Corrective Action Plans

Finding 1216525 (2024-011)

Material Weakness 2024

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.

View Audit 403025

Finding 1216524 (2024-010)

Material Weakness 2024

Pottawatomie County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.

View Audit 403025

Finding 1216520 (2024-003)

Material Weakness 2024

Easton Area School District

PA

Reporting

Management Corrective Action Plan: The District acknowledges the finding regarding the untimely submission of required reports to the Pennsylvania Department of Education related to federal grant programs. Management recognizes the importance of timely and accurate reporting to ensure compliance wit...

Management Corrective Action Plan: The District acknowledges the finding regarding the untimely submission of required reports to the Pennsylvania Department of Education related to federal grant programs. Management recognizes the importance of timely and accurate reporting to ensure compliance with grant requirements and maintain effective oversight of federal funding. The delays in submission were primarily the result of staffing transitions within the Business Office and challenges associated with completing prior year financial information needed for reporting purposes. The District has worked cooperatively with the Pennsylvania Department of Education throughout this process and has taken steps to address outstanding reporting requirements. To address this matter, the District has begun implementing corrective actions which include: Establishing internal reporting calendars and compliance deadlines for all required state and federal submissions; Assigning specific staff responsibilities for grant reporting and monitoring; Implementing supervisory review procedures to ensure reports are completed accurately and submitted timely; and Providing additional oversight and coordination related to federal grant compliance and reporting requirements. Individual(s) Responsible: CFO, Finance Officer Anticipated Completion Date: Prior to issuance of the Fiscal Year 2025 Financial Statements

View Audit 403014

Finding 1216467 (2024-001)

Material Weakness 2024

Bais Yaakov Elementary of Rockland County

NY

Internal Control / Segregation of Duties Reporting Significant Deficiency

The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before t...

The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight.

View Audit 402966

Finding 1216435 (2024-003)

Material Weakness 2024

Consolidated Public Water Supply District No 1 of Clark County Mo

MO

Prior year late filing due to problems with accounting software conversion, which has been resolved and any future filings will be on a timely basis

View Audit 402946

Finding 1216434 (2024-002)

Material Weakness 2024

Consolidated Public Water Supply District No 1 of Clark County Mo

MO

Internal Control / Segregation of Duties

The Board and management are aware of the inadequate separation of accounting duties when reviewing the monthly operations and financial results of the District. As an ongoing mitigating control, at the board meetings management and the board members review the monthly check register of disbursement...

The Board and management are aware of the inadequate separation of accounting duties when reviewing the monthly operations and financial results of the District. As an ongoing mitigating control, at the board meetings management and the board members review the monthly check register of disbursements, interim financial reports, summary of cash and certificates of deposits held, and contract pay applications and construction project status as presented by the project engineer for review and approval by the Board.

View Audit 402946

Finding 1216433 (2024-001)

Material Weakness 2024

Consolidated Public Water Supply District No 1 of Clark County Mo

MO

Internal Control / Segregation of Duties

Management monitors all pay applications for work performed but will more closely

View Audit 402946

Finding 1216383 (2024-003)

Material Weakness 2024

County of Carbon

PA

Student Financial Aid Subrecipient Monitoring Reporting

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entit...

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity Identifying Number: not available; 14.228, Community Development Block Grants, Passed Through Pennsylvania Department of Community and Economic Development, U.S. Department of Housing and Urban Development; 93.558, Pass-Through Granter #'s C000073823, C000075969, C000082698, C000086225, and C000088719, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available, 21.023, Emergency Rental Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available. Prior Year Finding Number: 2023-005 Criteria: Pursuant to the provisions of the Uniform Guidance, under Section 200.512(a), the County is required to complete and submit its Single Audit and related Data Collection Form within nine months of the end of its fiscal period (September 30) of the following year. Condition/Context The County's Single Audit and reporting package was delayed for the year ended December 31, 2023 beyond the nine-month due date. Effect: The County is not in compliance with certain requirements of the Uniform Guidance, including the Single Audit reporting requirements. Questioned Costs: None. Cause: Reconciliations and reports were not completed on a timely basis, and therefore, the completion and filing of its December 31, 2023 Single Audit and reporting package was not prioritized. Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframes. Views of Responsible Officials and Planned Corrective Actions: The County plans to have information ready for the auditors to get 2024 done in a reasonable time frame. Between staffing and priorities, the County hopes to have cleared by the 2025 audit.

View Audit 402918

Finding 1216368 (2024-001)

Material Weakness 2024

First Person Care Clinic, Inc.

NV

Reporting

Parties responsible for all action items: CEO First Person Care Clinic – Harsh Chhawchharia, harsh@firstpersonclinic.org, phone 702-572-3500 Controller First Person Care Clinic – Demetrio Ordas, dordas@firstpersonclinic.org, phone 702-572-3500 Finding 2024- 001 Reporting (L) Significant Deficiency i...

Parties responsible for all action items: CEO First Person Care Clinic – Harsh Chhawchharia, harsh@firstpersonclinic.org, phone 702-572-3500 Controller First Person Care Clinic – Demetrio Ordas, dordas@firstpersonclinic.org, phone 702-572-3500 Finding 2024- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. Throughout 2024, our organization struggled to overcome ongoing obstacles due to a lack of personnel. Despite our efforts to hire additional administrative support, the process proved arduous, and we encountered difficulties in finding suitable candidates. In our quest for solutions, we proactively engaged with other FQHCs and NV PCA, exploring the potential for collaborative personnel arrangements. Moreover, our existing staff members underwent periods of illness, as did their families, further straining our capacity to fulfill our responsibilities effectively. As a result, the burden on our small team, consisting of just one additional staff member alongside myself and the CFO, became overwhelming. Juggling multiple roles and responsibilities amid personal and familial health challenges made it exceedingly difficult to keep up with the demanding workload. These circumstances underscored the urgent need for additional support and highlighted the critical importance of finding viable solutions to address our staffing limitations. CEO and CFO Timeframe: 2-4 months a. Staff Augmentation: We are actively working on hiring dedicated administrative support staff who will be responsible for assisting with routine tasks. This strategic addition to our team will allow the CEO and CFO to focus more effectively on their core responsibilities. b. Streamlined Processes: We are in the process of reviewing and optimizing our internal processes. This critical step will help enhance the overall efficiency of managing tasks related to federal reporting and grants management. c. Task Delegation: With the inclusion of additional staff members, we will delegate specific responsibilities to ensure that FFR quarterly reports are not only prepared but also submitted promptly. d. Reporting Calendar: We will be implementing a comprehensive reporting calendar that clearly outlines deadlines and assigns responsibilities. This organized approach will assist us in staying on track and meeting our reporting obligations consistently. e. Training and Development: Our team is committed to continuous improvement. To this end, we will be providing training and development opportunities for our staff to enhance their skills and knowledge in grants management and federal reporting. This investment in their professional development will result in greater accuracy and efficiency. In addition to these measures, we are exploring the possibility of engaging a third-party company if we encounter challenges in hiring employees directly. We are actively in discussions with other hiring companies and Locum tenants companies as needed to ensure that we have all the resources required to address this issue effectively. By implementing these measures, we aim to overcome historical challenges related to understaffing and limited access to essential resources. The collaborative efforts of the FPCC finance team, combined with streamlined processes and improved technology, will position us to submit FFR quarterly reports and the annual submission to the federal clearinghouse promptly and efficiently.

View Audit 402908

Finding 1216364 (2024-003)

Material Weakness 2024

City of Reading

PA

Cash Management Reporting

Condition During the 2024 fiscal year, grant expenditures related to a Commonwealth of Pennsylvania grant (see finding 2024-001) for the public safety building were reported in the American Rescue Plan fund. Since they were reported in the American Rescue Plan fund they were then included in the rep...

Condition During the 2024 fiscal year, grant expenditures related to a Commonwealth of Pennsylvania grant (see finding 2024-001) for the public safety building were reported in the American Rescue Plan fund. Since they were reported in the American Rescue Plan fund they were then included in the report submitted for that time period. Cause The decentralized grant administration at the City lead to missing communication between the departments and the improper accounting for the public safety building grant. Recommendation The City should continue to refine its grant administration and accounting functions to allow for a seamless accounting for grant awards. The current decentralized structure for grant administration can allow for grants awarded to not be properly accounted for and grant reimbursement or expenditures not performed timely. Management Response City management agrees with this finding. Grants Manager is in training to use the automated tracking system within Tyler Munis. The system has much greater capability than what we have been using or leveraging to date. During the first 2 quarters of 2026 we are taking steps to use the Tyler Maturity Model to refine and make sure we fully built out and turned on all features, including those for grant activity and project management. We look forward to the opportunity to grow and professionally our operations and grant accounting. Anticipated Completion Date - June 2026 Sincerely, Michael R. Oppenheimer City Controller City of Reading

View Audit 402899

Finding 1216357 (2024-003)

Material Weakness 2024

City of Mena Federal Funds

AR

Cash Management

Management of the City is committed to taking steps to ensure that expenses eligible for reimbursement are submitted to the FAA as soon as possible by the City Airport.

View Audit 402893

Finding 1216356 (2024-002)

Material Weakness 2024

City of Mena Federal Funds

AR

Cash Management

Management of the City is committed to taking steps to ensure that expenses eligible for reimbursement are submitted to the FAA as soon as possible by the City Airport.

View Audit 402893

Finding 1216355 (2024-001)

Material Weakness 2024

City of Mena Federal Funds

AR

Cash Management

Management of the City is committed to taking steps to enhance the bookkeeping and accounting at the City Airport. The City has further committed to documenting the invoice detail for each specific project be reconciled to the City's accounting records at the airport.

View Audit 402893

Finding 1216333 (2024-003)

Material Weakness 2024

City of Dade City

FL

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Significant Deficiency Finding Number: 2024-003 Federal Award Finding and Questioned Costs Corrective Action Plan The City will evaluate their processes and procedures over internal controls to ensure that all employee rate changes and payroll registers are appropriately documented and maintained. W...

Significant Deficiency Finding Number: 2024-003 Federal Award Finding and Questioned Costs Corrective Action Plan The City will evaluate their processes and procedures over internal controls to ensure that all employee rate changes and payroll registers are appropriately documented and maintained. While we maintain that oversight was in place, we concur with the finding and have identified the responsibility of the process to be placed on the finance department's fiscal assistants. The lack of documented review of the reporting process is noted, and procedures are now in place for documentation of the review and approval of the data as it is reported on portals as required. The Finance Officer will direct an accountant on staff or a professional consultant to complete the preparation of the reporting so that he/she can review and authorize the submission of reports. The implementation of upgraded software and strengthened internal control policies and procedures is a priority. Anticipated Completion Date September 30, 2026 Responsible Party The Finance Officer

View Audit 402827

Finding 1216332 (2024-001)

Material Weakness 2024

Aroostook Mental Health Services, Inc.

ME

Cash Management

2024-001 Other Matter – Financial assistance listing number 93.912 – HRSA ACORP – Cash management Name of contact person: Christy Daggett Corrective Action: The Organization will ensure that future grant draws through the payment management system are performed accurately. Additional training will b...

2024-001 Other Matter – Financial assistance listing number 93.912 – HRSA ACORP – Cash management Name of contact person: Christy Daggett Corrective Action: The Organization will ensure that future grant draws through the payment management system are performed accurately. Additional training will be provided to staff to deter errors from occurring in the future. Proposed implementation date: The corrective action plan will be implemented immediately.

View Audit 402822

Finding 1216330 (2024-103)

Material Weakness 2024

The Village at Oasis Park - Phase I, Inc.

AZ

HUD Housing Programs Reporting Significant Deficiency § 200.512

Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Hous...

Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: Part 1: Immediate corrective actions (to address immediate noncompliance). Submit all overdue Single Audit and REAC reporting packages immediately to resolve the current noncompliance. Task Responsible Party 1.1. Prepare and submit delinquent reports: 1.1.1. Assemble and finalize the overdue Single Audit Reporting Package for FY 2024 and submit it to the Federal Audit Clearinghouse (FAC). Chief Financial Officer (CFO) 1.1.2. Assemble and finalize all overdue REAC Annual Financial Statements (AFS) for FY 2024 and submit them to HUD's Financial Assessment Subsystem (FASS-MF) via the REAC Secure Systems. Property Manager 1.2. Notify HUD: 1.2.1. Immediately notify the local HUD Field Office and the assigned Account Executive of the finding and the plan for submission of all delinquent reports. Property Manager 1.3. Document and address penalties: 1.3.1. Address any penalties or noncompliance flags resulting from the late filings, which may include interaction with HUD's Departmental Enforcement Center (DEC). Property Manager / CFO Part 2: Systemic corrective actions (to prevent future noncompliance) Implement new policies and procedures to ensure all future HUD Single Audit and REAC submissions are filed on time. Task Responsible Party 2.1. Revise and implement internal policies: 2.1.1. Draft a written policy defining the timelines and responsibilities for all HUD financial and audit reporting, including Single Audit and REAC AFS submissions. This policy will be housed in the organization's Operations Manual. CEO / CFO 2.2. Develop a comprehensive compliance checklist: 2.2.1. Create and implement a calendar-based checklist for all HUD reporting requirements, with deadlines for every stage of the process, including financial data collection, auditor engagement, and submission. CFO / Property Manager 2.3. Enhance financial review and control procedures: 2.3.1. Implement a formal review and approval process for all financial statements and audit packages. Require a documented review by the CFO and sign-off by the CEO and Board of Directors before any submission. CFO 2.4. Improve communication and oversight: 2.4.1. Establish a quarterly meeting with all key staff involved in HUD reporting (CFO, Property Manager, accounting staff) to review deadlines and ensure all tasks are on schedule. CEO 2.4.2. Assign a designated staff member as the primary point of contact for external auditors and the HUD REAC Secure Systems. Property Manager 2.5. Provide staff training: 2.5.1. Schedule and conduct training for all relevant staff on the new policies, checklists, and the HUD reporting platforms (FAC and REAC Secure Systems). Third Party Training Professionals, HUD and Property Manager’s compliance officer 2.6. Address external auditor issues (if applicable): 2.6.1. Evaluate the relationship with the current external audit firm. If timeliness was a factor in the audit report delay, establish clear communication protocols and deadlines in the new engagement letter. Consider a different firm for future audits if necessary. CFO Part 3: Monitoring and future enforcement (to sustain compliance) Create a monitoring plan to ensure the corrective actions are working and that late filings do not recur. Task Responsible Party 3.1. Ongoing monitoring: 3.1.1. The CFO will provide a monthly report to the CEO on the status of all HUD reporting deadlines. The report will highlight upcoming deadlines and progress toward completion. CFO 3.2. Annual review: 3.2.1. Conduct an annual review of the HUD Reporting Policy and Compliance Checklist to ensure they are current and effective. CEO / CFO 3.3. Update internal audit program: 3.3.1. Incorporate the timely filing of HUD reports into the organization's internal audit or quality assurance program. CFO Anticipated Completion Date: December 2025

View Audit 402820

Finding 1216329 (2024-102)

Material Weakness 2024

The Village at Oasis Park - Phase I, Inc.

AZ

HUD Housing Programs Reporting Significant Deficiency

Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing...

Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. The Sponsor shall immediately remedy all past errors by correcting and if applicable, resubmit all vouchers that were inaccurate, incomplete, or submitted late. The Sponsor shall work with the property manager to create a detailed checklist to ensure all required fields and steps are completed for each voucher before submission. From there, we shall provide HUD with a report showing all corrected vouchers and detailing how the current data was reconciled with the original incorrect submissions. 2. Systemic preventative measures: • Develop and implement a training program to create a formal training curriculum for all staff involved in voucher processing. • Update internal policies and procedures to ensure that the Sponsor’s policies and procedures to include a specific, standardized process for all Section 811 voucher submissions. • Establish a monitoring and oversight protocol to ensure regular, ongoing monitoring process to review voucher submissions for accuracy and timeliness. • Leverage HUD resources and technology to ensure that all staff involved in voucher processing are trained on and regularly use the latest guidance from the HUD Exchange and relevant HUD manuals, including the TRACS Manual Voucher Submission application. • The Chief Financial Officer will be responsible for ensuring all corrective actions are implemented and sustained. Anticipated Completion Date: December 2025

View Audit 402820

Finding 1216328 (2024-101)

Material Weakness 2024

The Village at Oasis Park - Phase I, Inc.

AZ

Eligibility Material Weakness

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistanc...

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD042; AZ20Q081002 Pass-Through grantors: N/A Compliance Requirement: Eligibility Questioned Costs: Unknown Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. Complete all missed annual recertifications immediately. • Method: The property manager shall immediately Identify every tenant file where an annual income recertification was not performed. Collect and verify all required documentation from the affected tenants, using third-party verification as the preferred method. • Responsible Party: Property Manager. 2. Document all eligibility factors and discrepancies. • Method: For every affected tenant file, thoroughly document the process of verifying income, assets, and eligibility. Include explanations for any missing third-party verifications and document all follow-up attempts. • Responsible Party: Property Manager. 3. Retransmit corrected HUD Form 50059 filings to the TRACS system. • Method: Submit corrections for each tenant with a file deficiency by using the "Correction/Retransmittal" (R) code on a new Form HUD-50059A. • Responsible Party: Property Manager. 4. Address any rent-related issues arising from the missing recertifications. • Method: Calculate any potential back-rent owed by tenants due to misreporting or changes in income. Based on HUD guidelines and property policy, negotiate repayment plans if necessary, but carefully follow guidance regarding tenant culpability. • Responsible Party: Property Manager. 5. Revise and formalize resident file management policies and procedures. • Method: Update internal policy and procedural documents to establish clear, step-by-step instructions for completing annual recertifications, including all documentation requirements. Incorporate a standardized checklist for each tenant file to ensure consistent application. • Responsible Party: Controller and Property Manager. 6. Implement an improved tickler and tracking system. • Method: Use property management software to automatically generate alerts and reports for upcoming recertification deadlines. Implement a double-check process where a supervisor reviews and signs off on the list of upcoming deadlines each month to ensure no file is missed. • Responsible Party: Property Manager. 7. Provide comprehensive training for all staff involved in recertifications. • Method: Conduct mandatory training for all staff on Section 811 program requirements, focusing specifically on annual income recertifications and acceptable documentation. Include regular refresher training and create a central, accessible library of HUD guidance. • Responsible Party: Third Party Training Professionals, HUD and Property Manager’s compliance officer. 8. Establish a quality control review process. • Method: Implement a desk review process where a senior staff member or third-party consultant periodically audits a sample of completed recertification files. This internal monitoring should check for accuracy, completeness, and proper documentation. • Responsible Party: Property Manager. 9. Develop a monthly compliance monitoring report. • Method: The report will summarize the status of all recertifications for the month, listing upcoming deadlines and noting any files that required a correction. This will be presented to senior management. • Responsible Party: Property Manager. 10. Conduct a follow-up review. • Method: Engage an external auditor or consultant to perform a follow-up review of recertification files after the first year of the new procedures. This independent assessment will verify that the corrective actions are working effectively. • Responsible Party: Senior Management. 11. Provide status reports to HUD. • Method: As per the notice of noncompliance, submit regular reports to the relevant HUD Hub or Program Center detailing the progress on the CAP and any specific items requested. • Responsible Party: Property Manager and Chief Financial Officer of Sponsor. Anticipated Completion Date: December 2025

View Audit 402820

Finding 1216327 (2024-103)

Material Weakness 2024

The Village at Oasis Park - Phase Ii, Inc.

AZ

HUD Housing Programs Reporting Significant Deficiency § 200.512

Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Hous...

Finding 2024 – 103 – Single Audit Reporting Package and U.S. Housing and Urban Development REAC Submissions Not Filed Timely. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD046; AZ20Q091002 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: Part 1: Immediate corrective actions (to address immediate noncompliance). Submit all overdue Single Audit and REAC reporting packages immediately to resolve the current noncompliance. Task Responsible Party 1.1. Prepare and submit delinquent reports: 1.1.1. Assemble and finalize the overdue Single Audit Reporting Package for FY 2024 and submit it to the Federal Audit Clearinghouse (FAC). Chief Financial Officer (CFO) 1.1.2. Assemble and finalize all overdue REAC Annual Financial Statements (AFS) for FY 2024 and submit them to HUD's Financial Assessment Subsystem (FASS-MF) via the REAC Secure Systems. Property Manager 1.2. Notify HUD: 1.2.1. Immediately notify the local HUD Field Office and the assigned Account Executive of the finding and the plan for submission of all delinquent reports. Property Manager 1.3. Document and address penalties: 1.3.1. Address any penalties or noncompliance flags resulting from the late filings, which may include interaction with HUD's Departmental Enforcement Center (DEC). Property Manager / CFO Part 2: Systemic corrective actions (to prevent future noncompliance) Implement new policies and procedures to ensure all future HUD Single Audit and REAC submissions are filed on time. Task Responsible Party 2.1. Revise and implement internal policies: 2.1.1. Draft a written policy defining the timelines and responsibilities for all HUD financial and audit reporting, including Single Audit and REAC AFS submissions. This policy will be housed in the organization's Operations Manual. CEO / CFO 2.2. Develop a comprehensive compliance checklist: 2.2.1. Create and implement a calendar-based checklist for all HUD reporting requirements, with deadlines for every stage of the process, including financial data collection, auditor engagement, and submission. CFO / Property Manager 2.3. Enhance financial review and control procedures: 2.3.1. Implement a formal review and approval process for all financial statements and audit packages. Require a documented review by the CFO and sign-off by the CEO and Board of Directors before any submission. CFO 2.4. Improve communication and oversight: 2.4.1. Establish a quarterly meeting with all key staff involved in HUD reporting (CFO, Property Manager, accounting staff) to review deadlines and ensure all tasks are on schedule. CEO 2.4.2. Assign a designated staff member as the primary point of contact for external auditors and the HUD REAC Secure Systems. Property Manager 2.5. Provide staff training: 2.5.1. Schedule and conduct training for all relevant staff on the new policies, checklists, and the HUD reporting platforms (FAC and REAC Secure Systems). Third Party Training Professionals, HUD and Property Manager’s compliance officer 2.6. Address external auditor issues (if applicable): 2.6.1. Evaluate the relationship with the current external audit firm. If timeliness was a factor in the audit report delay, establish clear communication protocols and deadlines in the new engagement letter. Consider a different firm for future audits if necessary. CFO Part 3: Monitoring and future enforcement (to sustain compliance) Create a monitoring plan to ensure the corrective actions are working and that late filings do not recur. Task Responsible Party 3.1. Ongoing monitoring: 3.1.1. The CFO will provide a monthly report to the CEO on the status of all HUD reporting deadlines. The report will highlight upcoming deadlines and progress toward completion. CFO 3.2. Annual review: 3.2.1. Conduct an annual review of the HUD Reporting Policy and Compliance Checklist to ensure they are current and effective. CEO / CFO 3.3. Update internal audit program: 3.3.1. Incorporate the timely filing of HUD reports into the organization's internal audit or quality assurance program. CFO Anticipated Completion Date: December 2025

View Audit 402819

Finding 1216326 (2024-102)

Material Weakness 2024

The Village at Oasis Park - Phase Ii, Inc.

AZ

HUD Housing Programs Reporting Significant Deficiency

Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing...

Finding 2024 – 102 – Submission of Voucher information to HUD sub-systems. (Significant Deficiency, Compliance Finding-Other Matter) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD046; AZ20Q09100 Pass-Through grantors: N/A Compliance Requirement: Reporting Questioned Costs: N/A Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. The Sponsor shall immediately remedy all past errors by correcting and if applicable, resubmit all vouchers that were inaccurate, incomplete, or submitted late. The Sponsor shall work with the property manager to create a detailed checklist to ensure all required fields and steps are completed for each voucher before submission. From there, we shall provide HUD with a report showing all corrected vouchers and detailing how the current data was reconciled with the original incorrect submissions. 2. Systemic preventative measures: • Develop and implement a training program to create a formal training curriculum for all staff involved in voucher processing. • Update internal policies and procedures to ensure that the Sponsor’s policies and procedures to include a specific, standardized process for all Section 811 voucher submissions. • Establish a monitoring and oversight protocol to ensure regular, ongoing monitoring process to review voucher submissions for accuracy and timeliness. • Leverage HUD resources and technology to ensure that all staff involved in voucher processing are trained on and regularly use the latest guidance from the HUD Exchange and relevant HUD manuals, including the TRACS Manual Voucher Submission application. • The Chief Financial Officer will be responsible for ensuring all corrective actions are implemented and sustained. Anticipated Completion Date: December 2025

View Audit 402819

Finding 1216325 (2024-101)

Material Weakness 2024

The Village at Oasis Park - Phase Ii, Inc.

AZ

Eligibility Material Weakness

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistanc...

Finding 2024 – 101 – Annual Recertification of Income Not Performed, Documentation of Eligibility (Material Weakness, Material Noncompliance) Federal program information: Funding agency: U.S. Department of Housing and Urban Development Title: Supportive Housing for people with disabilities Assistance Listing Number: 14.181 Award year: 2023/2024 Award numbers: Project 123-HD046; AZ20Q09100 Pass-Through grantors: N/A Compliance Requirement: Eligibility Questioned Costs: Unknown Contact Name: Joe Keeper, Chief Financial Officer of the Sponsor Corrective Action Planned: 1. Complete all missed annual recertifications immediately. • Method: The property manager shall immediately Identify every tenant file where an annual income recertification was not performed. Collect and verify all required documentation from the affected tenants, using third-party verification as the preferred method. • Responsible Party: Property Manager. 2. Document all eligibility factors and discrepancies. • Method: For every affected tenant file, thoroughly document the process of verifying income, assets, and eligibility. Include explanations for any missing third-party verifications and document all follow-up attempts. • Responsible Party: Property Manager. 3. Retransmit corrected HUD Form 50059 filings to the TRACS system. • Method: Submit corrections for each tenant with a file deficiency by using the "Correction/Retransmittal" (R) code on a new Form HUD-50059A. • Responsible Party: Property Manager. 4. Address any rent-related issues arising from the missing recertifications. • Method: Calculate any potential back-rent owed by tenants due to misreporting or changes in income. Based on HUD guidelines and property policy, negotiate repayment plans if necessary, but carefully follow guidance regarding tenant culpability. • Responsible Party: Property Manager. 5. Revise and formalize resident file management policies and procedures. • Method: Update internal policy and procedural documents to establish clear, step-by-step instructions for completing annual recertifications, including all documentation requirements. Incorporate a standardized checklist for each tenant file to ensure consistent application. • Responsible Party: Controller and Property Manager. 6. Implement an improved tickler and tracking system. • Method: Use property management software to automatically generate alerts and reports for upcoming recertification deadlines. Implement a double-check process where a supervisor reviews and signs off on the list of upcoming deadlines each month to ensure no file is missed. • Responsible Party: Property Manager. 7. Provide comprehensive training for all staff involved in recertifications. • Method: Conduct mandatory training for all staff on Section 811 program requirements, focusing specifically on annual income recertifications and acceptable documentation. Include regular refresher training and create a central, accessible library of HUD guidance. • Responsible Party: Third Party Training Professionals, HUD and Property Manager’s compliance officer. 8. Establish a quality control review process. • Method: Implement a desk review process where a senior staff member or third-party consultant periodically audits a sample of completed recertification files. This internal monitoring should check for accuracy, completeness, and proper documentation. • Responsible Party: Property Manager. 9. Develop a monthly compliance monitoring report. • Method: The report will summarize the status of all recertifications for the month, listing upcoming deadlines and noting any files that required a correction. This will be presented to senior management. • Responsible Party: Property Manager. 10. Conduct a follow-up review. • Method: Engage an external auditor or consultant to perform a follow-up review of recertification files after the first year of the new procedures. This independent assessment will verify that the corrective actions are working effectively. • Responsible Party: Senior Management. 11. Provide status reports to HUD. • Method: As per the notice of noncompliance, submit regular reports to the relevant HUD Hub or Program Center detailing the progress on the CAP and any specific items requested. • Responsible Party: Property Manager and Chief Financial Officer of Sponsor. Anticipated Completion Date: December 2025

View Audit 402819

Finding 1216308 (2024-001)

Material Weakness 2024

Greene County

NY

Reporting Internal Control / Segregation of Duties Significant Deficiency

CORRECTIVE ACTION PLAN Finding – 2024-001 Coronavirus State and Local Recovery Funds, ALN 21.027 Compliance Requirement - Reporting Criteria Recipients of SLFRF funds are required to submit complete, accurate and timely Project and Expenditure Reports in accordance with U.S. Department of Treasury g...

CORRECTIVE ACTION PLAN Finding – 2024-001 Coronavirus State and Local Recovery Funds, ALN 21.027 Compliance Requirement - Reporting Criteria Recipients of SLFRF funds are required to submit complete, accurate and timely Project and Expenditure Reports in accordance with U.S. Department of Treasury guidance and the Uniform Guidance. Reporting requirements include: • Accurate reporting of obligations and expenditures by project and expenditure category. • Submission of all required data elements prescribed by Treasury. • Retention of documentation is sufficient to support reported financial and programmatic information. Condition The County did not fully comply with U.S. Department of Treasury SLFRF reporting requirements for the period ended December 31, 2024. Specifically, the County’s Project and Expenditure Report submitted through the Treasury Reporting Portal was incomplete and/or inaccurate. Noted exception included: • Inaccurate reporting of obligated and expended amounts for one or more SLFRF projects. As a result, the SLFRF report submitted was not complete, accurate, or fully supported as required. Recommendation We recommend that the County: 1) Establish and document formal SLFRF reporting policies and procedures. 2) Implement a reconciliation process between accounting records and reported SLFRF data. 3) Require supervisory review and approval of all SLFRF submissions prior to reporting to Treasury. 4) Provide ongoing training to staff responsible for SLFRF compliance and reporting. 5) Maintain complete and organized documentation to support all reported obligations and expenditures. Response We are in agreement with the recommendation and management will take steps to strengthen internal controls over SLFRF reporting. These actions include enhancing reconciliation procedures between the accounting records and amounts reported to the Treasury reporting portal and implementing an additional level of supervisory review prior to report submission. Anticipated Completion Date This will be corrected for the December 31, 2025 audit. Person Responsible Deborah Gallo Deputy County Treasurer

View Audit 402796

Finding 1216303 (2024-003)

Material Weakness 2024

Connecticut Children's Medical Center and Subsidiaries

CT

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconcil...

Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconciliation Workflow and System Controls The State of Connecticut utilizes CT WiZ, a centralized vaccine ordering and supply management system. To maintain ordering privileges, the program enforces a strict regulatory safeguard: inventory must be fully reconciled every two weeks. Failure to complete this reconciliation triggers an automated, hard stop within CT WiZ, preventing any additional vaccine orders from being placed. To ensure absolute accuracy and data integrity, our practice executes a standardized, threepart reconciliation process that typically leverages a dual-provider verification model: • Part 1: Physical Count (Floor Staff): Clinical nurses on the floor conduct a manual, physical inventory of all vaccine doses, cross-referencing exact lot numbers and expiration dates. • Part 2: Electronic Health Record Alignment (Coordinator): The designated Vaccine Coordinator reviews the physical counts against the electronic Lot Manager log within Epic to identify and resolve any administrative discrepancies. • Part 3: State System Data Entry (Coordinator): The verified quantities are formally submitted into the CT WiZ portal to complete the biweekly cycle and clear the system for subsequent orders. Staffing Redundancy: While a single coordinator may occasionally manage all three steps if cross-covering the floor, the workflow is deliberately structured to divide tasks between floor nurses (physical counts) and site coordinators (via EMR reconciliation and CT WiZ entry). 2. Vaccine Oversight Team Vaccine operations are managed through a centralized leadership structure with site-specific accountability to ensure consistent oversight at clinic locations. Vaccine operations may be managed by a senior nurse practice manager, practice manager, lead nurse or a backup coordinator. This triad ensures continuous coverage, strict adherence to ordering schedules, and immediate troubleshooting for storage or inventory alerts. 3. Storage, Handling, and Annual Training Compliance In alignment with state oversight expectations and the strict guidelines governing CVP asset management, cold-chain integrity and proper handling are heavily protected. To mitigate risk and standardize knowledge across all care teams, the following educational requirements are mandated: • Mandatory Annual Training: All rostered nursing personnel - including core staff, float pool, and per diem nurses - are strictly required to complete annual training modules dedicated to CVP guidelines and CDC Storage and Handling. • Verification of Competency: Training must be completed through the official CDC TRAIN platform, and employees must submit their earned certificates of completion to clinical leadership to be maintained on file for audit readiness. Name(s) of Contact Person(s) Responsible for Corrective Action: Matthew Farr, VP Ambulatory Operations, Cynthia O’Brien, Senior Nurse Manager Practice Operations Anticipated Completion Date: 01/01/2026

View Audit 402778

Finding 1216302 (2024-002)

Material Weakness 2024

Connecticut Children's Medical Center and Subsidiaries

CT

Allowable Costs / Cost Principles § 200.430

Corrective Action Planned: Management acknowledges the finding related to the lack of formal documentation maintained evidencing a hindsight review of employee working hours to verify alignment between actual hours. The Effort Reporting requirement is now met with a revamped process that includes an...

Corrective Action Planned: Management acknowledges the finding related to the lack of formal documentation maintained evidencing a hindsight review of employee working hours to verify alignment between actual hours. The Effort Reporting requirement is now met with a revamped process that includes an updated institutional effort reporting policy and development of a newly developed effort reporting workflow that aligned with the relatively recent (April 2024) implementation of new ERP system Oracle. This new process applies to those team members who have effort either charged, in-kind or cost-shared, to a grant funded project. The new Effort Reporting workflow formally went live institution wide on 10/1/25, with a pilot implementation done in September 2025. Effort reporting is conducted monthly and requires a preview of all team members with effort allocated to grants from an automated report. Each report is reviewed for accuracy and then each line item is entered into a Smartsheet format for automated delivery of an individual effort report to each team member. A mid-month report is automated to flag and identify upcoming end dates of grant funding in preparation of the next month effort report. This midmonth review is necessary to adjust for any edits needed in preparation for the next month effort report workflow. In addition, the new process allows for follow up with escalation if individual effort report(s) are not signed by respective team member(s) within the prescribed monthly due date. Name(s) of Contact Person(s) Responsible for Corrective Action: Kimberly Davey, Director Office for Sponsored Programs Anticipated Completion Date: Completion 9/30/2025, active as of 10/01/2025

View Audit 402778

Finding 1216237 (2024-010)

Material Weakness 2024

Barclay College

KS

Subrecipient Monitoring Material Weakness

2024-010 Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: We will review items not fully implemented. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026

View Audit 402736

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