Corrective Action Plans

Finding 1155821 (2025-001)

Material Weakness 2025

ID

Reporting Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.512

Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...

Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025

View Audit 368214

Finding 1155793 (2025-001)

Material Weakness 2025

Ocracoke Health Center, Inc.

NC

Reporting HUD Housing Programs Equipment & Real Property Management

Management will review its finance infrastructure and the related cost/benefit of hiring additional staff with the required expertise.

View Audit 368201

Finding 1155791 (2025-002)

Material Weakness 2025

Warren Village, Inc.

CO

HUD Housing Programs Internal Control / Segregation of Duties

Cognizant or Oversight Agency for Audit, Warren Village, Inc. respectfully submits the following corrective action plan for the year ended March 31 , 2025. Audit period: Ended March 31 , 2025 The findings from the 3/31/2025 schedule of findings and questioned costs are summarized below. The find ing...

Cognizant or Oversight Agency for Audit, Warren Village, Inc. respectfully submits the following corrective action plan for the year ended March 31 , 2025. Audit period: Ended March 31 , 2025 The findings from the 3/31/2025 schedule of findings and questioned costs are summarized below. The find ings are numbered consistently with the numbers assigned in the schedule. Financial Statement Audit Findings Material Weakness 2025-001: Adjusting Journal Entries Recommendation: Auditors recommend the Organization improve communication with the Partnership and the Partnership auditor to ensure all related Partnership transactions are recorded timely, accurately and within the appropriate period. Action Taken: Management will engage the Partnership auditor earlier in more thorough communication around audited financial statement details and reconciling entries in future years, beginning with the 2025 calendar year audit commencing March 2026. Management was challenged by the one-time, varying construction project and LIHTC partner deliverables, complex legal entity pieces, and shortage of review and financial integration time between audits. Responsible Party: Vice President of Strategy, Finance & Operations Anticipated Date of Completion: June 2026 Responsible Contact: Amy Fleming, 303-320-5050 or email afleming@warrenvillage.org . Federal Award Findings and Questioned Costs Elig ibility, Significant Deficiency 2025-002: U.S. Department of Housing and Urban Development - Section 8 - Housing Assistance Payments Program Assistance Listing No.14.195 Recommendation: Auditors recommend that the Organization confer with Property Management staff to examine selected tenant files from the transition of property management companies through the recertification period of all tenants up to July and August 2025 to ensure appropriate evidence is contained within all tenant files to support complete tenant certification and eligibility. Action Taken: We have discussed with property management a review of all tenant files fromJune 2024 to August 2025 and requested a third-party compliance company or equivalent experience be engaged. Corrections will be made where feasible along with ongoing process improvements, including the implementation of a new internal Housing Director position to provide greater oversight of files and property management accountability. The Housing Director was hired July 21, 2025, with a target date set of December 31, 2025, for completed file review. Responsible Party: Housing Director, Vice President of Strategy, Finance & Operations and Property Management (Rocky Mountain Communities) Anticipated Date of Completion: January 2026 Responsible Contact: Amy Fleming, 303-320-5050 or email afleming@warrenvillage.org If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Amy Fleming, Vice President of Strategy, Finance & Operations at 303-320-5050 or email at afleming@warrenvillage.org.

View Audit 368188

Finding 1155767 (2025-001)

Material Weakness 2025

Central Park Senior Residences, Inc.

KS

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the securi...

Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the security deposit cash account to the former tenant. Action(s) taken or planned on the finding: The management agent refunded $407 to the former tenant on August 25, 2025.

View Audit 368134 Questioned Costs: $1

Finding 1155765 (2025-001)

Material Weakness 2025

Southern Hills Senior Residences, Inc.

KS

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent will ...

Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent will reimburse $3,118 to the Corporation.

View Audit 368133 Questioned Costs: $1

Finding 1155715 (2025-001)

Material Weakness 2025

National Crime Victim Law Institute

OR

Cash Management Internal Control / Segregation of Duties

National Crime Victim Law Institute (NCVLI) recognizes and agrees with the recommendation to reconcile contract billings to the accounting records and a closer in time review of the reconciliation before invoicing the government agency. While NCVLI has historically done this type of reconciliation, ...

National Crime Victim Law Institute (NCVLI) recognizes and agrees with the recommendation to reconcile contract billings to the accounting records and a closer in time review of the reconciliation before invoicing the government agency. While NCVLI has historically done this type of reconciliation, during this particular year where a confluence of events made the year-end more challenging (e.g., quarterly contract billings that straddle two fiscal years, loss of staffing and accounting contractor due to budget cuts, delayed reconciliation with Lewis & Clark College due to Lewis & Clark’s processes which serves as a bank account for NCVLI), we agree the process becomes even more critical. NCVLI agrees that costs charged to federal awards should be supported by the accounting records and has historically ensured this happened. We will, however, further improve internal processes to enhance accuracy of tracking, comparing and reviewing billings and expenses to mitigate the chance of this happening in the future. Notably, this error was fixed immediately by adjusting the next monthly billing for June 2025.

View Audit 368000

Finding 1155657 (2025-006)

Material Weakness 2025

Charter Township of Redford

MI

Subrecipient Monitoring Reporting Material Weakness

Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contac...

Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026

View Audit 367921

Finding 1155654 (2025-005)

Material Weakness 2025

Charter Township of Redford

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

Corrective Action Plans

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