Corrective Action Plans

Finding 572363 (2024-001)

Significant Deficiency 2024

NY

HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles

Name of Auditee: Port Jervis Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Linda Drew, Executive Director Phone: (845) 856-8621 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2024-001 (a)...

Name of Auditee: Port Jervis Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Linda Drew, Executive Director Phone: (845) 856-8621 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2024-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendations, please see below for action taken. (b) Action taken - The Authority submitted all required closeout documentation and received approval from HUD on July 3, 2025. (c) Planned implementation date of corrective action - Completed by December 31, 2025.

View Audit 363460

Finding 572360 (2024-003)

Significant Deficiency 2024

Charlotte Community Health Clinic, Inc.

NC

Procurement, Suspension & Debarment

Procurement – Written Rate Quotes Recommendation: CLA recommends the procurement policy is consistently followed. Explanation of disagreement with audit finding: Management takes Partial Exception with the audit finding. Action planned in response to finding: Management Response: Management takes...

Procurement – Written Rate Quotes Recommendation: CLA recommends the procurement policy is consistently followed. Explanation of disagreement with audit finding: Management takes Partial Exception with the audit finding. Action planned in response to finding: Management Response: Management takes Partial Exception with this Finding. In an effort to be a good steward of Taxpayer/Federal Funding, Management consciousness chose to continue to work with a Construction Project Manager who had been previously vetted via the CCHC procurement process. CCHC had multiple projects in que and to ensure completion in the most expeditiously and fiscally responsible manner, Management chose to continue to work with a proven entity and monitor for spikes in cost and/or other outliers that may have caused a scintilla of concern. CCHC is currently in the process of revising the Procurement Policy to acknowledge potential future situations and may on occasion find the most cost effective/efficient option is a Sole Source award. Name(s) of the contact person(s) responsible for corrective action: Carolyn C. Allison, CEO Planned completion date for corrective action plan: August 31, 2025

View Audit 363456

Finding 572358 (2024-002)

Significant Deficiency 2024

Charlotte Community Health Clinic, Inc.

NC

Internal Control / Segregation of Duties Significant Deficiency Special Tests & Provisions

Special Provisions - Sliding Fee Discount Recommendation: CLA recommends that the sliding fee discount program assessment form is reviewed to ensure the proper rate is used for each patient. Documentation of the review should be maintained. Explanation of disagreement with audit finding: Management...

Special Provisions - Sliding Fee Discount Recommendation: CLA recommends that the sliding fee discount program assessment form is reviewed to ensure the proper rate is used for each patient. Documentation of the review should be maintained. Explanation of disagreement with audit finding: Management takes Exception with the audit finding. Action planned in response to finding: Management Response: Management takes Exception with this Finding. Due to unforeseen circumstances CCHC’s FYE 2023 Annual Audit was not completed until November 2024. Of the sample examined for FYE 2023, Management was advised one sliding fee calculation was inaccurate. To address the FYE 2023 audit finding and to have a more robust reviewing process, Management conducted staff training and revised the oversight to include two signatures on all Sliding Fee Applications. The newly minted work process was introduced in December 2024. During the course of the FYE 2024 Annual Audit, the initial audit sample only included Sliding Fee Applications for the period January 2024-October 2024: resulting in 100% of the sample not having a secondary review. A review step that up until November 2024 had not been previously cited by the Auditors. Management would like to note, Sliding Fee calculation was 100% accurate as of December 2024. Name(s) of the contact person(s) responsible for corrective action: Carolyn C. Allison, CEO Planned completion date for corrective action plan: Completed December 2024

View Audit 363456

Finding 572357 (2024-001)

None 2024

Preservation of Affordable Housing, INC

MA

HUD Housing Programs Period of Performance

One of the four CMF funded projects, Barry Farm, is a two-phase project. The construction start was delayed due to local permitting challenges and COVID-related issues which resulted in the project not being completed by the original Project Completion date of March 27, 2024. Management informed C...

One of the four CMF funded projects, Barry Farm, is a two-phase project. The construction start was delayed due to local permitting challenges and COVID-related issues which resulted in the project not being completed by the original Project Completion date of March 27, 2024. Management informed CDFI Fund of the delays in the project and on May 16, 2024, CDFI Fund provided a one-year cure period to March 31, 2025. At that time, Management informed CDFI Fund that the second phase of the Barry Farm project would require a longer cure period due to a 30-month delivery schedule, driven by the incorporation of a large geothermal system, with delivery set for late 2026. CDFI Fund directed Management to report on the second phase’s progress with a new cure period request annually until project completion. During the cure period, Barry Farm’s first phase was completed, and is now leased up and operating. In March 2025, Management informed CDFI of the project status for phase two which is now 24% complete and remains on schedule for completion in November 2026. CDFI Fund provided a one-year cure period until March 31, 2026. Management has otherwise significantly exceeded the grant’s performance targets and will request cure period extensions until project completion.

View Audit 363432

Finding 572355 (2024-001)

Material Weakness 2024

Saugatuck Child Care Services Inc.

CT

Allowable Costs / Cost Principles

• Description – The organization does not have a comprehensive cost allocation plan and what was documented was not always applied consistently throughout the year. • Views of Responsible Officials and Planned Corrective Action – Management agrees with the finding. The allocations plan was adjuste...

• Description – The organization does not have a comprehensive cost allocation plan and what was documented was not always applied consistently throughout the year. • Views of Responsible Officials and Planned Corrective Action – Management agrees with the finding. The allocations plan was adjusted in the fiscal year ending August 31, 2025 according to square footage, administrative involvement and payroll fees and we will work to formally document the plan. • Names and Title of Responsible Official – Kathy Sabitsky, Finance Manager • Anticipated Completion Date – This will be implemented by the end of August 2025.

View Audit 363429

Finding 572354 (2024-001)

Material Weakness 2024

City of Springfield

MA

Reporting Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303

Views of Responsible Officials and Planned Corrective Actions: Management agrees and plans to provide for additional training to ensure those preparing and reviewing the reports have the appropriate understanding and information to ensure accuracy and completeness in the information being reported. ...

Views of Responsible Officials and Planned Corrective Actions: Management agrees and plans to provide for additional training to ensure those preparing and reviewing the reports have the appropriate understanding and information to ensure accuracy and completeness in the information being reported. Management will create, to review and sign, a "checklist" of requirements needed to ensure compliance with the program's rules. The checklist will be reviewed, and incorporated into the minutes, as part of the weekly ARPA Oversight Meetings. The checklist will be completed and signed by management prior to submitting any reports. Past reports will be reviewed and corrected prior to submission of the next quarterly report. All changes will be incorporated into the City's controls prior to the submission of the next quarterly report due April 30, 2025.

View Audit 363426

Finding 572350 (2024-001)

Significant Deficiency 2024

Metropolitan Transportation Authority

NY

Questioned Costs Allowable Costs / Cost Principles Cash Management

FEDERAL AWARDS—CORRECTIVE ACTION PLAN REFERENCE # 2024-001 Federal Transit Cluster - ALN Number: 20.507; 20.525; and 20.526 Contract Number: C40261TECHINSP; C33941EFA-MTAB; C40265TECH-MTAB; U3NY-2023-101-02 and U9NY-2018-059-01 Significant Deficiency-Non-Compliance Agen...

FEDERAL AWARDS—CORRECTIVE ACTION PLAN REFERENCE # 2024-001 Federal Transit Cluster - ALN Number: 20.507; 20.525; and 20.526 Contract Number: C40261TECHINSP; C33941EFA-MTAB; C40265TECH-MTAB; U3NY-2023-101-02 and U9NY-2018-059-01 Significant Deficiency-Non-Compliance Agency: U.S. Department of Transportation Criteria: Activities Allowed/Allowable Costs/Cost Principles including Indirect Costs––Direct - As stated in Uniform Grant Guidance - §200 Requirements for Allowable Costs: a. Costs did not consist of improper payments, including (1) payments that should not have been made or that were made in incorrect amounts (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements; (2) payments that do not account for credit for applicable discounts; (3) duplicate payments; (4) payments that were made to an ineligible party or for an ineligible good or service; and (5) payments for goods or services not received (except for such payments where authorized by law). Condition/Context: The MTA has Activities Allowed/Allowable Costs/Cost Principles including Indirect Costs procedures in place. MTA has corporate policies and procedures regarding Activities Allowed/Allowable Costs. We tested the Federal Transit Cluster’s Allowable Costs compliance. Based on our review of sixty samples related to Personnel Services and Other than Personnel Services for this cluster, we noted that four samples related to an MTA Bus Company personnel’s hourly rate were charged at higher rate. We noted that the rate per personnel file and employee payroll register differs from the actual rate used by the agency to charge labor costs. The agency calculated labor cost using the annual earnings that is divided by 52 weeks because there are 52 weeks a year, but MTA payroll department used 52.1428 weeks based upon 365/7 days a week, which created variances in labor costs billed and actual recorded labor costs. For Contract # - U3NY-2023-101-02 and U9NY-2018-059-01 – We noted two instances of sixty samples reviewed where the agency used 2023 approved overhead rate of 98.18% instead of the 2024 approved overhead rate of 98.98%. Recommendation: We recommend that MTA ensure that all personnel are reviewed and should be charged at the correct hourly rates as required by §200 CFR Subpart E – Allowable Costs. We also recommend that approved indirect rate applied to direct costs. Corrective Action Plan: MTA Bus will work with the project team to implement the correct rate and calculate the variance. MTA Bus will return the credit to the FTA as needed. Going forward, MTA Bus will review the employee wage rates from the official data sources to ensure that the correct rates are applied. SIR Finance will ensure that the overhead rates on the labor sheets are reflecting the correct percentage by adding a "verification measure" to a checklist while performing internal audits and approvals of the invoices prior to submission. Additionally, SIR-Finance will adjust the formatting within the invoice spreadsheets for easier visibility to a potential error in the calculated overhead percentage. Action Date: MTABUS – 1ST QUARTER 2026 SIRTOA - Effective Immediately - on July 2025 Invoices Final Implementation Date: MTABUS – 2ND QUARTER 2026 SIRTOA – July 2025 Name And Phone Number of Person Responsible For Implementation: MTABUS Marixsa Rivera Assistant Budget Chief • Project Development 718-927-8056 SIRTOA Marissa Rand Assistant Director, Finance & Timekeeping - SIR 347-694-6448

View Audit 363411 Questioned Costs: $1

Finding 572349 (2024-001)

Significant Deficiency 2024

Hawaii Council for the Humanities

HI

Reporting Significant Deficiency § 200.328

Views of Responsible Official(s) and Planned Corrective Action: Management concurs with the finding. The report found lacking was reviewed by the Executive Director, and the error was based on a difference between cash and accrual accounting. Management will review federal financial reports with co...

Views of Responsible Official(s) and Planned Corrective Action: Management concurs with the finding. The report found lacking was reviewed by the Executive Director, and the error was based on a difference between cash and accrual accounting. Management will review federal financial reports with contracted accountants and retrieve source documents before submitting. Management will also review scope of contracted accounting services to ensure it includes review of all NEH reports.

View Audit 363403

Finding 572348 (2024-003)

Material Weakness 2024

Sinai Health System and Affiliates

IL

HUD Housing Programs Reporting Material Weakness

Finding Number: 2024-003 Condition The Corporation did not submit the budget to HUD within 30 days of the start of their fiscal year. Planned Corrective Action: Sinai Health System has developed an action plan to ensure that financial statements and other materials are submitted in a timely fashio...

Finding Number: 2024-003 Condition The Corporation did not submit the budget to HUD within 30 days of the start of their fiscal year. Planned Corrective Action: Sinai Health System has developed an action plan to ensure that financial statements and other materials are submitted in a timely fashion to lenders and are compliant with the HUD Regulatory Agreements. The action plan consists of the following components: o Development of a policy that outlines HUD requirements and identifies individuals responsible for meeting the requirements; the Senior Finance Team and Compliance team should be educated on this annually. o Regular communication (no less than quarterly) between Finance and the Compliance Officer regarding HUD deadlines and deviation from these deadlines. o Development of a checklist that will be utilized by the Compliance and Finance departments regarding HUD requirements and deadlines. o Reporting to the Audit and Compliance Committee of the Board that the checklist has been completed/deadlines have been met. This will be a regular agenda item. Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025

View Audit 363396

Finding 572347 (2024-002)

Material Weakness 2024

Sinai Health System and Affiliates

IL

HUD Housing Programs Reporting Material Weakness

Finding Number: 2024-002 Condition The Corporation did not submit the financial statements to HUD within 180 days of their fiscal year. Planned Corrective Action: Sinai Health System has developed an action plan to ensure that financial statements and other materials are submitted in a timely fa...

Finding Number: 2024-002 Condition The Corporation did not submit the financial statements to HUD within 180 days of their fiscal year. Planned Corrective Action: Sinai Health System has developed an action plan to ensure that financial statements and other materials are submitted in a timely fashion to lenders and are compliant with the HUD Regulatory Agreements. The action plan consists of the following components: o Development of a policy that outlines HUD requirements and identifies individuals responsible for meeting the requirements; the Senior Finance Team and Compliance team should be educated on this annually. o Regular communication (no less than quarterly) between Finance and the Compliance Officer regarding HUD deadlines and deviation from these deadlines. o Development of a checklist that will be utilized by the Compliance and Finance departments regarding HUD requirements and deadlines. o Reporting to the Audit and Compliance Committee of the Board that the checklist has been completed/deadlines have been met. This will be a regular agenda item. Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025

View Audit 363396

Finding 572342 (2024-004)

None 2024

Town of Eagle

CO

Procurement, Suspension & Debarment § 200.213 § 200.303

Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding and will implement policies and procedures to ensure that potential vendors are not suspended or debarred prior to contracting with them for goods and services.

View Audit 363385

Finding 572341 (2024-003)

None 2024

Town of Eagle

CO

Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.318 § 200.319 § 200.320

Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding and will adopt a formal Federal procurement policy which includes all elements identified in 2CFR Sections 200.303 and 200.318 through 200.626.

View Audit 363385

Finding 572340 (2024-002)

Significant Deficiency 2024

Town of Eagle

CO

Procurement, Suspension & Debarment § 200.213 § 200.303

Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding and will implement policies and procedures to ensure that potential vendors are not suspended or debarred prior to contracting with them for goods and services.

View Audit 363385

Finding 572339 (2024-001)

Significant Deficiency 2024

Town of Eagle

CO

Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.318 § 200.319 § 200.320

Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding and will adopt a formal Federal procurement policy which includes all elements identified in 2CFR Sections 200.303 and 200.318 through 200.626.

View Audit 363385

Finding 572336 (2024-003)

Material Weakness 2024

Northwest Alabama Regional Airport Authority, Inc.

AL

Internal Control / Segregation of Duties

The Airport Director will begin reviewing and documenting approval for all expenses and financial reconciliations. Effective immediately, check signing ability will be removed from the employee responsible for the accounts payable process. In addition, management will evaluate current office personn...

The Airport Director will begin reviewing and documenting approval for all expenses and financial reconciliations. Effective immediately, check signing ability will be removed from the employee responsible for the accounts payable process. In addition, management will evaluate current office personnel and determine if accounting functions can be segregated between current personnel or if an addition of an employee is needed. The recommended processes and action plan was implemented in July 2024.

View Audit 363381

Finding 572334 (2024-005)

Significant Deficiency 2024

Jasper County

IL

Procurement, Suspension & Debarment § 200.318 § 200.327

The County Board should draft and approve policies and procedures for the procurement of contractors per the Compliance Supplement, Code of Federal Regulations, United States Codes, and Federal Acquisition Regulations to ensure the proper advertisement and selection of contractors and consultants, a...

The County Board should draft and approve policies and procedures for the procurement of contractors per the Compliance Supplement, Code of Federal Regulations, United States Codes, and Federal Acquisition Regulations to ensure the proper advertisement and selection of contractors and consultants, and to prevent conflicts of interest during the selection of contractors and consultants. Management Response: Management will draft and approve the recommended procurement policies and procedures and disseminate the information to department heads and County employees during the fall of 2025.

View Audit 363379

Finding 572330 (2024-001)

None 2024

Ncsc/usa Housing Development Corporation

FL

HUD Housing Programs Reporting

Oversight Agency for Audit, NCSC/USA Housing Development Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Fl...

Oversight Agency for Audit, NCSC/USA Housing Development Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 207/223(f) Mortgage Insurance for the Refinancing of Existing Multifamily Housing Projects, ALN 14.155 Recommendation: Management should implement procedures to ensure that the increase to the reserve for replacement account is properly applied with timely HUD authorization via form HUD-9250. Action Taken: Staff training has been provided to ensure the correct RR amounts are deposited and a timely increase from HUD is received. This has been included in the monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO

View Audit 363368

Finding 572329 (2024-001)

None 2024

Lewisburg Public Housing, Inc.

IN

Management will ensure the appropriate audit documentation is provided to the auditors so the audited financial statements can be completed and submitted to RD in a timely manner.

View Audit 363367

Finding 572231 (2024-003)

Material Weakness 2024

Nash Edgecombe Wilson Community Action, Inc.

NC

Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs

Corrective Action: The Agency has purchased a software package to track and file inspections. The staff has been trained on the software, and it has been implemented in fiscal year 2025. The Agency is in the process of performing inspections on all units in fiscal year 2025. Once inspections are ...

Corrective Action: The Agency has purchased a software package to track and file inspections. The staff has been trained on the software, and it has been implemented in fiscal year 2025. The Agency is in the process of performing inspections on all units in fiscal year 2025. Once inspections are completed, Agency will be in compliance with HUD.

View Audit 363358 Questioned Costs: $1

Finding 572230 (2024-002)

Material Weakness 2024

Nash Edgecombe Wilson Community Action, Inc.

NC

HUD Housing Programs

Corrective Action: The Agency has implemented procedures to evaluate the Utility rate data every year. The Agency has already evaluated fiscal year 2025.

View Audit 363358

Finding 572229 (2024-001)

Material Weakness 2024

Nash Edgecombe Wilson Community Action, Inc.

NC

HUD Housing Programs

Corrective Action: The Agency is working with a CPA to catch up on missed filings, and has noted future deadlines for going forward.

View Audit 363358

Finding 572210 (2024-005)

Significant Deficiency 2024

Municipality of Cabo Rojo

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties

We will improve our internal control procedures related to record keeping and adjustments in order to ensure compliance with the March 31st federal requirement. Implementation Date: During the 2025-2026 fiscal year. Responsible Person: Warynex Carlo Hernández, Finance Department Director

View Audit 363351

Finding 572207 (2024-003)

Material Weakness 2024

Keokuk Housing Authority

IA

Questioned Costs Cash Management

Finding 2024-003 See response to finding 2024-002.

View Audit 363328 Questioned Costs: $1

Finding 572203 (2024-002)

Material Weakness 2024

Iowa Falls Community School District

IA

Internal Control / Segregation of Duties

We recognize the importance of strong internal controls and understand the concerns around segregation of duties. Due to our limited staffing, complete segregation isn't always feasible. However, we’ve implemented compensating controls such as increased oversight by supervisors, regular review of tr...

We recognize the importance of strong internal controls and understand the concerns around segregation of duties. Due to our limited staffing, complete segregation isn't always feasible. However, we’ve implemented compensating controls such as increased oversight by supervisors, regular review of transactions, and board-level monitoring where appropriate. Additionally, we are aware of an upcoming retirement and plan to re-evaluate and revise our internal procedures at that time to strengthen controls and improve segregation of duties where possible.

View Audit 363324

Finding 572202 (2024-001)

Significant Deficiency 2024

National Church Residences

OH

Reporting Period of Performance Significant Deficiency § 200.502 § 200.510

Finding Number: 2024-001 Condition: The expenditures were reported for the Capital Magnet Fund throughout the award period from the year ended June 30, 2019 to the year ended June 30, 2024 on the schedule of expenditures of federal awards (SEFA) but did not accurately report the amount of administr...

Finding Number: 2024-001 Condition: The expenditures were reported for the Capital Magnet Fund throughout the award period from the year ended June 30, 2019 to the year ended June 30, 2024 on the schedule of expenditures of federal awards (SEFA) but did not accurately report the amount of administrative expenditures incurred during the performance period, and, therefore, the SEFA was not complete and accurate for the year ended June 30, 2019 to the year ended June 30, 2024. Planned Corrective Action: Management has implemented procedures and controls to ensure reports are reviewed prior to submission and distributed funds are reported properly and in the correct period. Contact person responsible for corrective action: Lindsey Dehring, Vice President of Financial Planning & Analysis Anticipated Completion Date: July 31, 2025

View Audit 363317

Corrective Action Plans

Filters