or other restricted activities. VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION: Management believes that the organization maintains a comprehensive and effective system of internal controls over financial reporting, compliance, and grant administration. The findings relate to a specific control deficiency identified during the audit which were both impacted by a lack of communications from the funding agency and the 43-day Federal Government shutdown from October 1, 2025 to November 12, 2025, and do not, in management's view, reflect a systemic weakness in the overall control environment. Management acknowledges the circumstances that resulted in the findings and recognizes the opportunity to strengthen certain procedures and documentation practices. The conditions identified were limited in scope and occurred despite the existence of established policies, oversight processes, and monitoring activities designed to promote compliance with applicable federal requirements.

View Audit 404935

Finding 1218839 (2025-001)

Material Weakness 2025

Housing Authority of the City of Alexander City

AL

HUD Housing Programs

– HUD Comprehensive Compliance Monitoring Review, Public Housing Program –14.850, Housing Choice Vouchers – 14.871, Resident Opportunities and Supportive Services -14.870 Family Self-Sufficiency Program – 14.896; Grant Period – year ended September 30, 2025. Corrective Action: The Authority has comp...

– HUD Comprehensive Compliance Monitoring Review, Public Housing Program –14.850, Housing Choice Vouchers – 14.871, Resident Opportunities and Supportive Services -14.870 Family Self-Sufficiency Program – 14.896; Grant Period – year ended September 30, 2025. Corrective Action: The Authority has completed all corrective actions submitted to HUD on March 24, 2025. The Authority received the official close out letter that all findings have been closed on March 12, 2026. Responsible Party: Darold Sterling, Executive Director, (256)329-2201. Anticipated Completion Date: September 30, 2026.

View Audit 404934

Finding 1218835 (2025-001)

Material Weakness 2025

The Joseph P. Addabbo Family Health Center, Inc.

NY

Procurement, Suspension & Debarment

The Center now uses Sreamline Verify, an online software, which searches each vendor before they are hired. There is also a monthly search performed for all vendors.

View Audit 404925

Finding 1218832 (2025-003)

Material Weakness 2025

Codman Square Health Center, Inc. and Affiliate

MA

Cash Management Questioned Costs Significant Deficiency § 200.302 § 200.303 § 200.305

Item 2025.003 - Cash Management Recommendation The Organization should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting, a grant and contracts consulting firm....

Item 2025.003 - Cash Management Recommendation The Organization should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting, a grant and contracts consulting firm. A drawdown policy will be established for the July 2026 Board Meeting for approval.

View Audit 404919

Finding 1218831 (2025-002)

Material Weakness 2025

Codman Square Health Center, Inc. and Affiliate

MA

Reporting

Item 2025.002 - Reporting Recommendation The Organization should establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the reports are accurate. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire ...

Item 2025.002 - Reporting Recommendation The Organization should establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the reports are accurate. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting to assist in the restructure of the grant department and workflow. In addition, the Health Center converted GL accounting and grant tracking to Sage lntacct. The updated grant reporting and tracking will include workpaper for reconciliation and supporting documents for reporting.

View Audit 404919

Finding 1218830 (2025-001)

Material Weakness 2025

Codman Square Health Center, Inc. and Affiliate

MA

Allowable Costs / Cost Principles Questioned Costs § 200.40 § 200.430

Item 2025.001 - Activities Allowed or Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that the allocations are reviewed and approved by the appropriate supervisor. Repeat Finding Not a repeat finding. Action Taken The Heal...

Item 2025.001 - Activities Allowed or Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that the allocations are reviewed and approved by the appropriate supervisor. Repeat Finding Not a repeat finding. Action Taken The Health Center converted the payroll system from Paycom to Paylocity which has capacity for grant hours tracking. We should have compliance in three months after implementation. The first pay date using Paylocity will be 7/2/2026 covering the pay period from 6/14/2026 to 6/27/2026. In addition, The Health Center's new GL system, Sage lntacct, also has grant accounting capability. With these two systems conversions, we should be able to track time and effort compliance.

View Audit 404919

Finding 1218823 (2025-002)

Material Weakness 2025

Little Rivers Health Care, Inc.

VT

Procurement, Suspension & Debarment § 200.214

Finding: 2025-002 Condition Found: The Organization did not have adequately designed internal controls to ensure compliance with Federal suspension and debarment requirements. Specifically, the Organization did not perform SAM.gov exclusion screenings for all contractors. SAM.gov checks were perform...

Finding: 2025-002 Condition Found: The Organization did not have adequately designed internal controls to ensure compliance with Federal suspension and debarment requirements. Specifically, the Organization did not perform SAM.gov exclusion screenings for all contractors. SAM.gov checks were performed only for employees, rather than being performed for all applicable vendors whose yearly expenditures charged to the grant met or exceeded $25,000. As a result, the Organization’s exclusion screening process was not consistently applied to all vendors who met the expenditure threshold. Individual(s) Responsible for Corrective Action: Andrew Barter, CEO Planned Corrective Action: On May 7, 2026, Little Rivers Health Care completed a comprehensive review of all vendors to identify those meeting the federal suspension and debarment screening threshold, with no results. This review identified no excluded or debarred vendors and included all vendors associated with business conducted during 2025. In addition, searches conducted for periods prior to 2025, which included vendors utilized during 2025, did not identify any excluded parties. While the Organization inadvertently failed to perform the required vendor screenings during 2025, the retrospective review, together with the 2026 screening process, demonstrated that none of the applicable vendors were suspended, debarred, or otherwise excluded from participation in federal programs during the period under review. Recognizing the oversight in 2025 and to ensure ongoing compliance, the Organization established a formal vendor exclusion monitoring process consisting of a four-member review team. While the review process itself is relatively straightforward, the team was intentionally designed with redundancy to ensure continuity during periods of staff absence, turnover, or organizational transition. This approach provides multiple levels of oversight and helps ensure that the control remains effective over time. The review team will conduct SAM.gov exclusion screenings and validation reviews twice annually, during May and November of each year, for all vendors meeting applicable federal requirements. Meetings have been scheduled indefinitely with no planned end date. The next scheduled review dates are November 10, 2026, May 11, 2027, and November 9, 2027. Documentation of completed reviews and any required follow-up actions will be maintained as part of the Organization's compliance records. Anticipated Completion Date: May 7, 2026 (Corrective action completed). Ongoing semiannual SAM.gov exclusion screening reviews will continue indefinitely each May and November.

View Audit 404913

Finding 1218822 (2025-001)

Material Weakness 2025

Little Rivers Health Care, Inc.

VT

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs

Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly appli...

Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly applied a sliding fee discount to a patient account, resulting in a discount that was not consistent with the Organization's sliding fee discount policy. Individual(s) Responsible for Corrective Action: Andrew Barter, CEO Planned Corrective Action: The identified error resulted from a contracted third-party billing company applying a sliding fee discount that was inconsistent with Little Rivers Health Care's Sliding Fee Discount Program policy. Upon identification of the finding, the account was reviewed and corrected to ensure the patient received the appropriate discount. To prevent future occurrences, Little Rivers Health Care re-instituted its monthly monitoring and review procedures in May 2026. These monitoring activities had been conducted consistently through the fall of 2025 and include periodic audits of patient accounts receiving sliding fee discounts, verification of discount calculations, and oversight of third-party billing activities. Findings from these reviews are documented, and corrective action is taken promptly when discrepancies are identified. In addition, the contracted billing company has been reminded of the organization's sliding fee discount requirements and expectations for compliance. To provide ongoing oversight and validation of compliance with the Sliding Fee Discount Program, Little Rivers Health Care has also implemented quarterly review meetings involving the Billing Manager, Controller, and Chief Executive Officer. These meetings have been formally scheduled, with the first occurrence set for July 20, 2026. The quarterly reviews will evaluate monitoring results, validate adherence to policy requirements, identify trends or potential risks, and ensure continuous compliance with program requirements. Anticipated Completion Date: May 20, 2026 (Corrective action completed), for reinstatement of monthly monitoring procedures. Quarterly compliance review meetings with the Billing Manager, Controller, and CEO are scheduled to commence on July 20, 2026, and will continue on an ongoing basis as part of the Organization's continuous compliance monitoring process.

View Audit 404913

Finding 1218821 (2025-003)

Material Weakness 2025

Corpus Christi Housing Authority

TX

Questioned Costs Special Tests & Provisions HUD Housing Programs

Authority Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor and has initiated corrective actions to strengthen compliance with Housing Quality Standards (HQS) inspection requirements and related abatement procedures. Management identified that staff...

Authority Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor and has initiated corrective actions to strengthen compliance with Housing Quality Standards (HQS) inspection requirements and related abatement procedures. Management identified that staffing turnover and transition-related training gaps contributed to delays in the timely processing and enforcement of failed inspection reinspections and landlord abatements during the audit period. In response, the Authority has implemented enhanced monitoring and supervisory review procedures over failed inspections and reinspection timelines to ensure compliance with HUD requirements. Management has reinforced staff training related to HQS enforcement, reinspection tracking, and Housing Assistance Payment (HAP) abatement procedures. In addition, the Authority is utilizing system generated tracking reports and management oversight tools to identify failed inspections approaching required corrective action deadlines and to ensure timely follow-up and enforcement actions are completed. The Authority believes these corrective measures will strengthen internal controls over compliance and help ensure continued adherence to HUD Housing Quality Standards requirements and related special tests and provisions compliance requirements. Isaiah Norris, Vice President of the Housing Choice Vouchers Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2026.

View Audit 404911

Finding 1218820 (2025-002)

Material Weakness 2025

Corpus Christi Housing Authority

TX

Questioned Costs Eligibility HUD Housing Programs

Authority's Response and Planned Corrective Plan: The Authority accepts the auditor’s recommendation. Management acknowledges the importance of maintaining complete and readily available tenant file documentation to support eligibility determinations and ongoing program compliance for the Housing Vo...

Authority's Response and Planned Corrective Plan: The Authority accepts the auditor’s recommendation. Management acknowledges the importance of maintaining complete and readily available tenant file documentation to support eligibility determinations and ongoing program compliance for the Housing Voucher Cluster. The documents noted as unavailable during the audit relate to file maintenance and documentation retention. Management does not believe the exceptions indicate that the sampled households were ineligible for assistance; however, the Authority recognizes that required documentation must be consistently maintained and available for audit review. In response, the Authority will implement a corrective action plan that includes increased supervisory review of tenant files, enhanced file completion checklists, periodic internal quality control reviews, and additional staff training on required eligibility documentation, including consent forms, lead-based paint documentation, HAP contracts, and tenancy addenda. The Authority will also strengthen monitoring procedures to ensure missing or incomplete documents are identified and corrected timely. Management will assign responsibility for periodic file review to Housing Choice Voucher leadership and will document follow-up actions taken. These procedures are intended to improve internal controls over tenant file maintenance and ensure continued compliance with HUD requirements, Uniform Guidance, and the applicable compliance supplement. Isaiah Norris, Vice President of the Housing Choice Vouchers Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2026.

View Audit 404911

Finding 1218817 (2025-001)

Material Weakness 2025

Southern Nevada Regional Housing Authority

NV

HUD Housing Programs

Finding 2025-001 - Section 8 Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance & Material Weakness Management Response and Corrective Action Plan The Southern Nevada Regional Housing Authority (SNRHA) agrees with the audit finding and recommendation. During the audit per...

Finding 2025-001 - Section 8 Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance & Material Weakness Management Response and Corrective Action Plan The Southern Nevada Regional Housing Authority (SNRHA) agrees with the audit finding and recommendation. During the audit period, the Agency was finalizing its transition from paper files to electronic records while simultaneously establishing a dedicated Quality Control (QC) Unit. These organizational and process changes contributed to inconsistencies in file documentation, income verification procedures, and compliance monitoring. Management notes that compliance improved during the audit period, with the overall tenant file error rate decreasing from 32% in 2024 to 28.3% in 2025 and income-related errors decreasing from 21% to 11.7%. While these improvements demonstrate significant progress, SNRHA recognizes the need to further strengthen internal controls to ensure full compliance with HUD requirements and reduce the risk of future errors. The Housing Authority respectfully submits this Corrective Action Plan (CAP) in response to Finding 2025-001 concerning deficiencies in Section 8 tenant file eligibility determinations and internal controls over tenant files, identified as both noncompliance and a material weakness. Corrective Action Plan: Staffing Enhancements • One (1) Housing Programs Supervisor (Compliance) to oversee quality control, audit readiness, policy implementation, and compliance monitoring. • Two (2) Senior Occupancy Specialists (SOS) to assist with file reviews, staff mentoring, and compliance guidance. • One (1) Office Assistant (OA) to support administrative processes, document management, and workflow efficiency. These staffing enhancements will improve internal controls through increased supervision, workload distribution, and technical assistance. Target Completion Date: September 30, 2026. Quality Control (QC) Procedures • 100% QC review of all provisional (new-hires) staff files. • 100% QC review of all new admissions, lease-ups, and contract executions. • 25% monthly QC review of files processed by non-provisional staff. • Quarterly SEMAP review for overall key performance indicators • Use standardized QC checklists aligned with HUD regulations, HOTMA requirements, SEMAP indicators, and annual audit standards. • Track eligibility transactions, QC findings, corrective actions, and retraining efforts through a centralized Smartsheet system. • Issue monthly individual and departmental compliance scorecards. • Provide coaching and retraining for staff exceeding a 5% monthly error rate. Target Completion Date: Implemented and ongoing. Training and Professional Development The Authority will strengthen staff competency through structured training initiatives: • Eighteen (18) staff members will complete the Nan McKay HCV Rent Calculation Training with HOTMA requirements in July 2026 • Updated Standard Operating Procedures (SOPs) will be finalized and staff trained on: o Annual and interim reexaminations o Portability o Terminations o Moves and contracts • Staff will receive training on: o Accurate system data entry and validation procedures • The entire department will complete monthly assigned ASPIRE trainings, aligned with: o Eligibility requirements o QC findings and trends o SEMAP indicators and audit findings. • Senior Occupancy Specialists (SOS) will provide ongoing one-on-one technical assistance and timely follow-up on error corrections. Internal Controls and Process Improvements The Authority will enhance internal controls through: • Standardized workflows aligned with updated SOPs • Increased supervisory oversight of eligibility determinations • Integration of QC findings into continuous process improvements • Strengthened documentation practices to ensure audit compliance • Improved segregation of duties where applicable • Mandatory verification that EIV reports are generated, reviewed, and retained in tenant files prior to certification completion. • Verification of utility allowance calculations using the Authority's Board-approved Utility Allowance Schedule. • Monitoring inspection due dates through Yardi and management dashboards. • Reestablishment of inspection due dates within Yardi and monthly monitoring of inspection batching reports Target Completion Date: September 30, 2026 Monitoring and Oversight The Compliance Supervisor will oversee the implementation of this plan and: • Monitor QC processes and staff performance. • Analyze trends in error rates and compliance deficiencies. • Report progress to Compliance & Training Administrator. Monthly reviews of QC data will be conducted to identify systemic issues and adjust training and procedures as needed to sustain compliance. Person(s) Responsible: Rosa Elaine Garcia, Director of Housing Programs, in assistance with Compliance & Training Administrator, Housing Programs Supervisor (Compliance) and Training and Development Specialist

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