Corrective Action Plans

Finding 1155654 (2025-005)

Material Weakness 2025

MI

Matching / Level of Effort / Earmarking Cash Management Material Weakness § 200.303

Finding Number: 2025-005 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corre...

Finding Number: 2025-005 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corrective Action: The Township will update the Grant Policy to include a requirement for dual review on all grant reporting. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026

View Audit 367921

Finding 1155653 (2025-004)

Material Weakness 2025

Charter Township of Redford

MI

Procurement, Suspension & Debarment

Finding Number: 2025-004 Condition: The Township did not have a control in place to retain evidence that it performed a check to verify the contractors used under these programs were not suspended or debarred. Planned Corrective Action: The Township will put controls in place around retaining suppor...

Finding Number: 2025-004 Condition: The Township did not have a control in place to retain evidence that it performed a check to verify the contractors used under these programs were not suspended or debarred. Planned Corrective Action: The Township will put controls in place around retaining support for suspension and debarment verifications. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026

View Audit 367921

Finding 1155472 (2025-002)

Material Weakness 2025

Village of Decatur

MI

Procurement, Suspension & Debarment Subrecipient Monitoring

Management drafted an updated procurement policy to comply with the requirements of the Uniform Guidance, which was approved by the Village Council at a special meeting on June 23, 2025.

View Audit 367758

Finding 1155379 (2025-001)

Material Weakness 2025

Pineview, Inc.

IN

Questioned Costs

The Project deposited $272 into the reserve for replacement account.

View Audit 367628 Questioned Costs: $1

Finding 1155378 (2025-001)

Material Weakness 2025

Mapleview, Inc.

IN

Questioned Costs

The Project deposited $3,150 into the reserve for replacement account.

View Audit 367626 Questioned Costs: $1

Finding 1155368 (2025-001)

Material Weakness 2025

Milwaukee Health Services, Inc.

WI

Special Tests & Provisions

Milwaukee Health Services, Inc. (the "Organization") submits the following corrective action plan for the identified finding and questioned costs for the year ending January 31, 2025. Finding 2025-001: Special Tests and Provisions - Sliding Fees Statement of Condition: External auditors reviewed 40 ...

Milwaukee Health Services, Inc. (the "Organization") submits the following corrective action plan for the identified finding and questioned costs for the year ending January 31, 2025. Finding 2025-001: Special Tests and Provisions - Sliding Fees Statement of Condition: External auditors reviewed 40 sliding fee transactions to verify if the amount charged under the Organization's sliding fee program was calculated properly based on the patient's income level and in compliance with the Organization's sliding fee policy. External auditors noted that two ofthe sampled transactions were not properly determined resulting in the patients being over or undercharged for services. Corrective Action: The Organization will review its sliding fee policies and monitor determinations. Staff responsible for sliding fee determinations will be trained on properly computing sliding fees. The Organization will also review the system controls and safeguards within OCHIN Epic (Electronic Health Record) for assisting in sliding fee calculation accuracy. Person Responsible for Corrective Action: Joyce Nwatuobi, Chief Financial Officer Anticipated Timing for Completion of Corrective Action: November 30, 2025.

View Audit 367610

Finding 1155343 (2025-002)

Material Weakness 2025

Pioneer Apartments INC

WY

Questioned Costs Cash Management Material Weakness

Finding 2025-002 See response to finding 2025-001.

View Audit 367580 Questioned Costs: $1

Finding 1154987 (2025-001)

Material Weakness 2025

Community Health Centers of Central Wyoming, Inc.

WY

Special Tests & Provisions Material Weakness Significant Deficiency

2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the sta...

2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the staff on the form, and process to review each application to ensure compliance with the approved policy. The following actions will be taken: 1. Develop a formal peer review form and process for reviewing sliding fee scale applications. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 11, 2025 2. Provide training to all billing staff for peer review process and forms. Implementation of the process after training. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 12, 2025 and September 1, 2025 3. Monitor for effectiveness. After completion of peer review, the two managers will review and provide feedback to each employee monthly. Billing staff will be responsible for completing reviews and feedback on process and form structure. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: September 18, 2025 4. Verify effectiveness. The CFO and Revenue Cycle Manager will conduct a random audit of the peer review forms and ensure compliance with the policy for slide applications and ensure the peer review forms are completed, signed and dated. Anticipated completion date: March 1, 2026 Contact person responsible for corrective action: Evan Condelario, CFO

View Audit 367336

Finding 1154962 (2025-004)

Material Weakness 2025

Miami-Cass County Rural Electric Membership Corporation

IN

Questioned Costs Eligibility

Management of Miami-Cass REMC and Subsidiary will implement procedures to prevent unallowable costs. In addition, the State of Indiana Office of Community and Rural Affairs will be alerted of the questioned costs. Management agrees with this finding.

View Audit 367301 Questioned Costs: $1

Finding 1154961 (2025-003)

Material Weakness 2025

Miami-Cass County Rural Electric Membership Corporation

IN

Management of Miami-Cass REMC and Subsidiary was aware of lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate duties at this time. Management Agrees with the findings.

View Audit 367301

Finding 1154960 (2025-002)

Material Weakness 2025

Miami-Cass County Rural Electric Membership Corporation

IN

Management of Miami-Cass REMC and Subsidiary will implement procedures to monitor and review accounts throughout the year. Management agrees with the findings.

View Audit 367301

Finding 1154959 (2025-001)

Material Weakness 2025

Miami-Cass County Rural Electric Membership Corporation

IN

Procurement, Suspension & Debarment Subrecipient Monitoring

Management of Miami-Cass REMC and Subsidiary will properly adhere to its written policy that governs the process for the procurement of materials and services in the future and add additional monitoring to prevent future error. Management agrees with the findings.

View Audit 367301

Finding 1153882 (2025-003)

Material Weakness 2025

Housing Authority of the City of Trinidad

CO

HUD Housing Programs Matching / Level of Effort / Earmarking

2025-002. HUD Project loan made to other HUD Programs Corrective action planned: Trinidad Housing Authority is searching for other Accounting Services for the Housing Authority. We are currently working on a payment plan with payroll for Corazon Square and have started processing payments to Low Ren...

2025-002. HUD Project loan made to other HUD Programs Corrective action planned: Trinidad Housing Authority is searching for other Accounting Services for the Housing Authority. We are currently working on a payment plan with payroll for Corazon Square and have started processing payments to Low Rent. As we are moving forward in our search for accounting services, we will continue to pay equal amounts monthly to Low Rent. Contact person: Kathee Gutierrez Adams, Interim Executive Director. Anticipated completion date: Our goal is to be completely in compliance by end of fiscal year March 31, 2026.

View Audit 366945

Finding 1153768 (2025-003)

Material Weakness 2025

Housing Authority of the City of Meadville

PA

HUD Housing Programs Allowable Costs / Cost Principles Cash Management

HACM Management will sign all Capital Fund vouchers going forward.

View Audit 366863

Finding 1153764 (2025-001)

Material Weakness 2025

Foothills Community Health Care, Inc.

SC

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

In Finding 2025-001, it was reported that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing. In addition, one patient ...

In Finding 2025-001, it was reported that the Organization did not maintain proper documentation of all necessary elements of sliding fee discounts as required by the Organization’s policy. This was a result of sliding fee applications being incomplete, expired, or missing. In addition, one patient who qualified for a discount did not receive a discount. Management recognizes the importance of complying with federal sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, procedures will be established to ensure employees are trained to maintain the required documentation, including sliding fee applications, for sliding fee discounts provided. The Organization will establish procedures to ensure that selected patient records are reviewed by a supervisor on a periodic basis to ensure that the required documentation is properly maintained and that the patients receive the proper discount in accordance with the Organization’s policies.

View Audit 366861

Finding 1153703 (2025-001)

Material Weakness 2025

Gardner Commons Development Corporation

ME

Reporting § 200.512

View of Responsible Official and Corrective Action The delay in the submission of the Data Collection Form was a direct result of the audit team moving to a new accounting firm and a miscommunication as to which firm was going to assist with the completion of the Data Collection Form. Management has...

View of Responsible Official and Corrective Action The delay in the submission of the Data Collection Form was a direct result of the audit team moving to a new accounting firm and a miscommunication as to which firm was going to assist with the completion of the Data Collection Form. Management has taken steps to ensure that the Data Collection Form for the year-ended June 30, 2025 will be submitted timely. Upon identifying the late submission, management immediately completed the submission of the 2024 Data Collection Form and reporting package on August 12, 2025.

View Audit 366840

Finding 1153477 (2025-002)

Material Weakness 2025

The Corporation of Gonzaga University

WA

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported wit...

FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported within the federally required timeframe. Strengthening this process will support the timeliness of federal compliance. Response: There is no disagreement with this audit finding. Action taken in response to finding: Some of the corrective actions noted in our response to finding 2025-001 also apply here. For example, quality assurance reports to identify students who withdraw from all classes in a part of term and the upcoming joint training and process mapping session with Student Financial Services and the Registrar’s Office will strengthen understanding of how enrollment status updates drive downstream compliance, including R2T4 processing. These steps will also ensure exceptions are addressed consistently and that communication channels between offices are clear. To address immediate gaps specific to R2T4 compliance, the Registrar’s Office has enhanced training regarding R2T4 compliance requirements related to recording withdrawals and enrollment changes in a timely, accurate and consistent manner. Additional quality checks are being implemented to confirm that withdrawal dates and status changes are entered accurately into the student information system so that R2T4 calculations are completed within federal timeframes. Together, these interventions are designed to ensure the timeliness and accuracy of R2T4 processing and compliance with federal requirements. We expect to have these corrective actions completed by September 12, 2025. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research

View Audit 366726

Finding 1153470 (2025-001)

Material Weakness 2025

The Corporation of Gonzaga University

WA

Student Financial Aid Special Tests & Provisions Reporting

FINDING 2025‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a reconciliation between the system of record and the reporting system to ensure all student changes (enrollment status an...

FINDING 2025‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a reconciliation between the system of record and the reporting system to ensure all student changes (enrollment status and address changes) are reported on a timely basis. Response: There is no disagreement with this audit finding. Action taken in response to finding: Gonzaga has already taken action and implemented quality assurance reports and monitoring to ensure all student changes (enrollment status and address changes) are reported timely. Additionally, to strengthen compliance going forward, Student Financial Services and the Registrar’s Office are partnering to conduct a joint annual training and process mapping session for key personnel. This session will provide an overview of enrollment reporting requirements, outline the steps needed when exceptions to normal policies occur, and evaluate processes to improve understanding of how decisions affect both upstream and downstream functions. The session will also focus on building a shared understanding of reporting processes, identifying gaps in procedures and knowledge, and establishing communication channels so that exceptions are addressed timely, consistently and appropriately. These actions are designed to enhance internal controls and ensure compliance of timely reporting between the system of record and the reporting system, and we expect to complete this training by September 12, 2025. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research

View Audit 366726

Finding 1153460 (2025-003)

Material Weakness 2025

Cheboygan Housing Commission

MI

Internal Control / Segregation of Duties

The current Occupancy Specialist is developing a training and implementation plan to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that HQS inspections are pe...

The current Occupancy Specialist is developing a training and implementation plan to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that HQS inspections are performed in a timely manner and in accordance will all applicable HUD requirements.

View Audit 366709

Finding 1153459 (2025-002)

Material Weakness 2025

Cheboygan Housing Commission

MI

HUD Housing Programs Internal Control / Segregation of Duties

The current Occupancy Specialist is developing a training and implementation plan to ensure that rent reasonableness calculations are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenan...

The current Occupancy Specialist is developing a training and implementation plan to ensure that rent reasonableness calculations are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of rent reasonableness calculations and other required paperwork is included in the tenant files.

View Audit 366709

Finding 1153458 (2025-001)

Material Weakness 2025

Cheboygan Housing Commission

MI

HUD Housing Programs Internal Control / Segregation of Duties

The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant ...

The current Occupancy Specialist is developing a training and implementation plan to ensure that annual tenant recertifications are performed in a timely manner and in accordance will all applicable HUD requirements. The Executive Director is developing controls and procedures to ensure that tenant files are reviewed for compliance with regulatory citations and ensure that supportive documentation of income from tenants and other required paperwork is included in the tenant files.

View Audit 366709

Finding 1153433 (2025-001)

Material Weakness 2025

Blue Ridge Rural Water CO INC

SC

HUD Housing Programs

The duties will be segregated as much as possible and the Directors will remain involved in the financial affairs of the Company to provide oversight and independent review functions.

View Audit 366673

Finding 1153310 (2025-002)

Material Weakness 2025

Mountain Famly Health Centers

CO

Questioned Costs Subrecipient Monitoring Eligibility

Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...

Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.

View Audit 366550 Questioned Costs: $1

Finding 1153268 (2025-001)

Material Weakness 2025

B.r.l Housing Corporation

OH

HUD Housing Programs Reporting Special Tests & Provisions

Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the f...

Finding 2025-001 Delay in Deposit of Surplus Cash into Residual Receipts Account ___ : Comments on Findings and Recommendations: Surplus cash of $76,388 from FY 2024 was deposited into the Residual Receipts account 98 days after year-end, exceeding HUD's 60-day requirement by 38 days. Although the full amount was deposited, the delay constituted noncompliance with HUD's timing rules. To address this, management will implement procedures to ensure surplus cash deposits are made within 60 days based on unaudited computations, track and schedule deposits in advance, formally request HUD approval if deferrals are necessary, and maintain documentation of all related communications and approvals for compliance purposes. Actions Taken or Planned on the Findings: This was paid on check # 9841 Working on an implementation program for the future. Completion Date: August 25, 2025 Finding Resolution Status: In-Process Contact Person: Controller: Don Trigg Accountant: Charley Hinkle

View Audit 366462

Finding 1153168 (2025-005)

Material Weakness 2025

Outpatient Medical Center, Inc.

LA

Procurement, Suspension & Debarment § 200.214

2025-005 Suspension and Debarment Corrective action planned: OMC currently has a policy and procedure for vendor exclusion checks prior to executing contracts. This finding appears to be an incidental omission that resulted in no excluded vendors being identified. In one case, the vendor was an exis...

2025-005 Suspension and Debarment Corrective action planned: OMC currently has a policy and procedure for vendor exclusion checks prior to executing contracts. This finding appears to be an incidental omission that resulted in no excluded vendors being identified. In one case, the vendor was an existing one for many years. The CFO/Designee will monitor to assure exclusion checks prior to CEO signing any contracts or purchase orders with any vendor over $25,000 per year and will update policy as necessary in accordance with regulations. OMC will seek HRSA guidance on periodic review of existing vendors Anticipated completion date: September 30, 2025 Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations

View Audit 366393

Corrective Action Plans

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