Corrective Action Plans

Finding 499413 (2024-002)

Significant Deficiency 2024

MO

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

a. We concur with the finding and recommendation. b. The Board is responsible for evaluating the condition of the replacement and extension fund account. The funding of the account will be more closely controlled. As cash flow allows, efforts will be made to remedy the underfunding of the account. A...

a. We concur with the finding and recommendation. b. The Board is responsible for evaluating the condition of the replacement and extension fund account. The funding of the account will be more closely controlled. As cash flow allows, efforts will be made to remedy the underfunding of the account. A responsible member of the Board will be assigned to oversight responsibilities. c. The Board of Directors is responsible for oversight of the funding of the replacement and extension fund account. d. The anticipated completion date of correcting the underfunding of the account will be within two years

View Audit 322270

Finding 498829 (2024-001)

Significant Deficiency 2024

Brescia University Inc.

KY

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

Students’ information is submitted by the Clearinghouse to NSLDS based on a report generated from the University’s Student Information System database. Due to significant database software changes, the report no longer included all of the information required on a student who had withdrawn. The Un...

Students’ information is submitted by the Clearinghouse to NSLDS based on a report generated from the University’s Student Information System database. Due to significant database software changes, the report no longer included all of the information required on a student who had withdrawn. The University has identified the error with the report and has created a new database report that includes all of the required information, including for students who have withdrawn. The new database report will be submitted to the Clearinghouse and to NSLDS. Student information, including social security numbers, is submitted to the Clearinghouse based on reports from the University’s Student Information System database. To prevent submitting batches with incorrect social security numbers, the Registrar’s Office will provide a report of student information to the Financial Aid Office prior to submitting batches to the Clearinghouse. The Financial Aid Office will verify the SIS data with the Financial Aid database, and report any discrepancies to the Registrar’s Office for correction, prior to the batch submission.

View Audit 321580

Finding 498233 (2024-002)

Material Weakness 2024

Denmark Technical College

SC

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Enrollment Reporting Corrective Action Plan: The Office of the Registrar will lead the implementation of new internal controls to ensure all enrollment status changes are reviewed and submitted in a timely manner in accordance with federal requirements. Specifically, measures will be taken to me...

Enrollment Reporting Corrective Action Plan: The Office of the Registrar will lead the implementation of new internal controls to ensure all enrollment status changes are reviewed and submitted in a timely manner in accordance with federal requirements. Specifically, measures will be taken to meet the Title IV requirement that the College completes and reports within a minimum of 60 days all student status changes to the National Student Loan Data System (NSLDS). Anticipated Completion Date: Fiscal Year 2025. Name of Contact Person Responsible for the Corrective Action Plan: Rashad Rogers

View Audit 320975

Finding 497663 (2024-001)

Significant Deficiency 2024

Illinois Institute of Technology

IL

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

Finding - Section 200.430 of the Uniform Guidance stipulates that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: be supported by a system of internal control which provides reasonable assurance that the charge...

Finding - Section 200.430 of the Uniform Guidance stipulates that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The non-Federal entity's system of internal controls should include processes to review after-the-fact interim charges made to a Federal award based on budget estimates. The University did not complete an after the fact review of amounts charged to their research and development grants through their effort reporting process for the fall 2023 and spring 2024 terms until September of 2024. Corrective Action Plan Taken - Management agrees with the finding that Time and Effort reporting was not completed in a timely manner. The Research Administration Services (RAS) team has identified specific team members to ensure that semester certifications are processed in a timely manner going forward. The plan is now in place. Please feel free to contact me if you have any questions at 312-567-3825 or jfine3@iit.edu. Sincerely, Jeremy V. Fine Vice President for Finance Chief Financial Officer & Treasurer

View Audit 320443

Finding 497631 (2024-001)

Significant Deficiency 2024

Howard Payne University

TX

Questioned Costs Student Financial Aid Significant Deficiency

Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FA...

Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FAFSA after a term will be reviewed to determine how much Title IV aid they are eligible to have disbursed. The R2T4 calculation will be processed to learn the percentage earned. Exception to the R2T4 will be if student completed the module/term successfully. Person Responsible for Corrective Action Plan: Karen LaQuey, Director of Student Financial Aid Anticipated Date of Completion: Immediately

View Audit 320424 Questioned Costs: $1

Finding 497446 (2024-001)

None 2024

William Carey University

MS

Special Tests & Provisions Student Financial Aid Reporting

The University respectfully submits the following corrective action plan. Audit Period: June 30, 2024. The finding discussed below is numbered consistently with the number assigned in the schedule of findings and questioned costs. Corrective Action Plan for Federal Awards Findings and Questioned Cos...

The University respectfully submits the following corrective action plan. Audit Period: June 30, 2024. The finding discussed below is numbered consistently with the number assigned in the schedule of findings and questioned costs. Corrective Action Plan for Federal Awards Findings and Questioned Costs. 2024-001 Special Tests and Provisions - Enrollment Reporting. As a result of the delayed NSLDS enrollment reporting and subsequent finding, William Carey University has implemented the following measures to ensure timely future reporting. 1. Any difficulties in federal reporting, technical or otherwise, will be reported to the area vice president and to the CFO promptly. 2. Any difficulties in federal reporting, technical or otherwise, will be reported to the federal agency promptly for purposes of notification, to seek guidance regarding possible alternative reporting methods, and/or to request extension to the reporting period. 3. All documentation and communication regarding the reporting difficulty will be kept by the responsible department director and submitted to the CFO. The offices of Academic Affairs and Business Affairs will cooperate to ensure immediate implementation. Name of Responsible Person: Grant Guthrie, Vice President and Chief Financial Officer. Expected Date of Completion: Current.

View Audit 320239

Finding 496933 (2024-001)

Significant Deficiency 2024

Cccs Farm Labor Housing Corporation

CO

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. Th...

We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. These include the hiring of a new compliance manager and the cross-collaboration of three property accountants, with a master trial balance shared to support teammates when they are on vacation or turnover occurs. We will work to re/file these forms immediately and begin tracking their status to prevent inaccurate/untimely filing.

View Audit 319674

Finding 496232 (2024-001)

Significant Deficiency 2024

Lakefront Senior Residences, Inc.

KS

Subrecipient Monitoring HUD Housing Programs Reporting

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 27, 2023.

View Audit 319176

Finding 496228 (2024-001)

Significant Deficiency 2024

Southern Hills Senior Residences, Inc.

KS

Subrecipient Monitoring HUD Housing Programs Reporting

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 31, 2023.

View Audit 319174

Finding 496226 (2024-001)

Significant Deficiency 2024

Woodlake Senior Residences, Inc.

KS

Subrecipient Monitoring HUD Housing Programs Reporting

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 30, 2023.

View Audit 319173

Finding 486104 (2024-002)

Significant Deficiency 2024

Abilene Christian University

TX

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Responsible Individual: Tamara Long Vice President for Enrollment and Student Engagement Abilene Christian University Finding 2024-002 Special Tests & Provisions - Bonus & Incentives Related to Enrollment Agency Name: U.S. Deparlment of Education Program Name: Federal Pell Grant, Federal Direct Stud...

Responsible Individual: Tamara Long Vice President for Enrollment and Student Engagement Abilene Christian University Finding 2024-002 Special Tests & Provisions - Bonus & Incentives Related to Enrollment Agency Name: U.S. Deparlment of Education Program Name: Federal Pell Grant, Federal Direct Student Loans, SEOG, Federal Work Study and TEACH Grants August 19, 2024 Finding Summary: Incentive Compensation (34 CFR 668.14(b)(22)(i) Institutions are required, within the Program Participation Agreement (PPA), to acknowledge that they will not provide any commission, bonus, or other incentive payment based on any part, directly or indirectly, upon success in securing enrollments or awards of financial aid. The university documented several bonus payments to individuals related to enrollment strategies and goals. Corrective Action Plan (CAP): Based on the findings of the Special Tests and Provisions for Incentive Compensation as part of (34 CFR668.14(b)(22}(i), the offices of enrollment and financial operations have identified additional review and controls that will be put in place to mitigate future risk of non-compliance. Additional review will be required by a financial operations member for any requests made for enrollment related staff. In addition, a formal tenure bonus structure has already been put in place to ensure that no bonuses or incentives are given based on enrollment goals. Anticipated Completion Date: As the tenured bonus structure has already been activated, the review of bonuses raises, and incentive pay will immediately be required to go through an additional financial review for compliance. The anticipated completion date is July 1, 2024

View Audit 318751 Questioned Costs: $1

Finding 486102 (2024-001)

Significant Deficiency 2024

Abilene Christian University

TX

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

Responsible Individual: Eric Gumm Registrar and Director of First Year Program and Academic Development Center Abilene Christian University Finding 2024-001 concerning Enrollment Reporting Agency Name: U.S. Department of Education Program Name: Federal Pell Grant, Federal Direct Student Loans August...

Responsible Individual: Eric Gumm Registrar and Director of First Year Program and Academic Development Center Abilene Christian University Finding 2024-001 concerning Enrollment Reporting Agency Name: U.S. Department of Education Program Name: Federal Pell Grant, Federal Direct Student Loans August 19, 2024 Finding Summary: Enrollment Reporting (34 CFR 690.93(b)(2); 34 CFR 682.610; 34 CFR 685.309) Institutions are required to report enrollment information. The University's processes did not ensure timely and accurate student status reporting to National Student Loan Data System (NSLDS). Out of the population of 829 students with student attendance changes required to be reported, a sample of 25 students were selected for testing. The University failed to report 3 students who had changes in enrollment status. Of the three students the University failed to report, 2 students had withdrawn from the University. The University reported the incorrect enrollment effective dates for 3 students at the program and campus levels. The University failed to report graduated status for 2 students (students were reported as withdrawn and the University failed to subsequently update the status to graduated). The University reported the incorrect Program Enrollment Effective Date for 1 student. The University did not report a change in enrollment status in a timely manner for 1 student. Corrective Action Plan (CAP): Based on the findings within the Federal and State Financial Assistance Program audit, it was determined that a significant deficiency exists within the review of reporting for student enrollment through the National Student Loan Data System (NSLDS). The office of Student Financial Services has identified the need for regular reconciliation of updates to student enrollment status from the Banner point of record to the NSLDS system. Our plan of action begins with a comprehensive understanding of the roles and responsibilities between the financial aid office and the registrar's office. Once this is well documented, the Office of the Registrar will begin a monthly reconciliation of enrollment reporting for any student status changes that have happened within that month. Anticipated Completion Date: The timeline for this CAP begins with the formal documentation of the enrollment reporting process. This will take place prior to the start of the Fall 2024 semester. The reconciliation of reporting will begin in September 2024 after 12th day of enrollment is confirmed and sent to the Clearinghouse for updates. The anticipated completion date is July 1, 2024

View Audit 318751

Finding 485611 (2024-002)

Significant Deficiency 2024

Fulton County Community Unit School District No. 3

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.

View Audit 318383

Finding 485406 (2024-002)

None 2024

Lincoln Christian University

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...

2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.

View Audit 318153

Finding 485172 (2024-002)

Significant Deficiency 2024

Regis University

CO

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

Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...

Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.

View Audit 317977

Finding 479384 (2024-001)

None 2024

Casa Barranquitas, Inc. Hud Project No. 056-Eh-346-Wah-L8

PR

Questioned Costs Cash Management HUD Housing Programs § 200.305

We agree. The reimbursement has been processed in the Voucher for the month of August 2024. Procedures have been established improving the reviewing and monitoring process in order to detect and help to identify errors before vouchers processed.

View Audit 315891 Questioned Costs: $1

Finding 477896 (2024-001)

Significant Deficiency 2024

Clinica Campesina Family Health Services

CO

Significant Deficiency Matching / Level of Effort / Earmarking 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 retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...

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 retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.

View Audit 314530

Finding 1217652 (2023-006)

Material Weakness 2023

LAUREL ADVOCACY & REFERRAL SERVICES, INC.

MD

Reporting Subrecipient Monitoring HUD Housing Programs

LARS has implemented the following controls to address each element of this finding: HUD CoC Match Tracking: A grant-level match tracking schedule has been established for the CoC program. The schedule documents required match amounts, eligible match contributions, and cumulative match-to-date, and ...

LARS has implemented the following controls to address each element of this finding: HUD CoC Match Tracking: A grant-level match tracking schedule has been established for the CoC program. The schedule documents required match amounts, eligible match contributions, and cumulative match-to-date, and is updated at each reporting period. The Finance Director reviews the schedule prior to each drawdown and at fiscal year-end. Administrative Cost Limitation Monitoring: Written policies and procedures have been updated to include a procedure for monitoring the HUD CoC administrative cost limitation. The Finance Director calculates the limitation at the beginning of each grant year and monitors actual administrative costs on a quarterly basis. Grant Cutoff Procedures: A written grant financial management policy has been adopted that establishes cutoff procedures for recording expenditures within applicable grant performance periods. The accounting system has been configured to flag transactions with dates outside an active grant period for Finance Director review prior to posting. SEFA Preparation and Review: A formal SEFA preparation procedure has been implemented that requires: • A reconciliation of SEFA amounts to the general ledger and underlying grant records • A documented review of all grants and funding sources including state and local grants to determine proper SEFA inclusion and reporting treatment

View Audit 403810

Finding 1217387 (2023-004)

Material Weakness 2023

The Wellness Plan Medical Centers

MI

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Condition: The Organization lacked sufficient internal controls to ensure sliding fee discount applications were on file and included all of the necessary information regarding family size and income to support discount determinations made. Further, controls were not sufficient to ensure the correct...

Condition: The Organization lacked sufficient internal controls to ensure sliding fee discount applications were on file and included all of the necessary information regarding family size and income to support discount determinations made. Further, controls were not sufficient to ensure the correct sliding fee discount was applied. Planned Corrective Action: The organization will implement controls to ensure sliding fee applications are maintained and sliding fee adjustments are based on correct family income and resident size. Contact person responsible for corrective action: Charles Berry (CFO) Anticipated Completion Date: 6/30/2026

View Audit 403582

Finding 1216734 (2023-002)

Material Weakness 2023

STEPS to Recovery Homes

AZ

Reporting Matching / Level of Effort / Earmarking Special Tests & Provisions

Management of the Organization has an accounting firm engaged who will perform future required audits.

View Audit 403177

Finding 1214812 (2023-003)

Material Weakness 2023

Neighborhood Medical Center, Inc.

FL

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

FINDING 2023-003 - Sliding Fee Discount Program MATERIAL WEAKNESS; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93.224/93 .527, Health Center Program Cluster Compliance Requirement: Special Tests & Provisions Criteria: Section ...

FINDING 2023-003 - Sliding Fee Discount Program MATERIAL WEAKNESS; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93.224/93 .527, Health Center Program Cluster Compliance Requirement: Special Tests & Provisions Criteria: Section 330 of the Public Health Service Act and the HRSA Health Center Program Compliance Manual require health centers to maintain and operate a board-approved Sliding Fee Discount Program that adjusts patient charges based on income and family size using the current Federal Pove1ty Guidelines, applies uniformly to all patients and all in-scope services, and is supported by adequate documentation of eligibility determinations. In addition, Uniform Guidance requires nonfederal entities to establish and maintain effective internal controls over federal programs to provide reasonable assurance of compliance with federal statutes, regulations, and award terms. Condition: During testing of the Sliding Fee Discount Program within the Health Center Cluster, the Center could not provide documentation of the appropriate sliding fee discounts for certain patients in accordance with federal requirements. Context: The condition was identified through testing of the Health Center Cluster as pa1i of the single audit, which included testing patient fee assessments and sliding fee discount application as a special test required under the program. Controls were determined to be ineffective in 2 of 40 test items. Noncompliance was noted in 2 of 25 test items. Statistical sampling was not utilized. Cause: The condition was caused by inadequate internal controls over the implementation and monitoring of the Sliding Fee Discount Program, including limited supervisory review to ensure all sliding fee applications are maintained, reviewed, and properly applied. Effect or Potential Effect: The Center's failure to maintain documentation surrounding sliding fee discounts in accordance with federal requirements increases the risk of noncompliance with Health Center Program requirements and may result in patients being charged amounts not aligned with their ability to pay. The condition also increases the risk of adverse findings during HRSA oversight or other federal monitoring activities. Questioned Costs: No questioned costs were identified as a result of this finding. Repeat Finding: This is not a repeat finding. Recommendation: The Center should enhance internal controls over the Sliding Fee Discount Program by ensuring consistent documentation of income and family size, timely reassessment of eligibility in accordance with policy, consistent application of the board-approved sliding fee discount schedule to all applicable in-scope services, and periodic monitoring and supervisory review to ensure ongoingcompliance. Views of Responsible Officials: Neighborhood Medical Center has implemented quarterly SFDP internal audits and training for the intake staff to improve compliance oversight and documentation accuracy. A standardized audit tracking log documenting charts are reviewed, findings identified and corrective actions completed. An annual refresher for the staff has been implemented. A quick-reference eligibility checklist has also been developed for staff use. Person Responsible for Corrective Action: Ronica Mathis and Shenika Mathews Anticipated Completion Date for Corrective Action: This practice has already been implemented.

View Audit 401535

Finding 1214810 (2023-004)

Material Weakness 2023

Neighborhood Medical Center, Inc.

FL

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

FINDING 2023-004- Late Submission of Single Audit and FAC Data Collection Form SIGNIFICANT DEFICIENCY; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93 .011, 93.224/93.527, 93.526, and 93.918 Compliance Requirement: Reporting Cr...

FINDING 2023-004- Late Submission of Single Audit and FAC Data Collection Form SIGNIFICANT DEFICIENCY; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93 .011, 93.224/93.527, 93.526, and 93.918 Compliance Requirement: Reporting Criteria: Uniform Guidance requires nonfederal entities to submit the reporting entity's Uniform Guidance reporting package, including the audit report and completed Federal Audit Clearinghouse (F AC) Data Collection Form, to the F AC within the earlier of 30 calendar days after receipt of the auditor's rep01ts or nine months after fiscal year-end (2 CFR 200. 512( a)). Timely submission of the reporting package is required to facilitate federal oversight of award compliance. Context: The condition was identified during Single Audit testing of reporting requirements applicable to the Health Center Cluster. Sampling was not utilized. Condition: The Center did not submit its required Uniform Guidance reporting package, including the reporting entity's audit report and the FAC Data Collection Form, within the required submission timeframe. Specifically, the Uniform Guidance audit and related FAC Data Collection Form were submitted after the earlier of (1) 3 0 calendar days after receipt of the auditor's reports or (2) nine months after the end of the reporting entity's fiscal year. Cause: Due to a delay in the compiling of records related to the audit, the Center was not in compliance with the reporting requirements. Effect or Potential Effect: Failure to submit the Uniform Guidance audit and F AC Data Collection Form timely increases the risk of noncompliance with Uniform Guidance reporting requirements and may result in delayed federal oversight, increased monitoring by the awarding agency, or the imposition of additional administrative conditions. Questioned Costs: No questioned costs were identified as a result of this finding. Repeat Finding: This is a repeat finding. Recommendation: The Center should strengthen internal controls over Uniform Guidance audit reporting by ·implementing procedures to track submission deadlines, assigning responsibility for timely filing of the audit report and FAC Data Collection Form, and establishing management review processes to ensure compliance with Uniform Guidance reporting requirements. View of Responsible Officials: Neighborhood's prior auditor indicated just before time to begin the audit for FY2022; they would not be able to complete the audit because of staff sho1tages. Two RFPs were issued, and it took the center a year and a half to secure a new auditor. The 2022 and 2023 audits have been completed. Engagement contract has been issued for the 2024 audit.

View Audit 401535

Finding 1214739 (2023-006)

Material Weakness 2023

Detroit Central City Cmh, Inc.

MI

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

For 11 of 22 tenant files selected for testing, the Organization was unable to provide both the signed sublease agreement and the master lease agreement. One file lacked both documents. Although the Compliance Supplement does not require these documents for determining rent reasonableness under the ...

For 11 of 22 tenant files selected for testing, the Organization was unable to provide both the signed sublease agreement and the master lease agreement. One file lacked both documents. Although the Compliance Supplement does not require these documents for determining rent reasonableness under the Continuum of Care Program, the Organization’s internal policies require them. Management acknowledges the condition noted. While the Compliance Supplement does not require examination of lease agreements for this program and no instances of noncompliance were identified, we agree that maintaining complete tenant files—including signed sublease agreements and master lease agreements—is an important internal control to support documentation of rent reasonableness and compliance with our own policies. The missing documents resulted from inconsistent file maintenance during the audit period. The Organization has taken steps to strengthen its documentation and retention procedures to ensure all required lease documents are properly maintained and readily accessible going forward.

View Audit 401484

Finding 1214640 (2023-005)

Material Weakness 2023

Micronesia Conservation Trust

FM

Subrecipient Monitoring Matching / Level of Effort / Earmarking

Finding No.: 2023-005 Area: Level of Effort Views of responsible official and planned corrective actions: Management acknowledges the requirement to comply with the Level of Eﬀort provisions outlined in the grant agreement. Management conﬁrms that the Trust is committed to maintaining adequate syste...

Finding No.: 2023-005 Area: Level of Effort Views of responsible official and planned corrective actions: Management acknowledges the requirement to comply with the Level of Eﬀort provisions outlined in the grant agreement. Management conﬁrms that the Trust is committed to maintaining adequate systems and documentation to demonstrate that all required time, activities, and resources are properly allocated to grant-funded projects. To strengthen compliance, we will continue to ensure that staﬀ maintain accurate timesheets and activity logs, and that these records are reviewed on a regular basis by program and ﬁnance personnel. Management will also conduct periodic oversight reviews to conﬁrm that Level of Eﬀort requirements are being met and properly supported by documentation. Contact Person: Melanie Lawrence Aiseam, Chief Financial Officer Expected Completion Date: The Trust started training last year, and this is ongoing.

View Audit 401348

Finding 1214620 (2023-001)

Material Weakness 2023

Community of Hope, Inc.

FL

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

2023-001 REPORTING Recommendation: Reports prepared by the Executive Director should be reviewed by an independent person to ensure completeness and accuracy. Additionally, the Organization should design a control to ensure reports are submitted in a timely manner in accordance with compliance requi...

2023-001 REPORTING Recommendation: Reports prepared by the Executive Director should be reviewed by an independent person to ensure completeness and accuracy. Additionally, the Organization should design a control to ensure reports are submitted in a timely manner in accordance with compliance requirements. Corrective Action: Community of Hope recognizes that our expansion and growth have made it difficult to maintain full and timely compliance with some reporting criter+B11 ia. As such, we have created a compliance calendar that will alert staff to impending deadlines and requirements. In addition, we recently hired a staff member with compliance being a primary function. She is reviewing grant and policy compliance, making recommendations, and instituting changes to enhance compliance. Responsible party: Drew Warren, Executive Director Date Expected to be Corrected: March 1, 2026

View Audit 401303

Corrective Action Plans

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