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Corrective Action Plans

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Finding 1220605 (2025-001)
Material Weakness 2025
St. Mary's Manor for Senior Citizen Housing Development Fund Company, Inc.
NY
HUD Housing Programs
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405452
Finding 1220604 (2025-002)
Material Weakness 2025
St. Paul's Gardens Housing Development Fund Company, Inc.
NY
HUD Housing Programs
Corrective Action Plan: The return of tenant security deposits were not completed on time due to staff turnover. Stanan’s occupancy specialist and supervisor will closely monitor the timing of the return of security deposits. Anticipated Completion Date: The implementation of training and procedures...
Corrective Action Plan: The return of tenant security deposits were not completed on time due to staff turnover. Stanan’s occupancy specialist and supervisor will closely monitor the timing of the return of security deposits. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405451
Finding 1220603 (2025-001)
Material Weakness 2025
St. Paul's Gardens Housing Development Fund Company, Inc.
NY
HUD Housing Programs Eligibility
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405451
Finding 1220602 (2025-002)
Material Weakness 2025
Idaho Primary Care Association, Inc.
ID
Procurement, Suspension & Debarment Eligibility § 200.213
Documented Policies and Procedures related to Suspension and Debarment Recommendation: ICHCA should implement formal written policies in compliance with suspension and debarment requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action plan...
Documented Policies and Procedures related to Suspension and Debarment Recommendation: ICHCA should implement formal written policies in compliance with suspension and debarment requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: ICHCA staff were provided a refresher on suspension and debarment documentation requirements, and policies and procedures were updated to emphasis the need to retain documentation of exclusion and debarment inquiries. Personnel have been filing documentation with contracts as of April 2026. Name(s) of the contact person(s) responsible for corrective action: Kyle Rooks, CEO Planned completion date for corrective action plan: April 2026
View Audit 405450
Finding 1220601 (2025-001)
Material Weakness 2025
St. Agnes Senior Citizen Housing Development Fund Company, Inc.
NY
HUD Housing Programs Student Financial Aid Eligibility
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405449
Finding 1220600 (2025-001)
Material Weakness 2025
Saint Jeanne Jugan Village II
NY
HUD Housing Programs Eligibility
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405447
Finding 1220599 (2025-001)
Material Weakness 2025
Saint Jeanne Jugan Village I
NY
HUD Housing Programs Eligibility
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405446
Finding 1220598 (2025-002)
Material Weakness 2025
George Link, Jr. Apartments Housing Development Fund Company, Inc.
NY
HUD Housing Programs Student Financial Aid Matching / Level of Effort / Earmarking
Corrective Action Plan: The return of tenant security deposits were not completed on time due to staff turnover. Stanan’s occupancy specialist and supervisor will closely monitor the timing of the return of security deposits. Anticipated Completion Date: The implementation of training and procedures...
Corrective Action Plan: The return of tenant security deposits were not completed on time due to staff turnover. Stanan’s occupancy specialist and supervisor will closely monitor the timing of the return of security deposits. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405444
Finding 1220597 (2025-001)
Material Weakness 2025
George Link, Jr. Apartments Housing Development Fund Company, Inc.
NY
HUD Housing Programs Student Financial Aid Eligibility
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405444
Finding 1220596 (2025-001)
Material Weakness 2025
Cabrini Gardens Senior Housing Development Fund Company, Inc.
NY
HUD Housing Programs Eligibility
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405443
Finding 1220595 (2025-001)
Material Weakness 2025
Bishop Gerald J. Ryan Housing Development Fund Company, Inc.
NY
HUD Housing Programs Student Financial Aid Eligibility
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405442
Finding 1220594 (2025-001)
Material Weakness 2025
Bishop Kellenberg Gardens for Senior Citizen Housing Development Fund Company, Inc.
NY
HUD Housing Programs
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
View Audit 405440
Finding 1220592 (2025-001)
Material Weakness 2025
American Soybean Association
MO
Effective immediately, the required timeframe for contractors and consultants to submit trip reports to WISHH has been reduced from 30 days to 15 days following completion of travel. This revised requirement has been incorporated into ASA/WISHH contracting documents and provides additional time for ...
Effective immediately, the required timeframe for contractors and consultants to submit trip reports to WISHH has been reduced from 30 days to 15 days following completion of travel. This revised requirement has been incorporated into ASA/WISHH contracting documents and provides additional time for internal review and processing before the federal 45-day reporting deadline. The shortened submission timeline will significantly enhance our ability to monitor reporting requirements and ensure timely submission of all trip reports.
View Audit 405432
Finding 1220591 (2025-009)
Material Weakness 2025
Camillus House, Inc. and Subsidiaries
FL
Period of Performance Internal Control / Segregation of Duties Material Weakness
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
View Audit 405431
Finding 1220590 (2025-006)
Material Weakness 2025
Camillus House, Inc. and Subsidiaries
FL
Allowable Costs / Cost Principles Internal Control / Segregation of Duties
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting schedules Reconciliation • Perform quarterly true-ups between budget and actual Training • Train staff on allocation methodology and documentation Monitoring • Conduct periodic reviews and report results to management
View Audit 405431
Finding 1220589 (2025-005)
Material Weakness 2025
Camillus House, Inc. and Subsidiaries
FL
Allowable Costs / Cost Principles
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in Paylocity reflecting actual time worked Integration with Payroll Allocation • Ensure payroll allocations are based on actual time and effort • Perform monthly Finance review of payroll allocations Policy Updates • Update payroll and cost allocation policies to align with Uniform Guidance (§200.430) Training • Provide training to staff and annual refresher courses Monitoring and Oversight • Perform quarterly reviews and report to Audit and Finance Committees
View Audit 405431
Finding 1220588 (2025-008)
Material Weakness 2025
Camillus House, Inc. and Subsidiaries
FL
Special Tests & Provisions Allowable Costs / Cost Principles HUD Housing Programs
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitorin...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitoring • Perform quarterly compliance reviews
View Audit 405431
Finding 1220587 (2025-007)
Material Weakness 2025
Camillus House, Inc. and Subsidiaries
FL
Allowable Costs / Cost Principles
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in Paylocity reflecting actual time worked Integration with Payroll Allocation • Ensure payroll allocations are based on actual time and effort • Perform monthly Finance review of payroll allocations Policy Updates • Update payroll and cost allocation policies to align with Uniform Guidance (§200.430) Training • Provide training to staff and annual refresher courses Monitoring and Oversight • Perform quarterly reviews and report to Audit and Finance Committees
View Audit 405431
Finding 1220586 (2025-002)
Material Weakness 2025
Lifespan Corporation and Affiliates
RI
Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we wil...
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we will perform a detailed review of all salaries charged to federal grants to ensure there is no salary over the cap. Additionally, we will review automated control enhancements within our ERP system where possible to assist in recognizing compliance rules and/or enhance monitoring controls where possible. Contacts: Stephen Almonte, Vice President and Corporate Controller Salmonte3@brownhealth.org Bharat Ramratnam, MD, Senior Vice President of Research BRamratnam@brownhealth.org Planned Completion Date: October 31, 2026
View Audit 405426
Finding 1220572 (2025-001)
Material Weakness 2025
Lifespan Corporation and Affiliates
RI
Procurement, Suspension & Debarment § 200.320
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-001 AL Numbers: Various assistance listing numbers Program: Research and Development Cluster Correction Action: Brown Health management concurs with this finding. Based on the review, the underlying procurement procedures were general...
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-001 AL Numbers: Various assistance listing numbers Program: Research and Development Cluster Correction Action: Brown Health management concurs with this finding. Based on the review, the underlying procurement procedures were generally performed in accordance with established policy; however, supporting documentation was not consistently retained to evidence compliance. We have already initiated re-training at the department level and will be performing a detailed review of current purchase history to ensure appropriate documentation is retained. For fiscal year 2026, we will be reviewing all federal grant activity to ensure the appropriate documentation is maintained and/or sole source documentation is prepared including a lookback analysis of expenditures to date that did not retain the proper documentation. Additionally, we will review automated control enhancements within our ERP system where possible to assist in recognizing compliance rules in advance of spend. Contacts: Stephen Almonte, Vice President and Corporate Controller Salmonte3@brownhealth.org Bharat Ramratnam, MD, Senior Vice President of Research BRamratnam@brownhealth.org Planned Completion Date: October 31, 2026
View Audit 405426
Finding 1220320 (2025-001)
Material Weakness 2025
Jewish Family Service of Western Ma, Inc. & Lenox Charitable Fund, INC
MA
Reporting § 200.512
The Organization reviewed its current process and determined that procedures can be implemented when unforeseen circumstances arise to ensure the single audit reporting package is submitted by the 9 month deadline. The Organization has implemented new procedures which will ensure the reporting packa...
The Organization reviewed its current process and determined that procedures can be implemented when unforeseen circumstances arise to ensure the single audit reporting package is submitted by the 9 month deadline. The Organization has implemented new procedures which will ensure the reporting package is filed by the nine month deadline, when unforeseen circumstances arise, which include if the CEO or COO are both unable to file the reporting package by the 9 month deadline, another member of the leadership team will be responsible for making sure the reporting package is filed in a timely manner. The corrective action has been implemented as of June 29, 2026.
View Audit 405410
Finding 1220316 (2025-002)
Material Weakness 2025
Housing & Redevelopment Authority of Douglas County
MN
HUD Housing Programs Significant Deficiency
Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has reviewed their procedures for performing and documenting follow up of HQS inspections to ensure compliance moving forward. Planned Completion Date for CAP December 31, 2026
Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has reviewed their procedures for performing and documenting follow up of HQS inspections to ensure compliance moving forward. Planned Completion Date for CAP December 31, 2026
View Audit 405385
Finding 1220313 (2025-001)
Material Weakness 2025
Stt-Stj Div. of Lutheran Housing Assoc. for the Elderly of the V
VI
Special Tests & Provisions HUD Housing Programs Reporting
2025-001 Special Test & Provisions – Contract Rent Adjustment Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time.. Proposed Completion Date: April 9, 2026 Contact Person: Dasil Thomas-Williams, Director of Financial Affairs T...
2025-001 Special Test & Provisions – Contract Rent Adjustment Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time.. Proposed Completion Date: April 9, 2026 Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Telephone Number: (340) 772-4099 ext. 106
View Audit 405382
Finding 1220312 (2025-002)
Material Weakness 2025
Lutheran Gardens Apartments, INC Bougainvillea Gardens Apartment
VI
HUD Housing Programs Cash Management Special Tests & Provisions
Corrective Action: Currently, we are reviewing scheduling priorities to be able to meeting HUD timeline. Proposed Completion Date: December 27, 2024
Corrective Action: Currently, we are reviewing scheduling priorities to be able to meeting HUD timeline. Proposed Completion Date: December 27, 2024
View Audit 405381
Finding 1220311 (2025-001)
Material Weakness 2025
Lutheran Gardens Apartments, INC Bougainvillea Gardens Apartment
VI
HUD Housing Programs Special Tests & Provisions
Name of Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time. Proposed Completion Date: April 9, 2026
Name of Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time. Proposed Completion Date: April 9, 2026
View Audit 405381
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