Corrective Action Plans

Finding 1236240 (2025-002)

Material Weakness 2025

KS

Reporting

Identifying Number: 2025-002 Finding: The Agency did not submit its Data Collection Form (DCF) and reporting package to the Federal Audit Clearinghouse (FAC) by the required Uniform Guidance deadline. The submission occurred on October 1, 2025, one day after the required filing date, resulting in no...

Identifying Number: 2025-002 Finding: The Agency did not submit its Data Collection Form (DCF) and reporting package to the Federal Audit Clearinghouse (FAC) by the required Uniform Guidance deadline. The submission occurred on October 1, 2025, one day after the required filing date, resulting in noncompliance with federal reporting requirements. Corrective Actions Taken or Planned The Agency concurs with the finding. Although the Agency was working toward timely submission of the DCF and reporting package, they were submitted one day after the required filing date due to delays resulting from finance staff transitions. To ensure compliance with Uniform Guidance reporting requirements and prevent future late submissions, the following corrective actions will be implemented: 1. Establish a Formal Reporting Calendar A centralized compliance calendar will be created to track all Single Audit deadlines, including the DCF, and reporting package submission requirements. • Calendar will include automated reminders. • The calendar will be reviewed monthly by the VP of Finance and Controller. 2. Assign Clear Responsibility for FAC Submission VP of Finance and Controller will be formally assigned responsibility for preparing and submitting the DCF and reporting package. • Roles and responsibilities will be documented. 3. Strengthen Written Policies and Procedures The Agency will update its written procedures to include: • Detailed steps for preparing and submitting the DCF and reporting package to FAC. These procedures will be reviewed annually and updated as needed. Contact Persons Responsible for Corrective Action Vice President of Finance and Controller Anticipated Completion Dates • Reporting calendar implemented: September 30, 2026 • Written procedures updated: October 31, 2026

View Audit 411833

Finding 1236224 (2025-001)

Material Weakness 2025

The Family Conservancy, INC

KS

Reporting Allowable Costs / Cost Principles

Identifying Number: 2025-001 Finding: During testing, it was identified that the annual Federal Financial Report (SF-425) was not submitted by the reporting deadline prescribed in the grant terms and conditions and Office of Head Start reporting requirements. As a result, the Agency did not comply w...

Identifying Number: 2025-001 Finding: During testing, it was identified that the annual Federal Financial Report (SF-425) was not submitted by the reporting deadline prescribed in the grant terms and conditions and Office of Head Start reporting requirements. As a result, the Agency did not comply with federal reporting requirements applicable to the program. Corrective Actions Taken or Planned The Agency concurs with the finding. Although the SF-425 was prepared and initially submitted by the deadline, it was not certified as required for submission until after the deadline due to finance staff transitions and delays in obtaining system access. To ensure compliance with federal reporting requirements and strengthen internal controls, the following corrective actions will be implemented: 1. Establish a Formal Reporting Calendar and Tracking System A centralized reporting calendar will be developed to track all federal reporting deadlines, including SF-425 submissions. The calendar will include automated reminders and will be reviewed monthly by finance leadership to ensure timely preparation and submission. 2. Implement Supervisory Review and Sign-Off Procedures A supervisory review process will be implemented for all federal reports. The VP of Finance or Controller will verify the accuracy of cumulative expenditures and ensure the SF-425 is supported by accounting records before submission. 3. Strengthen Internal Controls and Written Procedures Written procedures will be updated to include detailed steps for preparing, reviewing, and submitting the SF-425. Procedures will clearly define roles, responsibilities, timelines, and documentation requirements. 4. Staff Training on Federal Reporting Requirements Finance and grants staff will receive training on SF-425 reporting requirements, Uniform Guidance reporting standards, and Head Start financial reporting expectations. Training will include review of the finding and emphasize the importance of timely and accurate reporting. 5. Continuity Controls to Address Turnover Risk To mitigate the impact of staff turnover, responsibility for federal reporting will be assigned to both a primary and secondary staff member. Cross-training will be implemented to ensure continuity and reduce reliance on a single individual. Contact Persons Responsible for Corrective Action Vice President of Finance and Controller / Head Start Fiscal Coordinator Anticipated Completion Dates • Reporting calendar and tracking system implemented: September 30, 2026 • Written reporting procedures finalized: October 31, 2026 • Staff training completed: November 30, 2026

View Audit 411833

Finding 1236220 (2025-002)

Material Weakness 2025

Town of Bellingham, Massachusetts

MA

Reporting Internal Control / Segregation of Duties

Finding 2025-002 COVID 19 - Coronavirus State and Local Fiscal Recovery Fund - AL No. 21.027 U.S. Department of Treasury Norfolk County Other Matters Related to Internal Control over Compliance of the Major Program Co11ditio11: Upon review of the Town of Bellingham's report filed with Norfolk County...

Finding 2025-002 COVID 19 - Coronavirus State and Local Fiscal Recovery Fund - AL No. 21.027 U.S. Department of Treasury Norfolk County Other Matters Related to Internal Control over Compliance of the Major Program Co11ditio11: Upon review of the Town of Bellingham's report filed with Norfolk County it was noted that one of the repmts submitted to Norfolk County did not agree with the Town's accounting ledgers. Criteri{I: The Town was required to submit quaiterly performance repmts to Norfolk County that are in agreement with the Town's accounting ledgers. Context: The quarterly report submitted to Norfolk County for the time period of October 1, 2024 through December 31, 2024 did not agree to the Town's accounting ledgers as they included returned funds to Norfolk County that were included in the project expense for the period being repo1ted in error. Effect: The Town of Bellingham was not in compliance with the Norfolk County repo1ting requirements. Questioned Costs: NIA- No questioned costs as it relates to repotting errors. Cause: The funds returned to Norfolk County were returned using an expense account, not a revenue account. This is why the returned funds were included in the expenditure report, sent to Norfolk County. Identification {IS a Repeat Finding: NIA - This is not a repeat finding. Recommendation: The Town of Bellingham should ensure that the repo1ts submitted to Norfolk County are in agreement with the Town's accounting ledgers. Responsible for Corrective Plan: CFO Estimated Completion Date: December 2026 Action Taken: Going forward, returning unexpended funds will not be treated as an expenditure.

View Audit 411832

Finding 1236219 (2025-001)

Material Weakness 2025

Town of Bellingham, Massachusetts

MA

Procurement, Suspension & Debarment § 200.318 § 200.326

Finding 2025-001 - COVID 19 - Coronavirus State and Local Fiscal Recovery Fund - AL No. 21.027 U.S. Department of Treasury Norfolk County Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Criteria: Non-federal entities other than states, including t...

Finding 2025-001 - COVID 19 - Coronavirus State and Local Fiscal Recovery Fund - AL No. 21.027 U.S. Department of Treasury Norfolk County Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Criteria: Non-federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. Condition: During our testing as it related to compliance with procurement we noted that an expense for engineering services for the Well #10 Permitting Project services charged to the major program would have required a formal bidding process as the project exceeded the simplified acquisition threshold of $250,000. Context: The Town had a ARPA project 1123 for well#l0 permitting project that they relied on a request for qualifications from 2011 for engineering services related to Town wide drinking water. The Well#l0 project was submitted on 12/20/22 for approval by Norfolk County. It is the auditor's professional judgment that separate procurement procedures should have been performed as the RFQ was approximately 11 years old and this was a new project. Although services are exempt under State procurement requirement, Federal Procurement rules would have required procurement procedures. Under Federal Procurement requirements expenses of $250,000 or more require a formal bid process. As the project costs and estimates at the time of the project exceeded $250,000, the Town should have performed formal bid procedures for this service. Questioned Costs: Based on vendor expenses charged to the grant in FY 2025 the total questioned costs were $54,060.65. Cause: The noncompliance occurred because the organization mistakenly relied on Massachusetts Chapter 30B exemptions, which govern state and local procurements, and did not recognize the need to comply with the more stringent federal procurement requirements for federal fund usage. Staff members were not sufficiently aware of the specific requirements under 2 CFR Part 200 and the precedence of federal procurement regulations over state law in this context. Effect or Potential Effect: There is a risk that the amounts charged to the federal awards major program may not be in accordance with procurement, suspension, and debarment principles. Itle11tijicatio11 as a Repeat Finding: 2024-002 Recommendation: Going forward, the Town of Bellingham should consider a separate bidding process for expenses related to federal grant awards. Responsible for Corrective Plan: CFO Estimated Completion Date: December 2026 Action Taken: We acknowledge the audit finding regarding our reliance on Massachusetts Chapter 30B exemptions for procurement involving federal funds. We understand that federal procurement regulations under 2 CFR Part 200 take precedence over state law and that we failed fully to comply with federal requirements for competitive bidding, sole-source justification, and documentation. We are committed to addressing this issue by reviewing our procurement policies to clearly differentiate between state and federal requirements, ensuring that federal standards govern all procurement involving federal funds. We will provide additional training to staff, implement stronger documentation procedures, and review past procurement to ensure full compliance moving forward.

View Audit 411832

Finding 1236217 (2025-001)

Material Weakness 2025

Johnson Health Center

VA

Eligibility

Johnson Health Center will strengthen its processes and oversight related to the Sliding Fee Discount Program to ensure staff are consistently applying the sliding fee process in accordance with JHC policies and applicable requirements. The Billing Department will develop a comprehensive training ma...

Johnson Health Center will strengthen its processes and oversight related to the Sliding Fee Discount Program to ensure staff are consistently applying the sliding fee process in accordance with JHC policies and applicable requirements. The Billing Department will develop a comprehensive training manual for front-end staff that outlines the proper procedures for determining and documenting sliding fee eligibility and applying the appropriate discount. In addition to the written training materials, the Billing Department will provide hands-on, on-the-job training to ensure staff understand how to properly complete each step of the sliding fee process. The Billing Department currently performs monthly audits of sliding fee transactions to identify errors and ensure the process is being followed appropriately. Going forward, our Director of Compliance will have a more active role in the monthly monitoring process. The Director of Compliance will review the Billing Department's monthly audit results and supporting documentation to validate that findings are accurate, complete, and appropriately addressed. Any identified issues will be communicated to the appropriate staff and corrected timely. This additional oversight will provide an independent review of the monthly monitoring process and help ensure that identified deficiencies are properly addressed and that the sliding fee process remains compliant on an ongoing basis. JHC will also implement a progressive disciplinary process for repeated failure to follow the Sliding Fee Discount Program procedures. The disciplinary actions will be applied as follows: • First occurrence: One-on-one counseling and review of the applicable procedures. • Second occurrence: Verbal warning and additional training. • Third occurrence: Written warning. • Fourth occurrence: Further disciplinary action, up to and including termination. The training manual and additional staff training will be implemented as part of JHC's corrective action process. Monthly monitoring by the Billing Department, with additional review by the Compliance Officer, will continue on an ongoing basis to ensure the corrective actions remain effective and that any future issues are identified and addressed promptly.

View Audit 411829

Finding 1236215 (2025-002)

Material Weakness 2025

New York College of Traditional Chinese Medicine

NY

Student Financial Aid Special Tests & Provisions Reporting

2025-002: Untimely Paid Credit Balance- Student Financial Assistance Cluster - (a) Federal Direct Student Loans -ALN # 84.268 - Year Ended December 31, 2025 Criteria: An institution must pay credit balances to students within fourteen days of the creation of such credit or within fourteen days of th...

2025-002: Untimely Paid Credit Balance- Student Financial Assistance Cluster - (a) Federal Direct Student Loans -ALN # 84.268 - Year Ended December 31, 2025 Criteria: An institution must pay credit balances to students within fourteen days of the creation of such credit or within fourteen days of the date the institution performs the Return calculation for withdrawn students. When a valid waiver has been obtained, an institution must pay the remaining balance on loan funds by the end of the loan period and any remaining other Title IV program funds by the end of the last payment period in the award year for which the funds were awarded (34 CFR 668.164 and 668.165). Condition: Sikich tested thirty-seven files, twenty-two of which had credit balances, and two students’ credit balances were not paid in a timely manner. We consider this finding to be an instance of non-compliance. Responsible Person: Darren Zhang Corrective Action Plan: The two students identified in this finding involve the same credit balance issue that was identified during the FY2024 audit. Although these transactions occurred in 2025, they occurred before the FY2024 audit was completed in September 2025 and before the related corrective measures were implemented. Therefore, these cases reflect our previous practice rather than a recurrence of the issue after the corrective actions were implemented. Under our previous practice, based on the option selected by the student on the Credit Balance Authorization Form, a student’s credit balance could be retained in the student’s account for future charges, including charges in the following award year. During the FY2024 audit, we became aware that Title IV loan credit balances retained under a valid authorization must be paid to the student by the end of the applicable loan period. Following the completion of the FY2024 audit in September 2025, we strengthened its procedures for monitoring Title IV credit balances and implemented a compliance calendar reminder to help ensure that credit balances are refunded within the required timeframe. The school also revised its Credit Balance Authorization Form. The previous option, “Leave the funds in my account and any remaining funds from the current award year in my account for next award year,” was revised to: “Leave the funds in my account and any remaining funds from the current award year in my account up to the end of the loan period.” These corrective measures have been implemented to ensure that Title IV credit balances are properly monitored and refunded within the applicable timeframe. Implementation Date: 09/26/2025

View Audit 411827

Finding 1236214 (2025-001)

Material Weakness 2025

New York College of Traditional Chinese Medicine

NY

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

2025-001: Inaccurate Enrollment Status Reporting- Student Financial Assistance Cluster - (a) Federal Direct Student Loans -ALN # 84.268 - Year Ended December 31, 2025 Criteria: Institutions are required to provide enrollment update responses to the Enrollment Reporting Roster File within fifteen day...

2025-001: Inaccurate Enrollment Status Reporting- Student Financial Assistance Cluster - (a) Federal Direct Student Loans -ALN # 84.268 - Year Ended December 31, 2025 Criteria: Institutions are required to provide enrollment update responses to the Enrollment Reporting Roster File within fifteen days of receipt (34 CFR 685.309). Condition: Sikich tested thirty-seven files and one student had enrollment status effective dates incorrectly reported to the National Student Loan Data System (NSLDS). This finding is repeated and was reported in the prior year as 2024-001. We consider this finding to be an instance of Noncompliance. Responsible Person: Darren Zhang Corrective Action Plan: This enrollment reporting issue identified for this student occurred in 2025, while the FY2024 audit was still in progress. The FY2024 audit was not completed until September 2025, and the corrective action related to the FY2024 finding was fully implemented on September 30, 2025. Therefore, although this finding relates to the same general area of enrollment status reporting as the prior-year finding, this particular instance occurred before the FY2024 audit was completed and before the related corrective measures were implemented. As stated in the FY2024 Corrective Action Plan, we reviewed the enrollment maintenance schedule and revised our procedures to ensure that enrollment status updates are completed within the required timeframe. The revised procedures were fully implemented beginning with the September 30, 2025 scheduled enrollment update. In addition, we have strengthened our review of enrollment status effective dates to ensure that the dates reported to NSLDS are consistent with our school records. Any discrepancies identified during the review will be corrected promptly. We will also review the NSLDS record and supporting documentation for the student identified in this finding and make any necessary correction to the enrollment status effective date. Implementation Date: 09/30/2025

View Audit 411827

Finding 1236213 (2025-002)

Material Weakness 2025

THE NATIONAL INSTITUTE FOR CRIMINAL JUSTICE REFORM

CA

Cash Management Subrecipient Monitoring § 200.305

Views of Responsible Officials and Corrective Action Plan: Management acknowledges and concurs with this finding and is developing formal policies and procedures related to cash management compliance requirements. NICJR’s drawdowns were due to extraordinary circumstances. There was an unprecedented ...

Views of Responsible Officials and Corrective Action Plan: Management acknowledges and concurs with this finding and is developing formal policies and procedures related to cash management compliance requirements. NICJR’s drawdowns were due to extraordinary circumstances. There was an unprecedented action taken by the federal government in announcing the pending cancellation of more than $800 million grants to thousands of non-profit organizations around the country. During the significant uncertainty surrounding the changing funding environment as well as our commitment to our subgrantee organizations, NICJR continued submitting reimbursement requests while awaiting additional guidance. NICJR will create a cash management policy to minimize the time elapsed between payment and request of funds to meet requirements of 2 CFR 200.305(b). Name of Responsible Person: Leah Wilson, Chief of Staff Implementation Date: July 1, 2026

View Audit 411825

Finding 1236209 (2025-002)

Material Weakness 2025

Waikiki Health

HI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2025.002 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...

Finding 2025.002 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit and again in 2024. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, including clarification of documentation requirements, acceptable forms of income verification, and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representative (PSR) staff to consistently assess and apply sliding fee discounts. The SOP includes clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership, provide corrective follow-up, and provide any needed training for PSR personnel on the updated policy and procedures. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls. Waikiki Health is also considering engaging an outside firm to assist with streamlining the sliding fee scale process and strengthening related internal controls.

View Audit 411822

Finding 1236207 (2025-001)

Material Weakness 2025

Waikiki Health

HI

Reporting

Federal Award Findings: Finding 2025.001 - Reporting Recommendation The Organization should also ensure that all reporting requirements are monitored and met on a timely basis. Action Taken Waikiki Health will implement a centralized HRSA reporting calendar and monitoring process to ensure all feder...

Federal Award Findings: Finding 2025.001 - Reporting Recommendation The Organization should also ensure that all reporting requirements are monitored and met on a timely basis. Action Taken Waikiki Health will implement a centralized HRSA reporting calendar and monitoring process to ensure all federal reporting requirements are identified, assigned, tracked, reviewed, and submitted by the required deadlines. The Finance Department, in coordination with will review all notices of award, HRSA reporting requirements, and related submission deadlines; assign responsible staff for each report; establish internal due dates before the federal deadline; and maintain documentation of review, approval, and submission. Management will perform periodic status reviews to verify that upcoming reporting requirements are on schedule and will escalate any delays promptly so corrective steps can be taken before deadlines are missed. This process is expected to be fully implemented during fiscal year 2026.

View Audit 411822

Finding 1236205 (2025-004)

Material Weakness 2025

Excelsior Springs Hospital

MO

Matching / Level of Effort / Earmarking

Corrective Action Plan: The Hospital is currently reviewing its financial situation and plans to resume deposits to the reserve account in the future.

View Audit 411818

Finding 1236198 (2025-001)

Material Weakness 2025

Blue Star Families, Inc.

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Views of Responsible Officials: Blue Star Families leadership appreciates the Auditors’ procurement reporting in the context of the revised Uniform Guidance guidelines. BSF will implement stronger policies and procedures into our vendor selection processes and the verification of an entity’s status ...

Views of Responsible Officials: Blue Star Families leadership appreciates the Auditors’ procurement reporting in the context of the revised Uniform Guidance guidelines. BSF will implement stronger policies and procedures into our vendor selection processes and the verification of an entity’s status in SAM.gov per these findings.

View Audit 411799

Finding 1236195 (2025-003)

Material Weakness 2025

Town of Centerville

IN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.302 § 200.303

FINDING 2025-003 Finding Subject: Federal Award Findings and Questioned Costs Contact Person Responsible for Corrective Action: Sarah Rice Contact Phone Number and Email Address: 765-855-5515, srice@town.centerville.in.us Views of Responsible Officials: Option 1: “We concur with the finding.”  Drin...

FINDING 2025-003 Finding Subject: Federal Award Findings and Questioned Costs Contact Person Responsible for Corrective Action: Sarah Rice Contact Phone Number and Email Address: 765-855-5515, srice@town.centerville.in.us Views of Responsible Officials: Option 1: “We concur with the finding.”  Drinking Water State Revolving Fund – Written Policies/Procedures to Determine Allowability of Costs using Federal Grant Funds- I will be getting in touch with our council president to make sure we come up with a policy on how to use federal funding with clear guidance on what costs are constituted as direct and indirect charges. Anticipated Completion Date: February 28, 2027 INDIANA

View Audit 411798

Finding 1236194 (2025-002)

Material Weakness 2025

Mdbm - Epsilon Senior Housing Corporation

MI

HUD Housing Programs Special Tests & Provisions

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 130...

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Significant Deficiencies 2025-002 Compliance Requirement: Special Tests and Provisions – Excess of Residual Receipts Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Project, Assistance Listing 14.155 Project-Based Rental Assistance, Assistance Listing 14.195 Recommendation: It is recommended that efforts be made to ensure compliance with the residual receipts excess fund requirements going forward. Planned Corrective Actions: Every effort will be made to ensure compliance with the residual receipts excess funds requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100.

View Audit 411794

Finding 1236193 (2025-001)

Material Weakness 2025

Mdbm - Epsilon Senior Housing Corporation

MI

HUD Housing Programs Special Tests & Provisions

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 130...

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Epsilon Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Significant Deficiencies 2025-001 Compliance Requirement: Special Tests and Provisions – Surplus Cash Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Project, Assistance Listing 14.155 Project-Based Rental Assistance, Assistance Listing 14.195 Recommendation: It is recommended that efforts be made to ensure compliance with the surplus cash remittance requirements going forward. Planned Corrective Actions: Every effort will be made to ensure that deposits are made within the 90-day allotted period. Planned Corrective Actions: Every effort will be made to ensure compliance with the residual receipts excess funds requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100.

View Audit 411794

Finding 1236190 (2025-002)

Material Weakness 2025

Mdbm - Drake Senior Housing Corporation

MI

HUD Housing Programs Special Tests & Provisions

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300,...

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Significant Deficiencies 2025-002 Compliance Requirement: Special Tests and Provisions – Excess of Residual Receipts Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Project, Assistance Listing 14.155 Project-Based Rental Assistance, Assistance Listing 14.195 Recommendation: It is recommended that efforts be made to ensure compliance with the residual receipts excess fund requirements going forward. Planned Corrective Actions: Every effort will be made to ensure compliance with the residual receipts excess funds requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100.

View Audit 411792

Finding 1236189 (2025-001)

Material Weakness 2025

Mdbm - Drake Senior Housing Corporation

MI

HUD Housing Programs Special Tests & Provisions

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300,...

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT MBDM – Drake Senior Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Boisvenu & Company, P.C., 30600 Telegraph Road, Suite 1300, Bingham Farms, Michigan 48025 Audit period: January 1, 2025 through December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Significant Deficiencies 2025-001 Compliance Requirement: Special Tests and Provisions – Surplus Cash Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Project, Assistance Listing 14.155 Project-Based Rental Assistance, Assistance Listing 14.195 Recommendation: It is recommended that efforts be made to ensure compliance with the surplus cash remittance requirements going forward. Planned Corrective Actions: Every effort will be made to ensure that deposits are made within the 90-day allotted period. Planned Corrective Actions: Every effort will be made to ensure compliance with the residual receipts excess funds requirement. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sridevi Nistala at (248) 626-6100.

View Audit 411792

Finding 1236186 (2025-004)

Material Weakness 2025

Housing Authority of the City of Renton

WA

Eligibility HUD Housing Programs

Forty (40) tenant files sampled by the auditors, seven (9) files did not have utility allowance calculation that agreed to the HUD form 50058; four (4) files did not have tied to the HAP register for the period as management was unable to locate documentation. Additionally, five (4) tenants were not...

Forty (40) tenant files sampled by the auditors, seven (9) files did not have utility allowance calculation that agreed to the HUD form 50058; four (4) files did not have tied to the HAP register for the period as management was unable to locate documentation. Additionally, five (4) tenants were not reexamined and re-certified annually. Based upon staffing issues and staff s inability to learn the HUD regulations with Annual Reexaminations and Administrative Plan requirements between 2023 - 2025, Annual Reexaminations were getting further and further behind. RHA had hired independent contractors back in 2025 to assist RHA catch up but that did not work out. After the conversion of the software in June 2024 to Scott Accounting and Computer Software (SACS) from YARDI, most of the HAP errors came from old PIC files that were pulled over from PIC because the current staff were not double data entering the AR s and IR s into both programs for the few months prior to submission. This caused the HAP issues. All files have been reviewed the past 1.5 years and all HAP has been corrected to landlords based off those errors. Prior staff did not put a checkmark in the box to print reports, which forced the software to put the reports into a Document Management storage system for each tenant. The CEO worked with the software vendor to force the pushing of all reports associated with the AR, IR, MI, PMI, Transfers, MO and PMO to go into Document Management system and store. All FY2024 and FY2025 files are being completed in FY2026 and will be done by December 2026. The CEO and COO are reviewing all files by HCV staff and ensuring that a Compliance Checklist is completed on each file and once the file is certified for its AR, the file automatically goes into Document Management. The 50058 form is reviewed to ensure that the Utility Allowance on the form is also what is pulled onto the 52667 Utility Allowance Schedule form. All AR supporting documents are also monitored and ensured that they scanned into the Document Management system under the tenant folder for that Transaction Type. Beginning January 2027, RHA will be searching for a Compliance Officer staff person to go through files each month (10% of each Program Specialist s case load for prior months Annual Reexams or other types of transactions that occurred that prior month)

View Audit 411791

Finding 1236185 (2025-003)

Material Weakness 2025

Housing Authority of the City of Renton

WA

HUD Housing Programs Eligibility Reporting

It has been identified that the FASSPHA Unaudited Submissions were not submitted by the February 28, 2025, deadline. RHA Administration has achieved in getting all outstanding Independent Audits completed and submitted for 2020-2024. The Unaudited FY2025 was submitted late by the contracted Fee Acco...

It has been identified that the FASSPHA Unaudited Submissions were not submitted by the February 28, 2025, deadline. RHA Administration has achieved in getting all outstanding Independent Audits completed and submitted for 2020-2024. The Unaudited FY2025 was submitted late by the contracted Fee Accountant for the 2nd year. RHA CEO will monitor the timeline of the contracted Fee Accountant going forward for FY2026 Unaudited Submission deadline of February 28, 2027. RHA CEO will monitor the progress of the Fee Accountant throughout the month of January 2027 with weekly reports/phone meeting. On or by February 10th, if the Fee Accountant does not feel they can have the Unaudited FASSPHA submitted by February 28th, an extension has to be requested by February 12th to get an additional 30-day extension approved by HUD by showing a verifiable extenuating circumstance preventing the on-time submission. Under 24 CFR § 902.60, a grace period of 15-days is provided to a PHA for the FASSPHA unaudited submission, which would give RHA until March 15, 2027 but if the extension was never requested on February 12, 2027, then the submission would have to occur prior to the end of the grace period of the 15- days. RHA Administration feels that prior years being completed and software conversion completed in 2024 and all corrections have been made on the GL, there should not be a future reason for the FASSPHA Unaudited Submission to not be on time by February 28th of each year.

View Audit 411791

Finding 1236184 (2025-002)

Material Weakness 2025

Housing Authority of the City of Renton

WA

HUD Housing Programs

RHA agrees with the finding. that the RHA inspection department was utilizing a 72-hour correction and reinspection timeframe for Life- Threatening (LT) deficiencies that required correction within 24 hours. This was due to inspection staff not reviewing the Administrative Plan or understanding Fede...

RHA agrees with the finding. that the RHA inspection department was utilizing a 72-hour correction and reinspection timeframe for Life- Threatening (LT) deficiencies that required correction within 24 hours. This was due to inspection staff not reviewing the Administrative Plan or understanding Federal Regulation requirements on LT or Life- Threatening deficiencies. RHA Administration is performing monthly reviews of trackable, updated Excel Spreadsheet for Failed Inspections and abatements. Along with the monthly review of its Failed Inspections and Abatements, RHA Administration is also performing quarterly training of the inspection department on inspection protocols and timelines, especially if the Administrative Plan is updated or federal inspection protocols change. Effective May 19, 2026, RHA revised its procedures to align with the requirements outlined in the RHA Administrative Plan. RHA now requires that all 24-hour Life-Threatening deficiencies be reinspected and verified within the required 24-hour timeframe after the landlord and/or tenant receives notification of the deficiency via email. RHA Administration recognizes the importance of ensuring that all LT deficiencies are addressed within the required timeframe and that units are placed into abatement when deficiencies are not corrected within the applicable timeframe. Corrective Action 3x3 Quality Control Process To ensure compliance with the required correction and reinspection timeframes and to prevent units from being incorrectly delayed from abatement, RHA will implement a 3x3 monthly quality-control process. 1. HCV Inspection Coordinator Monthly Inspection Report The HCV Inspection Coordinator will generate a monthly inspection report covering the previous month's inspection activity. The report will include, at a minimum: Total number of inspections completed which should be reconciled with RHA's Excel inspection tracker. Total number of inspections passed. Total number of inspections failed. 43 Identification of units currently on their second inspection attempt and within the applicable 30-day correction timeframe, with particular attention given to units approaching the abatement deadline. Total number of units placed into abatement, if applicable, for the reporting month. The Inspection Coordinator will compare the monthly report against the Excel inspection tracker to identify any discrepancies or missing inspection activity. 2. Inspector Secondary Review Following completion of the monthly report, the Inspector will conduct a secondary review of the inspection activity. The Inspector will verify that: Inspection results are accurate. Required were completed within the applicable timeframe. LT deficiencies were reinspected and verified within the required 24-hour timeframe. Units approaching or exceeding the applicable correction timeframe have been appropriately identified. Any unit requiring abatement has been appropriately processed. No inspection or deficiency has been inadvertently missed. Any discrepancies identified during the review will be corrected and documented. 3. HQS Supervisor and CEO Quality Control and Tracking The completed monthly inspection report will then be submitted to the HQS Supervisor and CEO for final quality-control review and tracking purposes. The HQS Supervisor / CEO will review the report to ensure that: Inspection activity is accurately reported. Correction and reinspection timeframes are being followed. LT deficiencies are being handled within the required 24-hour timeframe. Units requiring abatement are being identified and processed in a timely manner. Any discrepancies identified during the first two levels of review have been resolved. Ongoing Monitoring and Compliance RHA will conduct a monthly audit of all HQS inspections throughout FY 2026 to ensure compliance with the applicable inspection requirements and to prevent Indicator 12 from being missed. The 3x3 process will provide three levels of review: 1. HCV Inspection Coordinator 2. Inspector 3. HQS Supervisor / CEO This process is intended to provide an additional layer of accountability, identify discrepancies promptly, ensure accurate tracking of inspections and verify that required abatements are initiated within the applicable timeframe. RHA will maintain documentation of the monthly reviews and any corrective actions identified through the quality-control process. Any discrepancies discovered during the monthly audit will be

View Audit 411791

Finding 1236183 (2025-002)

Material Weakness 2025

County of Armstrong

PA

Subrecipient Monitoring

Finding 2025-002 Subrecipient Monitoring AL 93.778 and Medical Assistance Program and DHS Medical Assistance Transportation Program Criteria: Internal control procedures require the County to perform subrecipient monitoring procedures over the funding disbursed to the Program’s vendor. These monitor...

Finding 2025-002 Subrecipient Monitoring AL 93.778 and Medical Assistance Program and DHS Medical Assistance Transportation Program Criteria: Internal control procedures require the County to perform subrecipient monitoring procedures over the funding disbursed to the Program’s vendor. These monitoring procedures include documenting the procedures performed and the results of those procedures along with documenting the risk assessment associated with the selected procedures. Condition: During the audit, it was noted that the County was not performing subrecipient monitoring over the Program’s vendor. Cause: The County does not have adequate controls in place or the expertise to ensure proper subrecipient monitoring procedures. Effect: The Program’s vendor may be using grant funding inappropriately. This is a repeat finding from the prior year – Finding 2024- 002. Questioned Costs: The amount of questioned costs, if any, is undeterminable. Recommendation: The County should implement internal control procedures that ensure the vendor is being properly monitored and document those procedures and results of procedures. Management Response: Management is working to implement and document proper subrecipient monitoring internal controls. Anticipate Completion Date: Immediate

View Audit 411788

Finding 1236174 (2025-001)

Material Weakness 2025

The Contingent

OR

Allowable Costs / Cost Principles Student Financial Aid Material Weakness § 200.430

Management will reconfigure the system to require after-the-fact entry of actual hours worked and to restrict advance entry and approval, reinforce supervisory review procedures to ensure timely and accurate approval of timecards, and provide training to employees and supervisors on federal timekeep...

Management will reconfigure the system to require after-the-fact entry of actual hours worked and to restrict advance entry and approval, reinforce supervisory review procedures to ensure timely and accurate approval of timecards, and provide training to employees and supervisors on federal timekeeping requirements under 2 CFR 200.430. These actions will strengthen internal controls and ensure payroll costs charged to federal awards accurately reflect work performed going forward.

View Audit 411785

Finding 1236173 (2025-002)

Material Weakness 2025

CONVERGENT RESEARCH, INC.

MA

Procurement, Suspension & Debarment § 200.214

2025-002 Auditor’s Recommendation: Convergent Research, Inc. should strengthen its procurement controls to require documented suspension and debarment verification before execution of all applicable covered transactions. The documentation should identify the vendor, date of verification, source used...

2025-002 Auditor’s Recommendation: Convergent Research, Inc. should strengthen its procurement controls to require documented suspension and debarment verification before execution of all applicable covered transactions. The documentation should identify the vendor, date of verification, source used to perform the verification, and result of the search and should be retained in the procurement file. Corrective Action: Convergent Research has incorporated a required suspension and debarment verification step into its federal grant procurement workflow in Ironclad. The workflow documents the vendor, date of verification, source used to perform the verification, and the result of the search. Responsible for Corrective Action: The assigned FRO employee will complete the verification prior to initiating the workflow in Ironclad. Details are documented in Ironclad when the FRO employee initiates the review process. The assigned Convergent compliance reviewer must review all federal-grant-related responses prior to approving the transaction in Ironclad. Anticipated Completion Date: Implemented July 2026 — the Ironclad federal grant procurement workflow is live for all federally funded procurements.

View Audit 411779

Finding 1236172 (2025-001)

Material Weakness 2025

CONVERGENT RESEARCH, INC.

MA

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

2025-001 Auditor’s Recommendation: Convergent Research, Inc. should establish written procedures and management review controls to: ● Reconcile provisional indirect and fringe rates to actual allowable costs; ● Review award-specific provisions related to indirect costs, cost sharing, and budget flex...

2025-001 Auditor’s Recommendation: Convergent Research, Inc. should establish written procedures and management review controls to: ● Reconcile provisional indirect and fringe rates to actual allowable costs; ● Review award-specific provisions related to indirect costs, cost sharing, and budget flexibility; ● Identify all allowable costs incurred during the period of performance; and ● Perform and document a final award reconciliation before submitting final expenditure reports. Corrective Action: Convergent Research has updated its grant closeout procedures to require: 1. reconciliation of provisional fringe and indirect cost rates to actual allowable costs at the time of award closeout; 2. review of award-specific provisions related to indirect costs, cost sharing, and budget flexibility; 3. identification of all allowable costs incurred during the period of performance, including any unbilled amounts, before final reporting; and 4. a documented management review and final award-level reconciliation prior to submission of the final expenditure report. This reconciliation step has been incorporated into the Finance team's standard grant-closing checklist. Responsible for Corrective Action: The assigned Finance & Accounting Manager will complete the closeout procedures for review by the Head of Finance and the grant PI. Anticipated Completion Date: Implemented August 2026 — updated grant-closeout procedures are in effect for all open federal awards. Procedures are documented in Notion under Federal Grant Accounting Policy and Procedures.

View Audit 411779

Finding 1236169 (2025-015)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Reporting Procurement, Suspension & Debarment § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Missouri State Emergency Management Agency Audit Finding Number: 2025-015 – SEMA FFATA Reporting Name of the contact person responsible for corrective action: Nikol Enyart Anticipated completion date for cor...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Missouri State Emergency Management Agency Audit Finding Number: 2025-015 – SEMA FFATA Reporting Name of the contact person responsible for corrective action: Nikol Enyart Anticipated completion date for corrective action: Completed Corrective action planned is as follows: To avoid future errors, a comparison of the reports received from grant staff with those entered in SAM.GOV will be conducted, and any necessary corrections will be made before the reporting deadline. The absence of UEI numbers will be followed up monthly, and a tracking sheet will be maintained to document the follow-up and will be accessible to the Fiscal Manager for viewing.

View Audit 411772

Corrective Action Plans

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