Corrective Action Plans

Finding 1216608 (2025-001)

Material Weakness 2025

IL

Material Weakness Reporting Equipment & Real Property Management § 200.302

Project NOW, Inc. submits the following corrective action plan for the identified finding for the audit period July 1, 2024 through June 30, 2025. 2025-001 - Delinquent Audit Submission, Audit Preparedness, Timely Reconciliations and Material Adjustments Corrective Action: Lack of audit preparedness...

Project NOW, Inc. submits the following corrective action plan for the identified finding for the audit period July 1, 2024 through June 30, 2025. 2025-001 - Delinquent Audit Submission, Audit Preparedness, Timely Reconciliations and Material Adjustments Corrective Action: Lack of audit preparedness, reconciliations not done or not completed timely, and material adjustments either not completed properly and accurately or just not done at all were the cause and the reason for the delinquent audit submission. The Accounting Manager and one Grant Accountant left the organization early to mid FY2025. The CFO then decided to scale back her work hours before eventually leaving the organization prior to completing her agreed upon task of preparing the organization for the audit. The new CFO was hired in September 2025, and a temp Grant Accountant was hired full time in November 2025. Instead of replacing the Accounting Manager, a third Grant Accountant was brought in as a temp in February 2026 and will be hired full time in June 2026. Steps in the Corrective Action Process: Train and Crosstrain Finance Staff and Grant Accountants: Upon the new CFO's arrival, many of the duties for grant reporting as well as the majority of the month-end closing entries fell under one grant accountant. Some duties were delegated to the temp grant accountant, but a majority of the workload still fell to the other accountant. We will make sure that each grant accountant is trained on the grants they are responsible for as well as cross trained on other grants so grant reporting obligations do not go undone in the absence of one accountant. Person(s) Responsible: Steve Morenz, CFO Timing for Implementation: Current and ongoing Training the Accounting Staff in month end closing entries and the handling of material acquisitions and disposals: It was found during the audit that a new agency acquisition was not added to Project NOW's books properly, a new LLC had not been properly set up in the accounting system, and the sale of houses and the sale of vehicles were not handled correctly. The CFO will monitor such activities and make sure the proper accounting for such transactions is completed in the accounting system either at the time of sale or time of acquisition. Person(s) Responsible: Steve Morenz, CFO Timing for Implementation: Current and ongoing Returning to and following a strict month end closing schedule, having the books closed by the 15th of each month: At one point, from the last corrective action plan to this one, the Finance staff was current with their month end closings. But with the transitions that occurred they had again fallen behind, and at one point being up to six months behind in closing the months. With a fully trained Finance department, starting in January 2026 we were able to close two months during each calendar month and were current with our statement's closings by March 2026. The staff will work diligently to maintain this schedule. This will also help ensure grant reporting is done on a timely basis as well. Person(s) Responsible: Steve Morenz, CFO Timing for Implementation: Current and ongoing Balance Sheet Account Review and Reconciliation: Apparently other than monthly bank reconciliations, there has been no balance sheet account review done for quite some time. Moving forward, the CFO will work with the accounting staff to see that reconciliations of all balance sheet accounts for all entities will be done regularly and correctly so we are better prepared for audit season. Person(s) Responsible: Steve Morenz, CFO Timing for Implementation: Current and ongoing Monthly departmental revenue and expense reports distributed to each director by the 20th of each month: Again, prior to the latest staffing transitions, R&E reports were sent to department directors every month. This practice then fell by the wayside. We have re-implemented the distribution of month financial reports to all directors showing all revenues and expenses for the departments they manage and the grants they are responsible for. Regular meetings will be held between the CFO, specific grant accountant, and the directors to review their statements to see how their department is running and their compare financial results versus their budget. This will also help monitor activity on the organization's income statement, making sure those balances are accurate and complete. Project NOW, Inc. submits the following corrective action plan for the identified finding for the audit period July 1, 2024 through June 30, 2025. 2025-001 - Delinquent Audit Submission, Audit Preparedness, Timely Reconciliations and Material Adjustments Corrective Action: Lack of audit preparedness, reconciliations not done or not completed timely, and material adjustments either not completed properly and accurately or just not done at all were the cause and the reason for the delinquent audit submission. The Accounting Manager and one Grant Accountant left the organization early to mid FY2025. The CFO then decided to scale back her work hours before eventually leaving the organization prior to completing her agreed upon task of preparing the organization for the audit. The new CFO was hired in September 2025, and a temp Grant Accountant was hired full time in November 2025. Instead of replacing the Accounting Manager, a third Grant Accountant was brought in as a temp in February 2026 and will be hired full time in June 2026. Steps in the Corrective Action Process: Train and Crosstrain Finance Staff and Grant Accountants: Upon the new CFO's arrival, many of the duties for grant reporting as well as the majority of the month-end closing entries fell under one grant accountant. Some duties were delegated to the temp grant accountant, but a majority of the workload still fell to the other accountant. We will make sure that each grant accountant is trained on the grants they are responsible for as well as cross trained on other grants so grant reporting obligations do not go undone in the absence of one accountant. Person(s) Responsible: Steve Morenz, CFO Timing for Implementation: Current and ongoing Training the Accounting Staff in month end closing entries and the handling of material acquisitions and disposals: It was found during the audit that a new agency acquisition was not added to Project NOW's books properly, a new LLC had not been properly set up in the accounting system, and the sale of houses and the sale of vehicles were not handled correctly. The CFO will monitor such activities and make sure the proper accounting for such transactions is completed in the accounting system either at the time of sale or time of acquisition. Timing for Implementation: Current and ongoing Returning to and following a strict month end closing schedule, having the books closed by the 15th of each month: At one point, from the last corrective action plan to this one, the Finance staff was current with their month end closings. But with the transitions that occurred they had again fallen behind, and at one point being up to six months behind in closing the months. With a fully trained Finance department, starting in January 2026 we were able to close two months during each calendar month and were current with our statement's closings by March 2026. The staff will work diligently to maintain this schedule. This will also help ensure grant reporting is done on a timely basis as well. Person(s) Responsible: Steve Morenz, CFO Timing for Implementation: Current and ongoing Balance Sheet Account Review and Reconciliation: Apparently other than monthly bank reconciliations, there has been no balance sheet account review done for quite some time. Moving forward, the CFO will work with the accounting staff to see that reconciliations of all balance sheet accounts for all entities will be done regularly and correctly so we are better prepared for audit season. Person(s) Responsible: Steve Morenz, CFO Timing for Implementation: Current and ongoing Monthly departmental revenue and expense reports distributed to each director by the 20th of each month: Again, prior to the latest staffing transitions, R&E reports were sent to department directors every month. This practice then fell by the wayside. We have re-implemented the distribution of month financial reports to all directors showing all revenues and expenses for the departments they manage and the grants they are responsible for. Regular meetings will be held between the CFO, specific grant accountant, and the directors to review their statements to see how their department is running and their compare financial results versus their budget. This will also help monitor activity on the organization's income statement, making sure those balances are accurate and complete. Person(s) Responsible: Steve Morenz, CFO Timing for Implementation: Current and ongoing Person(s) Responsible: Steve Morenz, CFO

View Audit 403079

Finding 1216543 (2025-003)

Material Weakness 2025

High Plains Community Health Center, Inc.

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

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/categori...

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: We have found that our electronic medical record (eCW) is automatically classifying the federal poverty level (FPL) for all patients no matter if we have their insurance or household income inputted into the system. This has led to some inaccuracies in the rating of their FPL in eCW. We are actively manually overriding this setting, so we will have full control when to run the FPL after patient information is collected.

View Audit 403040

Finding 1216540 (2025-004)

Material Weakness 2025

Ppep Microbusiness and Housing Development Corporation

AZ

Internal Control / Segregation of Duties

The two residential properties purchased by PMHDC were the 42nd and 43rd properties purchased using funds from this award, which has been in place since 2012. The properties were included in the funding source approved Budget Narrative and Scope of Work. The requests for reimbursement were submitted...

The two residential properties purchased by PMHDC were the 42nd and 43rd properties purchased using funds from this award, which has been in place since 2012. The properties were included in the funding source approved Budget Narrative and Scope of Work. The requests for reimbursement were submitted for payment to the Department of Labor and subsequently processed and paid to the organization, without having submitted pre-acquisition documentation. The Federal Project Officer assigned to this award had previously visited the sites of the prior properties purchased on several occasions. Closeout reports required at the end of each funding cycle were submitted and subsequently approved by the funding source. At no time was a prior-approval package required to be submitted on any of the properties previously purchased.

View Audit 403039

Finding 1216540 (2025-004)

Material Weakness 2025

Ppep Microbusiness and Housing Development Corporation

AZ

Internal Control / Segregation of Duties

The properties purchased have always been listed as an item under the Contractual category in the federally approved budget and budget narrative; thus, while these costs appeared as a program expenditure for federal reporting purposes, the costs were properly categorized in PMHDC’s books as property...

The properties purchased have always been listed as an item under the Contractual category in the federally approved budget and budget narrative; thus, while these costs appeared as a program expenditure for federal reporting purposes, the costs were properly categorized in PMHDC’s books as property and equipment.

View Audit 403039

Finding 1216540 (2025-004)

Material Weakness 2025

Ppep Microbusiness and Housing Development Corporation

AZ

Internal Control / Segregation of Duties

PMHDC contends that it has substantially complied with the purpose of the award and has successfully developed permanent and temporary farm labor rental housing to meet the dire needs of migrant and seasonal farmworkers. The Organization is of the belief that the lack of prior written approval was a...

PMHDC contends that it has substantially complied with the purpose of the award and has successfully developed permanent and temporary farm labor rental housing to meet the dire needs of migrant and seasonal farmworkers. The Organization is of the belief that the lack of prior written approval was an administrative oversight, not previously enforced by the Department of Labor, and PMHDC, therefore, vigorously defends its position that no costs should be disallowed.

View Audit 403039

Finding 1216533 (2025-002)

Material Weakness 2025

Adams-Friendship Area School District

WI

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management

Condition: During our review of the Wisconsin Medicaid School-Based Services Program, the School District was unable to provide adequate supporting documentation for quarterly payroll costs reported to Medicaid. Additionally, the District could not provide a complete and reliable population of payro...

Condition: During our review of the Wisconsin Medicaid School-Based Services Program, the School District was unable to provide adequate supporting documentation for quarterly payroll costs reported to Medicaid. Additionally, the District could not provide a complete and reliable population of payroll transactions attributable to the Medicaid program to support payroll sampling procedures. Plan: The District will strengthen its internal controls over payroll reporting for the Medicaid School- Based Services Program by: establishing and maintaining detailed supporting documentation for all payroll costs claimed; developing procedures to ensure a complete and auditable payroll population can be generated for each reporting period; and providing training to staff responsible for Medicaid payroll reporting and documentation. Management should implement corrective actions to ensure future Medicaid payroll claims are fully supported and compliant with program requirements. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Nicki Ells, Business Manager Management Response: The Adams-Friendship School District accepts the plan for the Corrective Action listed above and does not dispute anything.

View Audit 403034

Finding 1216532 (2025-001)

Material Weakness 2025

Adams-Friendship Area School District

WI

Cash Management Reporting Internal Control / Segregation of Duties

Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correctly record capital asset activity. Plan: The District will implement internal controls to properly record capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completi...

Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correctly record capital asset activity. Plan: The District will implement internal controls to properly record capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Nicki Ells, Business Manager Management Response: The Adams-Friendship School District accepts the plan for the Corrective Action listed above and does not dispute anything.

View Audit 403034

Finding 1216529 (2025-010)

Material Weakness 2025

Pottawatomie County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

The Board of County Commissioners will work to assess and identify risks to design a written county-wide controls policy over federal grant programs to ensure compliance with grant requirements.

View Audit 403027

Finding 1216502 (2025-001)

Material Weakness 2025

County of El Paso, Texas

TX

Reporting Internal Control / Segregation of Duties

El Paso County Auditor’s Office, Grants Compliance and Audit Division, is developing and implementing internal controls to ensure compliance with federal and state reporting requirements.

View Audit 402996

Finding 1216501 (2025-001)

Material Weakness 2025

Las Vegas - Clark County Urban League

NV

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303

As noted, the Program was taken over by State subsequent to year end, and all employees that ran the program are no longer with the Organization. While we did maintain copies of records, accessibility with current staff is difficult and we expected the State would provide us with previous documentat...

As noted, the Program was taken over by State subsequent to year end, and all employees that ran the program are no longer with the Organization. While we did maintain copies of records, accessibility with current staff is difficult and we expected the State would provide us with previous documentation transitioned to them which, unfortunately, they have not. Going forward if any programs are terminated we will make sure previous documentation is maintained, categorized and current staff are able to access any records easily.

View Audit 402993

Finding 1216500 (2025-003)

Material Weakness 2025

City of Seal Beach

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.318 § 200.403 § 200.405

The City has taken steps to strengthen internal controls over the CDBG program. The City will additionally implement formalized procedures requiring, centralized project files containing procurement documentation, cost support, and project eligibility records, document procurement procedures consist...

The City has taken steps to strengthen internal controls over the CDBG program. The City will additionally implement formalized procedures requiring, centralized project files containing procurement documentation, cost support, and project eligibility records, document procurement procedures consistent with Uniform Guidance requirements, including cost/price analysis and justification for contractor selection, collection and review of Davis-Bacon documentation, including wage determinations and certified payrolls, when applicable, verification that required permits are obtained prior to construction and retention of inspection and completion documentation, and secondary review by City staff to ensure all required documentation is complete prior to project closeout. Additionally, the City will provide training to staff involved in CDBG program administration. Responsible Persons: Community Development Director Date of Implementation: Initiate FY 2025-26 with ongoing monitoring into FY 2026-27

View Audit 402990

Finding 1216499 (2025-002)

Material Weakness 2025

City of Seal Beach

CA

Equipment & Real Property Management Internal Control / Segregation of Duties

The misclassification and subsequent omission of approximately $20,000 in equipment expenditures occurred during the revision of the Annual Certification Report for the Equitable Sharing Program. While correcting the classification of overtime expenditures, a full reconciliation of total expenditure...

The misclassification and subsequent omission of approximately $20,000 in equipment expenditures occurred during the revision of the Annual Certification Report for the Equitable Sharing Program. While correcting the classification of overtime expenditures, a full reconciliation of total expenditures to the underlying accounting records was not completed, resulting in the inadvertent omission of equipment costs. The City has reinforced existing review procedures and implemented an additional step requiring a documented reconciliation of the Annual Certification Report totals to the general ledger prior to submission and after any revisions or resubmissions. Responsible Persons: Police Chief Date of Implementation: Initiate FY 2025-26 with ongoing monitoring into FY 2026-27

View Audit 402990

Finding 1216497 (2025-003)

Material Weakness 2025

Aurora East School District 131

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility

2025-003: Allocating Funds to Eligible School Attendance Areas and Schools Condition: The district’s approved Title I application established school-level building allocations under Title I Targeting Step 5 using a per-pupil allocation methodology based on low-income counts. The district should docu...

2025-003: Allocating Funds to Eligible School Attendance Areas and Schools Condition: The district’s approved Title I application established school-level building allocations under Title I Targeting Step 5 using a per-pupil allocation methodology based on low-income counts. The district should document school-level expenditures to verify that the per-pupil allocation is followed. The district does not have effective controls to monitor school-level expenditures for compliance with approved Title I building allocations. Six of the 20 schools overspent their allocation by approximately $554,000. The other schools were under their allocations as a result. Corrective Action Planned: The district is working with ISBE to ensure that our site-based resource allocations align with the district’s budget. Name of the Contact Person Responsible for Corrective Action: Mr. Daniel Ulrich, Executive Direct of Finance/ District Accountants/Auditor, Judy Freeman, District Accounts Grant Auditor, Chanbopha Loera Anticipated Completion Date: July 1st 2026.

View Audit 402987

Finding 1216495 (2025-002)

Material Weakness 2025

La Clinica Tepeyac

CO

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditor’s recommended the Organization update their termination procedures to verify that final payrolls are being calculated correctly and update their grant allocation process to ensure accurate wage rat...

Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditor’s recommended the Organization update their termination procedures to verify that final payrolls are being calculated correctly and update their grant allocation process to ensure accurate wage rates are used to calculate the allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has updated the payroll termination process to include a documented review before payroll is finalized. The finance team will review final payroll calculations for terminated employees after HR provides the termination details and payout calculation. Payroll changes and review steps are documented as part of the bi-weekly payroll update emails.

View Audit 402985

Finding 1216493 (2025-001)

Material Weakness 2025

La Clinica Tepeyac

CO

Internal Control / Segregation of Duties Subrecipient Monitoring

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/categori...

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 and that all documentation supporting the sliding discount provided is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization continues to make improvements to processes and procedures to ensure the accurate documentation and application of the sliding fee discounts. An improvement over the prior year's finding was realized, however more active internal audit checks and balances will need to be made to fully resolve these issues.

View Audit 402985

Finding 1216491 (2025-004)

Material Weakness 2025

Town of Charlestown, Rhode Island

RI

Reporting Internal Control / Segregation of Duties

Corrective Action:The Town will implement the following corrective actions to address this finding:1. The Town will establish formal written procedures for the preparation, review, reconciliation, and submission of all federal reports, including the Project and Expenditure Report required under the ...

Corrective Action:The Town will implement the following corrective actions to address this finding:1. The Town will establish formal written procedures for the preparation, review, reconciliation, and submission of all federal reports, including the Project and Expenditure Report required under the Coronavirus State and Local Fiscal Recovery Funds program.2. Prior to submission, the Town Treasurer/Finance Office will perform and document a reconciliation of all reported obligations and expenditures to the Town’s underlying accounting records for the applicable reporting period.3. The Town will require management review and approval of all federal reports before submission to ensure completeness, accuracy, and compliance with federal requirements.4. The Town will work with its third-party consultant to clearly define responsibilities related to report preparation and submission and require the consultant to provide a final draft report for Town review and approval prior to filing with the U.S. Treasury.5. The Town anticipates these corrective actions will be fully implemented for all future federal reporting submissions beginning with the next required reporting cycle.Responsible Official: Patrick Gormley, TreasurerAnticipated Completion Date: June 30, 2026

View Audit 402982

Finding 1216456 (2025-007)

Material Weakness 2025

Municipality of Yauco

PR

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

We will improve our internal control procedures related to record keeping and adjustments in order to ensure compliance with the March 31 federal requirement.

View Audit 402958

Finding 1216442 (2025-009)

Material Weakness 2025

Ajo Unified School District No. 15

AZ

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

2025-009: ALLOWABLE COSTS/COST PRINCIPLES Program: Education Stabilization Fund Federal Assistance Listing Number: 84.425U Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 21FESIII-111427-01A Questioned Costs: $909.10 Type of Finding: ...

2025-009: ALLOWABLE COSTS/COST PRINCIPLES Program: Education Stabilization Fund Federal Assistance Listing Number: 84.425U Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 21FESIII-111427-01A Questioned Costs: $909.10 Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: B. Allowable Costs/Cost Principles Condition: During testing of payroll disbursements charged to the Education Stabilization Fund (ESSER III) program, we noted that for two of 9 transactions tested, the District was unable to provide documentation demonstrating that extra duty stipends were properly approved and allowable under the grant. The total amount associated with these transactions was $909.10. Action planned in response to finding: The District will implement procedures to ensure all payroll expenditures charged to federal programs are properly authorized, supported, and allowable prior to processing, including requiring documented approval for all stipends and maintaining adequate supporting documentation. The District will also strengthen oversight over grant management by assigning responsibility for reviewing grant expenditures and monitoring grant budgets on an ongoing basis to ensure costs are appropriate, within approved budgets, and charged to the correct program. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Roman Soltero, Superintendent

View Audit 402951

Finding 1216441 (2025-002)

Material Weakness 2025

Highlands County, Florida

FL

Cash Management Material Weakness Reporting § 200.303

Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Assistance Listing No. 97.036 Recommendation: We recommend the County establish and implement formal procedures requiring supervisory review and approval of all reports submitted to grantors. Evidence of review should be docum...

Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Assistance Listing No. 97.036 Recommendation: We recommend the County establish and implement formal procedures requiring supervisory review and approval of all reports submitted to grantors. Evidence of review should be documented and retained, including the reviewer’s signature or electronic approval, the date of review, and the date of submission, to support compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has established a review and approval process for quarterly reports. Reports will be reviewed and signed by a member of management to ensure accuracy and completeness of the data being submitted. Name of the contact person responsible for corrective action: Tanya Cannady, Business Services Director Planned completion date for corrective action plan: June 2026

View Audit 402949

Finding 1216437 (2025-001)

Material Weakness 2025

Highlands County, Florida

FL

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Assistance Listing No. 97.036 Recommendation: We recommend the County implement a formal review and reconciliation process to ensure that employees' hours reported on Activity Logs are verified against the reimbursement reques...

Disaster Grants - Public Assistance (Presidentially Declared Disasters) – Assistance Listing No. 97.036 Recommendation: We recommend the County implement a formal review and reconciliation process to ensure that employees' hours reported on Activity Logs are verified against the reimbursement request prior to submitting it to the grantor. This review should be performed by personnel knowledgeable of the grant requirements and documented to evidence the review was completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will establish a process to maintain effective internal controls to ensure that the documentation is complete and accurately reflected in the reimbursement requests. An internal review and reconciliation process for employee activity logs will be performed prior to submitting to the grantor. Name of the contact person responsible for corrective action: Tanya Cannady, Business Services Director Planned completion date for corrective action plan: June 2026

View Audit 402949

Finding 1216416 (2025-001)

Material Weakness 2025

Veterans Health Foundation

PA

Cash Management Internal Control / Segregation of Duties § 200.303

Veterans’ Health Foundation Corrective Action Plan Federal Drawdown Internal Control Finding 2025-001 Management agrees with the finding. The identified exceptions resulted from inconsistent retention of documented review evidence during a period of transition in finance personnel. While drawdown re...

Veterans’ Health Foundation Corrective Action Plan Federal Drawdown Internal Control Finding 2025-001 Management agrees with the finding. The identified exceptions resulted from inconsistent retention of documented review evidence during a period of transition in finance personnel. While drawdown requests were supported by allowable expenditures and subject to financial oversight, documentation evidencing the control was not consistently maintained for certain transactions. To strengthen internal controls over federal drawdown requests and ensure continued compliance with 2 CFR 200.303, the Veterans Health Foundation will revise and formalize its drawdown procedures as follows: 1. Federal drawdown requests will be prepared by designated finance personnel and supported by appropriate expenditure documentation. 2. The Controller will review supporting documentation and authorize all federal drawdown requests prior to submission to ensure the accuracy, allowability, and appropriateness of reimbursement requests. 3. The CEO will perform and document a monthly reconciliation review of drawdown activity and related expenditures as an additional oversight and monitoring control. 4. The Foundation will update its formal policies and procedures within 60 days to reflect the revised drawdown preparation, review, authorization, reconciliation, and documentation retention requirements. 5. The Foundation is strengthening its document storage and records retention processes to ensure supporting documentation for drawdowns and other federal award activities is consistently maintained, centrally stored, and readily accessible for audit and compliance purposes. 6. As part of the Foundation’s broader administrative modernization initiative, the Foundation is implementing a new cloud-based file storage and records management system during the current fiscal year to improve document retention, access controls, continuity of operations, and long-term compliance oversight. 7. Management has communicated the revised control procedures to finance personnel and will monitor compliance with the updated process. The Foundation believes these corrective actions adequately address the finding and strengthen internal controls over federal cash management activities and records retention. Responsible Officials: Controller and Chief Executive Officer Anticipated Completion Date: Policy updates will be completed within 60 days. All other corrective actions have been implemented effective immediately, with the new cloud-based file storage system to be implemented during the current fiscal year.

View Audit 402933

Finding 1216369 (2025-001)

Material Weakness 2025

Dwight Way Housing, Inc.

CA

Procurement, Suspension & Debarment Eligibility HUD Housing Programs

DWIGHT WAY HOUSING INC 2220 OXFORD STREET BERKELEY, CALIFORNIA 94704 (510) 841-4410 CORRECTIVE ACTION PLAN March 31, 2026 Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Dwight Way Housing, Inc. respectfully submits the following corrective action plan for the ye...

DWIGHT WAY HOUSING INC 2220 OXFORD STREET BERKELEY, CALIFORNIA 94704 (510) 841-4410 CORRECTIVE ACTION PLAN March 31, 2026 Cognizant or Oversight Agency for Audit: Department of Housing and Urban Development Dwight Way Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Lindquist von Husen & Joyce LLP 301 Howard Street, Suite 850 San Francisco, CA 94105 Audit period: July 1, 2024, to June 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. FINDINGS—FINANCIAL STATEMENT AUDIT None noted. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS 2025-001 Compliance over Eligibility Requirements to Perform Annual Recertification - Assistance Listing No. 14.181. Program –Supportive Housing for Persons with Disabilities Significant Deficiency Dwight Way should develop an operating plan in order to ensure that recertifications are performed timely each year, despite of staff shortages. Action Taken: Unanticipated staff shortages created gaps in performance of annual recertifications at this location. New staff has since been hired in the Regional Manager role and the Director role. Both new employees are providing greater oversight and visiting the property regularly to track progress. In addition to our permanent staffing efforts, we have deployed a Property Operations Specialist to bring recertifications current at Dwight Way. This specialist is focused specifically on compliance tasks and critical deadlines. Additionally, senior leadership at the John Stewart Company has implemented enhanced tracking of recertifications across the full portfolio and now conducts monthly progress meetings with management team to monitor compliance, identify risks early, and ensure accountability. We are confident that these corrective actions will result in sustained improvement and ongoing compliance. If the Department of Housing and Urban Development has questions regarding this plan, please call Zelda Ryan, Corporate Controller, at (510) 841-4410 x304#. Sincerely, Eric Knecht, CFO Resources for Community Development

View Audit 402913

Finding 1216365 (2025-001)

Material Weakness 2025

American Samoa Medical Center Authority Lbj Medical Center

AS

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.514

Corrective actions were delayed due to the anticipated implementation of a new system that ws expected to address access and segregation of duties concerns. Since the new system will not be imiplemented immediately, management is proceeding with corrective action under the current system. Management...

Corrective actions were delayed due to the anticipated implementation of a new system that ws expected to address access and segregation of duties concerns. Since the new system will not be imiplemented immediately, management is proceeding with corrective action under the current system. Management is working to define and separate HR and Payroll rolls and access responsibilities so that employee information, pay rates, and payroll related functions are restricted to authorized personnel based on job duties. In the interim, periodic reviews of employee information, user access, and payroll related transactions will be performed. Any unauthorized changes will be documented and retained.

View Audit 402905

Finding 1216350 (2025-001)

Material Weakness 2025

Southern Indiana Community Health Care, Inc.

IN

Internal Control / Segregation of Duties

Management concurs with the recommendation and will review the policies and procedures surrounding sliding fee write-offs. In addition, management plans to implement changes to the system where write-offs are automatically calculated and applied. Management plans on providing additional training to ...

Management concurs with the recommendation and will review the policies and procedures surrounding sliding fee write-offs. In addition, management plans to implement changes to the system where write-offs are automatically calculated and applied. Management plans on providing additional training to staff and performing periodic reviews of sliding fee write-offs to ensure compliance with the policies and procedures.

View Audit 402877

Finding 1216348 (2025-001)

Material Weakness 2025

Presbyterian Medical Services

NM

Special Tests & Provisions Subrecipient Monitoring Eligibility

Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater ...

Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater error rate are receiving focused retraining and ongoing monitoring, with audit results shared with leadership to promote accountability. Two mandatory training sessions for CARs, AR staff, and administrators are being conducted to reinforce consistent and compliant program implementation. Persons Responsible: Steven Hansen, President & CEO; Pearl Lujan, Central Billing Office Director Estimated Completion Date: December 31, 2026

View Audit 402865

Corrective Action Plans

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