Corrective Action Plans

Finding 1159574 (2025-001)

Material Weakness 2025

IA

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs

Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and com...

Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and complete. Anticipated Completion Date September 30, 2025

View Audit 370220

Finding 1157136 (2025-001)

Material Weakness 2025

Community Health Centers of Burlington, Inc.

VT

Special Tests & Provisions Eligibility Internal Control / Segregation of Duties

Response to FY2025 Audit Finding: Impact: "Lack of policy enforcement may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries" Why: 1. Were staff not consistently collecting the required income and family size documentation...

Response to FY2025 Audit Finding: Impact: "Lack of policy enforcement may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries" Why: 1. Were staff not consistently collecting the required income and family size documentation? 2. Was training not comprehensive enough or did staff turnover lead to a knowledge gap? 3. Is the Organizations policy or process for documenting income unclear or not consistently enforced? 4. Was there a system in place to audit patient files internally to catch documentation errors? 5. Is the culture of compliance not strong enough to prioritize consistent documentation? Action: 1. Update/Revise sliding fee policy and procedure to clearly define acceptable documentation process for income verification and annual re-evaluation 2. Create and deliver comprehensive training to all relevant staff (front desk, enrollment specialist, and billing) 3. Implement ongoing monitoring – • Establish a new scheduled internal audit process to regularly review a sample of patient documentation for sliding fee documentation compliance. • Establish metrics to track progress, such as percentage of patient files with complete sliding fee documentation, for new and annual sliding fee applications. 4. Once all actions are complete and the issue is resolved, document these improvements to continue the cycle of compliance 5. Continue to audit files at random to ensure documentation compliance continues

View Audit 369470

Finding 1156614 (2025-001)

Material Weakness 2025

Plaza Esperanza INC

RI

HUD Housing Programs Internal Control / Segregation of Duties

Views of Responsible Officials and Planned CorrectivUnited States Department of Housing and Urban Development Plaza Esperanza, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025: Name of Audit Firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place ...

Views of Responsible Officials and Planned CorrectivUnited States Department of Housing and Urban Development Plaza Esperanza, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025: Name of Audit Firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place Suite 109 Lincoln, RI 02865 Audit period covered: 7/1/2024-6/30/2025 The findings from the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: Section 202 Project Rental Assistance—Assistance Listing # 14.157 Recommendation: The Corporation should design and implement internal controls to ensure that all security deposits are transferred in the required time period. Management should also conduct a monthly inspection of the security deposit listing. Action Taken: Management is in agreement with the auditor’s findings. Management has instructed all accounting personnel to review all matters related to tenant compliance. If the United States Department of Housing and Urban Development has questions regarding this plan, please call Frank Shea at (401) 296-3761.

View Audit 368966

Finding 1155987 (2025-001)

Material Weakness 2025

Saugatucket Spring INC

RI

Internal Control / Segregation of Duties

United States Department of Housing and Urban Development Saugatucket Springs, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025 Name of Audit Firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place Suite 109 Lincoln, RI 02865 Audit period covered:...

United States Department of Housing and Urban Development Saugatucket Springs, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025 Name of Audit Firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place Suite 109 Lincoln, RI 02865 Audit period covered: 7/1/2024-6/30/2025 The findings from the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2025-001: Section 202 Project Rental Assistance—Assistance Listing # 14.157 Recommendation: The Corporation should design and implement internal controls to ensure that all tenant files have proper documentation. Action Taken: Management is in agreement with the auditor’s findings. Management has instructed all accounting personnel to review all matters related to tenant compliance. If the United States Department of Housing and Urban Development has questions regarding this plan, please call Frank Shea at (401) 296-3761.

View Audit 368450

Finding 1155791 (2025-002)

Material Weakness 2025

Warren Village, Inc.

CO

HUD Housing Programs Internal Control / Segregation of Duties

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

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

View Audit 368188

Finding 1155715 (2025-001)

Material Weakness 2025

National Crime Victim Law Institute

OR

Cash Management Internal Control / Segregation of Duties

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

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

View Audit 368000

Finding 1155343 (2025-002)

Material Weakness 2025

Pioneer Apartments INC

WY

Questioned Costs Cash Management Material Weakness

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

View Audit 367580 Questioned Costs: $1

Finding 1153764 (2025-001)

Material Weakness 2025

Foothills Community Health Care, Inc.

SC

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

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

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

View Audit 366861

Finding 1153477 (2025-002)

Material Weakness 2025

The Corporation of Gonzaga University

WA

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

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

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

View Audit 366726

Finding 1153470 (2025-001)

Material Weakness 2025

The Corporation of Gonzaga University

WA

Student Financial Aid Special Tests & Provisions Reporting

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

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

View Audit 366726

Finding 1153460 (2025-003)

Material Weakness 2025

Cheboygan Housing Commission

MI

Internal Control / Segregation of Duties

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

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

View Audit 366709

Finding 1153459 (2025-002)

Material Weakness 2025

Cheboygan Housing Commission

MI

HUD Housing Programs Internal Control / Segregation of Duties

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

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

View Audit 366709

Finding 1153458 (2025-001)

Material Weakness 2025

Cheboygan Housing Commission

MI

HUD Housing Programs Internal Control / Segregation of Duties

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

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

View Audit 366709

Finding 1152940 (2025-001)

Material Weakness 2025

Community Workshop Residentials, INC G / Fha Project No. 072-Hd057

IL

Internal Control / Segregation of Duties HUD Housing Programs

Jeff Cottingham, Management agent, and Patti Gratton, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.

View Audit 366276

Finding 576208 (2025-001)

Material Weakness 2025

Freedom First Federal Credit Union

VA

Material Weakness Period of Performance Reporting

Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.

View Audit 366124

Finding 576159 (2025-001)

Material Weakness 2025

Sunrise Community Health

CO

Subrecipient Monitoring Internal Control / Segregation of Duties

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fe...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Management meetings will be scheduled with the COO, Director of Operations, and Dental Billing Supervisor(s) to provide updates on progress. Periodic internal auditing of sliding fee scale dental files will be completed. Quarterly management review of sliding fee scale program progress until Athena Dental is fully integrated with Athena Medical, where electronic health record issues were not detected regarding sliding fee scale adjustments. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kevin Maddox, CFO, at 636-236-5180

View Audit 366069

Finding 576147 (2025-004)

Material Weakness 2025

Community Action of Southern Indiana

IN

Internal Control / Segregation of Duties Equipment & Real Property Management Procurement, Suspension & Debarment

The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that the referenced actions took place in 2020, more than four years before the current audit period. This issue is not reflective of CASI's current internal control environment and doe...

The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that the referenced actions took place in 2020, more than four years before the current audit period. This issue is not reflective of CASI's current internal control environment and does not represent an active or ongoing failure. This was an isolated instance resulting from the actions of a previous administration, whose financial and compliance oversight practices have since been fully overhauled.Since then, CASI has undergone significant changes in staff and Board leadership, financial controls, and Head Start compliance procedures, which directly mitigate any recurrence of this issue. The current leadership bas self-disclosed the issue and is actively working to resolve it. This matter was voluntarily identified and disclosed by current leadership to both the auditors and the Head Start Regional Office. Efforts are ongoing to correct the SF-429 and properly record a Notice of Federal Interest in collaboration with OHS, despite delays resulting from the broader federal restructuring of the Head Start regional offices.

View Audit 366061

Finding 576119 (2025-001)

Significant Deficiency 2025

Berkshire Retirement Home INC

MA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should incr...

FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was increased from $1,182,615 to $1 ,282,815 effective 6/1/2025 with annual insurance renewals to be above the minimum required threshold. The new process implemented will now assess the budgeted potential organizational revenue growth prospectively in the current fiscal year and any calculation increase required will be made prior to the end of the current fiscal year before the insurance renewal for the next fiscal year to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Completion date for corrective action plan: 06/01/2025 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Edward Forfa, Executive Director at 413-445-4056 ext. 160.

View Audit 366047

Finding 575725 (2025-001)

Significant Deficiency 2025

Frontier Nursing University, Inc.

KY

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

Finding: The enrollment statuses in the National Student Loan Data System for students who took a Regular Academic Hiatus were incorrect during the time of their hiatus. Corrective Actions Taken or Planned: FNU will change the reported enrollment status of all students on a regular Academic Hiatus...

Finding: The enrollment statuses in the National Student Loan Data System for students who took a Regular Academic Hiatus were incorrect during the time of their hiatus. Corrective Actions Taken or Planned: FNU will change the reported enrollment status of all students on a regular Academic Hiatus (AH) from “Enrolled” to “Leave of Absence (LOA)” in the National Student Clearinghouse (NSC). Note that both status types indicate an enrolled status per NSC. To support this change, FNU will revise its internal procedures to ensure that students on a regular AH are coded as “Leave” in the Student Learning Management System. This status accurately reflects a temporary interruption in their program of study and aligns with enrollment reporting requirements. We will strengthen training for all staff involved in enrollment status reporting to ensure consistent understanding and proper implementation of the updated procedures. We believe these steps are important for improving the accuracy of our reporting and staying in compliance with federal student aid requirements. Estimated Completion Date: September 30, 2025 Responsible Personnel: Janice Ponstein, Director of Academic Records & Registrar

View Audit 365718

Finding 575602 (2025-004)

Significant Deficiency 2025

Village of Shelby

MI

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting

Finding 2025-004: Coronavirus State and Local Fiscal Recovery Funds Reporting Procedures Type of Finding: Control U.S. Department of Treasury Pass-through Entities: The Right Place, Inc. and Michigan Department of Treasury. Assistance Listing Number: 21.027 Award Numbers: COVID-19 Revitaliza...

Finding 2025-004: Coronavirus State and Local Fiscal Recovery Funds Reporting Procedures Type of Finding: Control U.S. Department of Treasury Pass-through Entities: The Right Place, Inc. and Michigan Department of Treasury. Assistance Listing Number: 21.027 Award Numbers: COVID-19 Revitalization and Placemaking Grant, COVID-19 American Rescue Plan Act Award Year End: June 30, 2026 and December 31, 2026 Specific Requirement: (L.) Reporting Recommendation: The Village should follow established procedures to require the documented review and approval of both RAP and ARPA grant reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Village is implementing a new procedure requiring that ARPA grant reports be reviewed and approved by a designated reviewer before submission in addition to RAP grant reports. The reviewer, who must possess the appropriate skills, knowledge, and experience relevant to the report's content, will ensure that the information is accurate, complete, and compliant with organizational standards and regulatory requirements. Responsible Person and Anticipated Completion Date: The Village Clerk/Treasurer will oversee the implementation of this plan by February 28, 2026. If the Michigan Strategic Fund has questions regarding this plan, please call Phillip Morse at 231-861-4401.

View Audit 365594

Finding 575564 (2025-001)

Significant Deficiency 2025

Village Cooperative of Le Sueur

MN

Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 365551

Finding 575330 (2025-001)

Significant Deficiency 2025

United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health

KS

Special Tests & Provisions Subrecipient Monitoring Eligibility

Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...

Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization 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 GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer

View Audit 365383

Finding 574904 (2025-001)

Significant Deficiency 2025

Dima Viii, Inc.

DE

Internal Control / Segregation of Duties

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA VIII, Inc. requires segregation of duties. We recognize that the current structure does not adequatel...

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA VIII, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Finance Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Accountant who has assumed responsibility for the day-to-day accounting tasks previously performed by the Senior Director of Housing & Facilities. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.

View Audit 365166

Finding 574903 (2025-001)

Significant Deficiency 2025

Dima Vii, Inc.

DE

Internal Control / Segregation of Duties

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA VII, Inc. requires segregation of duties. We recognize that the current structure does not adequately...

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA VII, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Finance Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Accountant who has assumed responsibility for the day-to-day accounting tasks previously performed by the Senior Director of Housing & Facilities. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.

View Audit 365165

Finding 574902 (2025-001)

Significant Deficiency 2025

Dima Iv, Inc.

DE

Internal Control / Segregation of Duties

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA IV, Inc. requires segregation of duties. We recognize that the current structure does not adequately ...

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA IV, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Finance Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Accountant who has assumed responsibility for the day-to-day accounting tasks previously performed by the Senior Director of Housing & Facilities. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.

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