Corrective Action Plans

Finding 1228838 (2025-001)

Material Weakness 2025

Brown-Nicollet Community Health Services

MN

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.303

Finding Number: 2025-001 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cassandra Sassenberg Corrective Action Planned: At Quarter End, the Fiscal S...

Finding Number: 2025-001 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cassandra Sassenberg Corrective Action Planned: At Quarter End, the Fiscal Supervisor and/or Fiscal Coordinator will request specific employee payroll information from payroll staff. Payroll staff will provide a UKG general ledger system report showing account breakouts of the allocation, rather than solely a summary total spreadsheet to allow for review by employee, account code, and time study participation status. For employees included on the participant list, only the portion of salary charged to account 11.420 will remain on Line A1 of the DHS-2550 report. Any portion charged to accounts 11.430 or 11.440 will be removed from Line A1 and reported as an administrative cost on Line E1. If an employee is not included on the participant list, the employee’s full salary, including any amount charged to account 11.420, will be reported as an administrative cost on Line E1. This process will ensure that only eligible participant payroll remains on Line A1 and prevent payroll costs from being removed from Line A1 in excess of the amount required. Anticipated Completion Date: 12/31/2026

View Audit 410424

Finding 1228718 (2025-002)

Material Weakness 2025

Proud Ground

OR

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Material Weakness § 200.303

Finding 2025-002 – Material Weakness in Internal Controls over Federal Award Compliance Criteria – 2 CFR 200.303 requires the recipient to establish, document, and maintain effective internal control over federal awards. Condition – The Organization has not established and documented internal contro...

Finding 2025-002 – Material Weakness in Internal Controls over Federal Award Compliance Criteria – 2 CFR 200.303 requires the recipient to establish, document, and maintain effective internal control over federal awards. Condition – The Organization has not established and documented internal control policies and procedures over compliance with federal award requirements other than procurement. It is also noted that the procurement policy that is documented does not conform to current federal limits. Context and Cause – The Organization’s current policies do not include a review of the fiscal policy for required changes on a scheduled basis. Effect of Condition – Incomplete documentation of policies regarding federal compliance could prevent management and the Board from providing adequate oversight over compliance activities of the Organization. Questioned Cost – None. Recommendation – We recommend the Organization develop and implement policies and procedures addressing the applicable federal compliance requirements for each federal program. Action Taken – Management concurs with the finding and has developed a corrective action plan. We understand that a material weakness is identified in internal controls over compliance. The material weakness is in internal controls over compliance, and not a compliance finding. Draft and adopt written internal control policies and procedures addressing each applicable compliance requirement, including defined roles, responsibilities, and approval processes. Update the Organization's procurement policy to conform to current Federal procurement thresholds and methods under 2 CFR §§ 200.317–200.327, including micro-purchase and simplified acquisition thresholds. Establish a recurring (at least annual) fiscal policy review cycle, with responsibility assigned to a specific role, to identify and incorporate required regulatory changes, including updates to Federal thresholds. Present the updated policies and procedures to the Board (or Finance/Audit Committee) for formal review and approval. Responsible parties: Fiscal Director. Anticipated completion date: October 31, 2026.

View Audit 410392

Finding 1228692 (2025-006)

Material Weakness 2025

ALTA MUNICIPAL UTILITIES

IA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.501

The Utility will work on a formal process for tracking all federal grants so that the reported federal expenditures are accurate.

View Audit 410372

Finding 1228688 (2025-004)

Material Weakness 2025

Farmington Municipal School District No. 5

NM

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking

Recommendation: The auditor recommends the District implement controls to ensure student files are complete and accurate and conduct training for Title I personnel and school sites over the appropriate level of written documentation required for different situations. Action Taken: The District will ...

Recommendation: The auditor recommends the District implement controls to ensure student files are complete and accurate and conduct training for Title I personnel and school sites over the appropriate level of written documentation required for different situations. Action Taken: The District will implement controls to ensure student files are complete and accurate and conduct training for Title I personnel and school sites over the appropriate level of written documentation required for different situations. Responsible Person: Michelle Hill, Student Information Coordinator Anticipated Completion Date: June 30, 2026

View Audit 410367

Finding 1228686 (2025-004)

Material Weakness 2025

Eldred Borough

NY

Internal Control / Segregation of Duties

Segregation of Duties - Auditor’s recommendation: We recognize the Borough has attempted to segregate duties to the best of its ability. The Borough should continue to seek opportunities to segregate duties including involvement from Council Members. Borough’s Response: Because of the limited number...

Segregation of Duties - Auditor’s recommendation: We recognize the Borough has attempted to segregate duties to the best of its ability. The Borough should continue to seek opportunities to segregate duties including involvement from Council Members. Borough’s Response: Because of the limited number of personnel in the office, the Borough recognizes the limitations with regards to segregation of duties and therefore will consider mitigating controls. The Borough will continue to seek involvement from the Borough Council in terms of reviewing financial information.

View Audit 410364

Finding 1228682 (2025-003)

Material Weakness 2025

Eldred Borough

NY

Internal Control / Segregation of Duties Material Weakness Reporting

Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Borough should continue to review and accept both proposed adjusting journal en...

Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Borough should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. Borough’s Response: The Borough has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the Borough believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the Borough considers such assistance provided by the auditors to be the most cost-effective manner to prepare such information. The Borough will also ensure that in the future all transactions will be properly reflected in the accounting software.

View Audit 410364

Finding 1228656 (2025-004)

Material Weakness 2025

Beltrami County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5ADM and 2505MN5MAP Award P...

CASE FILE REVIEWS Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Grants to States for Medicaid (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5ADM and 2505MN5MAP Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the County perform internal case file reviews and implement standard documentation that will formalize the performed reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will add additional documentation and specific casefile reviews will be implemented. Name of the contact person responsible for corrective action plan: Anne Lindseth, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2026

View Audit 410296

Finding 1228654 (2025-003)

Material Weakness 2025

Beltrami County

MN

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

RANDOM MOMENT STUDY (RMS) EMPLOYEE LISTING Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Grants to States for Medicaid (Medicaid Cluster) and Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.778 and 93.558 Pass-Through Agency: Minneso...

RANDOM MOMENT STUDY (RMS) EMPLOYEE LISTING Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Grants to States for Medicaid (Medicaid Cluster) and Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.778 and 93.558 Pass-Through Agency: Minnesota Department of Human Services and Minnesota Department of Health Pass-Through Numbers: 2505MN5ADM, 2505MN5MAP, and 2501MNTANF Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: It is recommended the County implement a quarterly review and reconciliation procedure to ensure that the population of participating workers included in each RMS listing agrees to the population of participating workers whose salaries and wages were recorded to the corresponding payroll accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will strive to implement quarterly review and reconciliation procedures over the RMS listing and corresponding payroll accounts. Name of the contact person responsible for corrective action plan: Anne Lindseth, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2026

View Audit 410296

Finding 1228634 (2025-001)

Material Weakness 2025

WABASH TELEPHONE COOPERATIVE INC

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management § 200.302 § 200.303

Finding 2025-001 Allowable Cost Principles and Activities Allowed or Unallowed Significant Deficiency in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need...

Finding 2025-001 Allowable Cost Principles and Activities Allowed or Unallowed Significant Deficiency in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need for a formalized, written policy governing expenditures charged to federal awards. To address identified significant deficiency, Wabash implemented a comprehensive written policy as of June 30, 2026. This policy will formalized the coding, review, and reporting processes for all federal expenditures. Key improvements included: • Enhanced Internal Controls: We established a clear segregation of duties to ensure oversight and accuracy. • Timely Reporting: We refined our payroll allocation process. Previously, payroll expenditures were withheld pending budget verification, which occasionally led to reporting delays. New controls will ensure that all expenditures, including payroll, are reported within the required quarterly timeframes. • Monitoring: The Controller will oversee the development of these procedures and remain responsible for ongoing monitoring and compliance. These steps will ensure our financial practices meet federal standards and provide rigorous oversight of project funds. Contact person(s): Cheryl Gaither, Controller Justin Gephart, Chief Operating Officer

View Audit 410271

Finding 1228623 (2025-002)

Material Weakness 2025

Town of Concord

MA

Subrecipient Monitoring Material Weakness Reporting § 200.1

Recommendation: The Town should implement procedures to reconcile all federal reporting to the general ledger. Response: A full reconciliation of the ARPA accounts has been performed and aligned with the previous compliance reporting. A chart of accounts conversion is under way which will segregate ...

Recommendation: The Town should implement procedures to reconcile all federal reporting to the general ledger. Response: A full reconciliation of the ARPA accounts has been performed and aligned with the previous compliance reporting. A chart of accounts conversion is under way which will segregate federal funds from one fund to six funds for comprehensive oversight in the general ledger.

View Audit 410260

Finding 1228585 (2025-004)

Material Weakness 2025

Town of Boxford

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Audit Finding Reference: 2025-004 Improve Compliance and Controls Over Reporting Planned Corrective Action: This finding was identified by the Town’s independent auditor during the FY2025 single audit and was not issued by the U.S. Department of the Treasury or another federal agency. Before any rem...

Audit Finding Reference: 2025-004 Improve Compliance and Controls Over Reporting Planned Corrective Action: This finding was identified by the Town’s independent auditor during the FY2025 single audit and was not issued by the U.S. Department of the Treasury or another federal agency. Before any remaining SLFRF Project and Expenditure Report is submitted, the preparer will reconcile current-period and cumulative expenditures to the general ledger and supporting grant schedule. A second finance official will review the reconciliation and proposed submission. The preparer and reviewer will sign and date the reconciliation, which will be retained with a copy of the submitted report. The same control will be used for a future material federal financial report when circumstances warrant. Planned Implementation Date of Corrective Action: Before the next remaining SLFRF report is submitted; otherwise, upon the next applicable material federal report Person Responsible for Corrective Action: Assistant Town Administrator/Finance Director and Town Accountant, with preparation and review duties appropriately separated

View Audit 410210

Finding 1228553 (2025-002)

Material Weakness 2025

Housing Authority of the County of Lawrence

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility § 200.430

Program: Public Housing Operating Fund AL Number: 14.850 Finding Number: 2025-002 Audit Finding (Copied & Pasted Directly from Auditor’s Report): Condition: During the audit we observed documentation showing employees recording a full 8 hour work day on time sheets while leaving work early. Manageme...

Program: Public Housing Operating Fund AL Number: 14.850 Finding Number: 2025-002 Audit Finding (Copied & Pasted Directly from Auditor’s Report): Condition: During the audit we observed documentation showing employees recording a full 8 hour work day on time sheets while leaving work early. Management was instructed to cease tracking and compensate employees for full time anyway. Context: Employee(s) doing the following activities and still getting compensated for a full 8 hour work day; Employee(s) leaving their assigned worksite prior to the end of work day, employee(s) not calling off or leaving early for appointments without correctly calling off nor submitting the proper leave slips, employee(s) arriving late and leaving early daily. Cause: Management override and lack of monitoring/enforcement Criteria: According to 2 CFR 200.430 Compensation - personal services, charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed Corrective Action to Be Taken: Reinstatement of accurate timekeeping with outlined policy and procedures including a discipline action plan for inaccurate payroll and leave slips submission. Strengthened controls and training; Support of management without overrides. Contact Responsible for Corrective Action: Gene Digennaro, Interim Executive Director PO Box 988 481 Neshannock Avenue New Castle, PA 16103 724-656-5100 ext. 204 gdigennaro@lawrencecountyha.com Tara Sheffler, Comptroller PO Box 988 481 Neshannock Avenue New Castle, PA 16103 724-656-5100 ext. 210 tsheffler@lawrencecountyha.com

View Audit 410183

Finding 1228495 (2025-001)

Material Weakness 2025

City of Charleston, South Carolina

SC

Reporting Procurement, Suspension & Debarment Internal Control / Segregation of Duties

Corrective Action Plan: The City of Charleston will implement internal controls and procedures to ensure all required reports are prepared, reviewed, and submitted within the program’s required timeframes, and with the correct amounts. Anticipated Completion Date: Fiscal Year 2026

View Audit 410145

Finding 1228493 (2025-002)

Material Weakness 2025

Pierre Indian Learning Center

SD

Reporting Internal Control / Segregation of Duties § 200.512

Corrective Action Plan for Finding 2025-002 Finding Title: Noncompliance with Single Audit Report Submission Requirements Federal Program(s): All programs included in the FY 2025 Single Audit Contact Person Responsible for Corrective Action: Dr. Veronica Morley, Superintendent Anticipated Completion...

Corrective Action Plan for Finding 2025-002 Finding Title: Noncompliance with Single Audit Report Submission Requirements Federal Program(s): All programs included in the FY 2025 Single Audit Contact Person Responsible for Corrective Action: Dr. Veronica Morley, Superintendent Anticipated Completion Date: March 31, 2027 Corrective Action Plan: Management concurs with the finding. The delay in submitting the Single Audit reporting package to the Federal Audit Clearinghouse was due delayed completion of audited financial statements. The school is in the process of getting current with audited financials statements.

View Audit 410142

Finding 1228419 (2025-005)

Material Weakness 2025

Glide Foundation

CA

Reporting Cash Management Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action: Management acknowledges that, for certain reimbursement requests, documentation evidencing review and approval prior to submission was not retained. Management notes, however, that the underlying expenditures included in the reimbursement...

Views of Responsible Officials and Planned Corrective Action: Management acknowledges that, for certain reimbursement requests, documentation evidencing review and approval prior to submission was not retained. Management notes, however, that the underlying expenditures included in the reimbursement requests were valid, properly recorded in the general ledger, and supported by appropriate accounting records. No questioned costs were identified, and the amounts requested for reimbursement were consistent with allowable program expenditures. Management believes the condition was limited to documentation of review rather than the absence of an actual review process. Reimbursement requests were prepared using underlying financial records and submitted based on incurred costs; however, evidence of supervisory review was not consistently retained during a period of staffing transition. Upon identification, management evaluated its cash management and drawdown processes and reinforced expectations related to documentation and retention of review and approval. Review and approval of reimbursement requests are now consistently evidenced through electronic or physical sign off, and supporting documentation is maintained in a centralized and accessible manner. In addition, management has reinforced alignment of drawdown activity with underlying accounting records to ensure consistency between reimbursement requests, financial reporting, and the general ledger. Management believes this condition represents a documentation gap during a defined period rather than a systemic breakdown in internal control over compliance. The underlying control activities—preparation of drawdowns based on recorded expenditures and supervisory oversight—were in place and functioning, and the enhancements implemented ensure consistent documentation and retention of those controls going forward. Management will continue to monitor these processes as part of ongoing financial operations to ensure compliance with applicable requirements, including 2 CFR Part 200. Management respectfully notes that this condition was limited to the retention of documentation evidencing review and approval and did not impact the allowability of costs, the accuracy of reimbursement requests, or compliance with program requirements. All expenditures were properly supported and recorded, and no questioned costs were identified.

View Audit 410100

Finding 1228416 (2025-004)

Material Weakness 2025

Glide Foundation

CA

Cash Management Reporting Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action: Management acknowledges that documentation supporting the review and approval of a reimbursement request was not retained, and that drawdown activity during the period did not consistently align with the timing of incurred expenditures. M...

Views of Responsible Officials and Planned Corrective Action: Management acknowledges that documentation supporting the review and approval of a reimbursement request was not retained, and that drawdown activity during the period did not consistently align with the timing of incurred expenditures. Management notes that this condition was identified during a period of staffing transition and resulted in a lapse in documentation and timeliness, rather than an absence of underlying financial controls. Management further notes that the expenditure underlying the reimbursement request were valid, properly recorded in the general ledger, and supported by appropriate accounting records. The condition was limited to documentation of review and the timing of drawdown activity, and no questioned costs were identified. Upon identification, management evaluated and reinforced its cash management and drawdown processes. Drawdown requests are now consistently prepared based on underlying accounting records and aligned with incurred expenditures. A formal review and approval step has been implemented and is now required prior to submission, with evidence of review retained electronically or physically for audit purposes. In addition, management has strengthened oversight of drawdown timing to better align reimbursements with the period in which costs are incurred, reducing the risk of delayed submissions and ensuring consistency with related financial reporting. Management believes this condition represents a lapse in execution and documentation during a defined period rather than a systemic breakdown in control design. Enhancements implemented have addressed the identified gaps and established a more consistent and well documented process for drawdown preparation, review, and submission in accordance with applicable requirements, including 2 CFR Part 200.

View Audit 410100

Finding 1228389 (2025-001)

Material Weakness 2025

Talbert House Health Center Dba Centerpoint Health

OH

Special Tests & Provisions Internal Control / Segregation of Duties

Finding 2025-001 — Special Tests and Provisions – Sliding Fee Discount Program Federal Program: Health Center Program Cluster, ALN 93.224 Federal Agency: U.S. Department of Health and Human Services (Health Resources and Services Administration) Condition (as reported): The Organization’s Board-appr...

Finding 2025-001 — Special Tests and Provisions – Sliding Fee Discount Program Federal Program: Health Center Program Cluster, ALN 93.224 Federal Agency: U.S. Department of Health and Human Services (Health Resources and Services Administration) Condition (as reported): The Organization’s Board-approved sliding fee discount schedule was not configured correctly within the eClinicalWorks (eCW) billing system, resulting in patient sliding fee discounts that were not calculated in accordance with the Organization’s approved schedule. Name of Contact Person Responsible for Corrective Action: Hope Beemer, Chief Financial Officer 513.318.1188 | hope.beemer@centerpointhealth.org Corrective Action Taken: The Organization has corrected the condition identified in the finding. Specifically: • In 2025, Centerpoint Health utilized an outside vendor for billing services. To strengthen internal oversight and accountability, billing was brought in-house in January 2026 with the hiring of a Director of Revenue Cycle Management. By April 2026, all billing and revenue cycle operations were fully transitioned to Centerpoint Health’s internal team. • The Board of Directors reviewed and approved an updated sliding fee discount schedule in May 2026, which was implemented in the eClinicalWorks (eCW) billing system with an effective date of February 1, 2026. • Prior to implementation, management verified that the approved schedule was accurately configured in eCW by comparing system-generated discounts to the Board-approved schedule across each discount tier. • Patient encounters affected during 2025 were reviewed and discounts are adjusted where necessary. This was completed by August 2026. Ongoing Controls to Prevent Recurrence: • Any change to the sliding fee discount schedule in eCW requires a secondary, independent review and approval before the change is activated. • Management performs a quarterly reconciliation of system-generated sliding fee discounts to the current Board-approved schedule and investigates and resolves any exceptions. • The sliding fee discount schedule is reviewed and approved by the Board of Directors at least annually and is updated for changes in the Federal Poverty Guidelines. • Billing and front-desk staff receive annual training on the sliding fee discount policy and schedule. Anticipated Completion Date: • Completed. The updated Board-approved sliding fee discount schedule was implemented effective February 1, 2026, and the ongoing monitoring controls described above are in effect.

View Audit 410075

Finding 1228385 (2025-015)

Material Weakness 2025

Boys and Girls Clubs of Puerto Rico INC

PR

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.318 § 200.334 § 200.403

In order to avoid this situation happening in the future, instruction will be provided to all personnel emphasizing that every purchase should be made through a purchase order. This will ensure that we follow the BGCPR formal procedure and ensure better internal control is being followed. In additio...

In order to avoid this situation happening in the future, instruction will be provided to all personnel emphasizing that every purchase should be made through a purchase order. This will ensure that we follow the BGCPR formal procedure and ensure better internal control is being followed. In addition, we will emphasize that no shipment should be received if such purchase is not in accordance with the specification disclosed in the purchase order. Contact Person: Purchase and procurement personnel Carlos Rivera Paul Barreras Amarilis Rodríguez (PACNA’s Project Manager) Team: Finance Team Anticipated Completion Date: September 30, 2026

View Audit 410044

Finding 1228375 (2025-012)

Material Weakness 2025

Boys and Girls Clubs of Puerto Rico INC

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.334 § 200.403 § 200.430

BGCPR will provide additional training and guidance to Human Resources personnel to ensure consistent adherence to the internal procedures established. Contact Person: Yezaida Reyes Angel Morales Paul Rivera Team: Finance, Compliance and Human Resources Team Anticipated Completion Date: September 30...

BGCPR will provide additional training and guidance to Human Resources personnel to ensure consistent adherence to the internal procedures established. Contact Person: Yezaida Reyes Angel Morales Paul Rivera Team: Finance, Compliance and Human Resources Team Anticipated Completion Date: September 30, 2026

View Audit 410044

Finding 1228371 (2025-010)

Material Weakness 2025

Boys and Girls Clubs of Puerto Rico INC

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.328 § 200.329

Due to the organization’s transition period, the reports were submitted late. After the new Finance Director started in June 25, 2025. In January 30, 2026, we received system access, all reports were submitted on February 4, 2026. This matter was presented in the most recent focus Area II monitoring...

Due to the organization’s transition period, the reports were submitted late. After the new Finance Director started in June 25, 2025. In January 30, 2026, we received system access, all reports were submitted on February 4, 2026. This matter was presented in the most recent focus Area II monitoring by the Agency, with no complaints noted. We will request additional system access for reporting purposes in case the person responsible is unavailable. Contact Person: Carlos Rivera Nora Boschetti Team: Finance Team Anticipated Completion Date: September 30, 2026

View Audit 410044

Finding 1228365 (2025-008)

Material Weakness 2025

Boys and Girls Clubs of Puerto Rico INC

PR

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

BGCPR acknowledges a significant oversight in the financial management of assets acquired with Community Development Block Grant – Disaster Recovery (CDBG-DR) funds. Specifically, it has been identified that certain property and equipment purchased using these funds were not properly recorded in the...

BGCPR acknowledges a significant oversight in the financial management of assets acquired with Community Development Block Grant – Disaster Recovery (CDBG-DR) funds. Specifically, it has been identified that certain property and equipment purchased using these funds were not properly recorded in the equipment detail ledger. As a result of this omission, these assets were incorrectly treated as expenses in the financial records, rather than being capitalized in accordance with BGCPR’s established financial policies and the federal guidelines governing the administration of CDBG-DR funds. This misclassification not only affects the accuracy of BGCPR’s financial statements but also represents a deviation from required asset management practices, which mandate the capitalization and tracking of equipment to ensure accountability, proper depreciation, and compliance with grant conditions. As a corrective measure, BGCPR will take the following actions: a. BGCPR will implement a corrective action plan to strengthen accounting processes related to account registration and equipment capitalization related to the CDBG-DR; b. Procurement procedures for requesting, approving, and accepting goods and services, Include agency consultation; c. Ensure accuracy in financial records that Maintain compliance with applicable regulations; d. Account for taxes and support service costs (e.g., installation, delivery); e. Ensure all purchases align with federal regulations. Contact Person: Paul Barrera Carlos Rivera Enrique Vélez Cortes Team: Finance Team Anticipated Completion Date: December 31, 2026

View Audit 410044

Finding 1228362 (2025-007)

Material Weakness 2025

Boys and Girls Clubs of Puerto Rico INC

PR

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.512

BGCPR acknowledges that the delay in the preparation and submission of its audited financial statements was influenced by several interrelated factors, primarily stemming from the challenges associated with a transitional period and the unexpected resignation of the Chief Financial Officer (CFO). Th...

BGCPR acknowledges that the delay in the preparation and submission of its audited financial statements was influenced by several interrelated factors, primarily stemming from the challenges associated with a transitional period and the unexpected resignation of the Chief Financial Officer (CFO). The absence of a key financial executive during this period significantly impacted on BGCPR’s ability to compile, review, and finalize the required financial documentation in accordance with established timelines. As a result, BGCPR was unable to meet the statutory deadlines for submitting the audited financial statements, including the data collection form and the complete reporting package, thereby resulting in non-compliance with applicable legal and regulatory reporting requirements. Recognizing the importance of timely and accurate financial reporting, BGCPR is committed to implementing corrective measures. These include the development and enforcement of a structured reporting calendar, the allocation of dedicated resources to support audit preparation, and the establishment of internal checkpoints to monitor progress. These actions are intended to ensure that future submissions are completed within the required deadlines, thereby restoring compliance and reinforcing BGCPR’s commitment to transparency and accountability. As a corrective measure, BGCPR will take the following actions: a. Developing and enforcing a structured reporting calendar; b. Allocating dedicated resources to support audit preparation; c. Establishing internal checkpoints to monitor progress and ensure accountability; d. Ensure future submissions meet the required deadlines. Contact Person: Paul Barrera Carlos Rivera Antonio Rosario Team: Finance Team Anticipated Completion Date: December 31, 2026

View Audit 410044

Finding 1228350 (2025-001)

Material Weakness 2025

Home Start INC

CA

Internal Control / Segregation of Duties Subrecipient Monitoring

Management acknowledges that personnel turnover during the audit period affected segregation of duties and continuity of financial and program oversight. Because the FY2024 audit was completed after the FY2025 fiscal year had ended, management did not have an opportunity to implement the prior-year ...

Management acknowledges that personnel turnover during the audit period affected segregation of duties and continuity of financial and program oversight. Because the FY2024 audit was completed after the FY2025 fiscal year had ended, management did not have an opportunity to implement the prior-year corrective actions in time to affect the FY2025 audit period. FY2025 was the first fiscal year in several years in which both the Chief Financial Officer and Accounting Manager were in place during the fiscal year and audit process, improving continuity, institutional knowledge, and supervisory oversight. Since the audit period, the Organization has further strengthened its leadership structure by elevating the Director of Programs position to Vice President of Programs in September 2025 and the Accounting Manager position to Controller in June 2026. The Organization is also implementing Blackbaud Financial Edge in FY2027. These system improvements, combined with stabilized staffing, will strengthen segregation of duties and reduce reliance on manual compensating controls. Management is committed to maintaining appropriate staffing levels, cross-training team members, and clearly defining backup responsibilities to ensure continuity of financial operations and compliance with internal control standards. Actions Taken • Stabilized key fiscal leadership positions and maintained continuity throughout FY2025 and the audit process. • Strengthened supervisory review, cross-training, and backup coverage for key financial functions. • Elevated the Director of Programs position to Vice President of Programs in September 2025. • Elevated the Accounting Manager position to Controller in June 2026. • Initiated implementation of Blackbaud Financial Edge with enhanced approval workflows, role-based access, and audit trails; planned go-live for October 2026.

View Audit 410036

Finding 1228335 (2025-001)

Material Weakness 2025

Oklahoma Student Loan Authority

OK

Special Tests & Provisions Material Weakness Reporting

Finding 2025-001: Material Weakness in Internal Control Over Compliance and Scope Limitation Over Special Tests and Provisions (Special Tests and Provisions) Condition: The Authority was unable to provide sufficient documentation and system data necessary for us to perform required audit procedures ...

Finding 2025-001: Material Weakness in Internal Control Over Compliance and Scope Limitation Over Special Tests and Provisions (Special Tests and Provisions) Condition: The Authority was unable to provide sufficient documentation and system data necessary for us to perform required audit procedures over certain Special Tests and Provisions applicable to the Federal Family Education Loans (Lenders) Program, ALN 84.032L. Specifically, support was not available for seven of the ten Special Tests and Provisions selected or required for testing. Because the required documentation and system data were not available, we were unable to obtain sufficient appropriate audit evidence to determine whether the Authority complied with the Special Tests and Provisions compliance requirement for the FFEL Program for the year ended June 30, 2025, The Reporting compliance requirement was tested without exception. In conjunction with our FY2025 program audit, please see the Authority's corrective action plan below: Management acknowledges that sufficient documentation was not available to support all audit requirements and agrees with the recommendation. The circumstances described in this finding resulted from the transition of FFEL Program loan servicing to Higher Education Servicing Corporation (HESC) and the subsequent sale of the FFEL loan portfolio to Kentucky Higher Education Student Loan Corporation (KHESLC). Although OSLA transferred borrower-level history and transaction data to the new servicing system, access to the legacy system was discontinued, eliminating access to certain detailed records needed to support portions of the compliance testing. Because the Authority no longer owns or services the FFEL portfolio, the specific circumstances that led to this finding are not expected to recur. Nonetheless, management has implemented enhanced records management controls to help ensure the retention and accessibility of supporting documentation and to mitigate similar risks in the future. Expected completion date: March 31, 2026

View Audit 410031

Finding 1228303 (2025-001)

Material Weakness 2025

Saint Michael's Clinics, Inc.

NJ

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Clinic management team acknowledges that from the audit selection made of 60 patients, 15 selections had findings. We agree with you that seven (7) of the 15 did not meet either, the six-month recertification requirements or had missing proof of income findings. We agree and are not contesting patie...

Clinic management team acknowledges that from the audit selection made of 60 patients, 15 selections had findings. We agree with you that seven (7) of the 15 did not meet either, the six-month recertification requirements or had missing proof of income findings. We agree and are not contesting patient selection numbers: 25, 27, 31, 38, 52, 56 and 59. We will address this in our corrective action plan. Staff have completed the six-month recertifications and gathered the missing income data Four (4) of the findings related to certification data being collected and uploaded in the hospital EPIC electronic medical records but were not formally signed by a case manager. We are in partial compliance with the data requirements, but we needed to finalize and ensure that controls are in place, so the service provider must sign the note. We had situations where the provider passed away or left the Peter Ho clinic, due to relocation. Staff have since completed the notes and we have developed a report within our EMR to notify the service provider that the note requires signature. The four missing signatures by the service provider were patient selections: 9, 24, 29, 41. Four (4) of the findings related to not having the original HIV diagnosis confirmed on the patient not successfully migrated into the new electronic medical record, EPIC. For three of these patients, the staff could not find the original HIV diagnosis on the chart. The patients were treated properly, but the original data was not retained. This was caused by not all data being successfully migrated when Peter Ho updated its EMR during CY 2021. The Peter Ho Clinic switched from Centricity to EPIC during 2021. The selected patients have been treated at Peter Ho prior to CY 2021. We did provide other supporting documentation that the patient has HIV, but we could not find the original documentation. The four patient selections that fell into this category are: 19, 30, 34 and 39. The corrective action plan as developed for CY 2024 will be continued to be reinforced and followed. A few new bullets have been added below to further assist in meeting the compliance guidance. A detailed plan of correction is identified below: • Quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. This process will remain in place. • Assistant Manager will implement an EPIC (EMR) precheck process for current assessments. All future assessments will have proof of diagnosis, proof of income, proof of ID, proof of address and proof of insurance on the template to include the dates in which those documents were collected. (new) • Data Analyst(s) generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Lead will remain directly accountable to review the progress of re-certifications. Further monitoring by the Assistant Manager of the clinic will continue. • An EPIC (EMR) report of unsigned encounters will be generated biweekly and reviewed by staff for open encounters and notes to be signed. (new) • The CCC-Lead and the Assistant Manager will continue to monitor retention of income verification documentation to ensure compliance purposes. • Document scanners will be provided to individual Certified Case Counselors to alleviate late or missed filings, documents will be scanned directly into EMR at the time of capture. • The Clinic staff will continue follow up with the patients that were non-compliant during the prior year audit and asked for the missing information. The medical record will be updated with any new information received. • Chart review for all upcoming appointments will be performed to capture/locate missing diagnosis because of data transfer failure from old EMR. If diagnosis is missing, rapid testing to be performed by the Counseling and Testing Department at that time to continue current treatment. (new) Contact Person: Mark Brown, Office Manager, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2026

View Audit 410017

Corrective Action Plans

Filters