Corrective Action Plans

Finding 1215558 (2025-005)

Material Weakness 2025

General John J Pershing Memorial Hospital Association

MO

Matching / Level of Effort / Earmarking § 200.303

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: Completed. Views of Responsible Officials and Planned Corrective Action: The Hospital now has an automatic monthly transfer set to move $4,400 fro...

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: Completed. Views of Responsible Officials and Planned Corrective Action: The Hospital now has an automatic monthly transfer set to move $4,400 from the operating account to the debt service account. Additionally, the fiscal year 2026 budget includes an expense assumption to set aside $4,400 per month into the debt service account.

View Audit 402223

Finding 1215556 (2025-001)

Material Weakness 2025

Nexus Recovery Center Inc.

TX

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

Finding 2025-001: Allowable Cost – Significant Deficiency in Internal Controls Over Compliance Program: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) Management Response: Management concurs with the finding. The exceptions identified resulted from a lapse in execution of ...

Finding 2025-001: Allowable Cost – Significant Deficiency in Internal Controls Over Compliance Program: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) Management Response: Management concurs with the finding. The exceptions identified resulted from a lapse in execution of established approval procedures, as 2 of the 25 sampled credit card transactions charged to the grant did not include documented supervisory approval prior to payment. However, compensating controls existed, including Finance Department review of all expenditures prior to payment of the Brex account and additional review of expenses charged to the grant during preparation of monthly grant invoices and reporting. No unallowable costs or, questioned costs, were identified. To remediate the finding, all supervisors have received additional training and reminders regarding requirements for timely review and approval of expenditures prior to payment processing. In addition, the accounting team has implemented procedures prohibiting payment processing until all required approvals have been completed and documented. Management believes these enhanced controls strengthen adherence to existing policies and reduce the likelihood of recurrence. Management notes that the supervisor associated with the exceptions is no longer employed by the Organization; however, corrective actions focus on strengthening processes and controls rather than reliance on personnel changes. Corrective Action Planned/Implemented: • Refresher training provided to supervisors regarding expenditure review and approval requirements. • Accounting procedures updated to prevent payment processing prior to completion and documentation of all required approvals. • Existing accounting department monitoring procedures will continue, including review of expenditures before payment and grant expenditure review during monthly reporting. Responsible Party: Controller / Accounting Department Implementation Date: Implemented as of April 2026

View Audit 402221

Finding 1215547 (2025-001)

Material Weakness 2025

Port Authority of the City of St. Paul

MN

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Material Weakness – Suspension and Debarment Recommendation: We recommend the Port re-implement its previous controls of using a tracking checklist and retaining documentation of the verification process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...

Material Weakness – Suspension and Debarment Recommendation: We recommend the Port re-implement its previous controls of using a tracking checklist and retaining documentation of the verification process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Port Authority will revise their process to ensure controls are in place and documentation is retained. Name of the contact person responsible for corrective action: Jan Almquist, Controller. Planned completion date for corrective action plan: December 31, 2026

View Audit 402217

Finding 1215492 (2025-005)

Material Weakness 2025

South Big Horn Hospital District

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

2025-005 - Reporting Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 2026.

View Audit 402151

Finding 1215478 (2025-001)

Material Weakness 2025

First Rising Mt. Zion Baptist Church Housing Corp.

DC

HUD Housing Programs Cash Management Significant Deficiency

Recommendation: We recommend that First Rising Mount Zion Baptist Church Housing Corporation, Inc. design and implement controls to prevent non-compliance with HUD requirements surrounding surplus cash deposits such as recalculating surplus cash at the end of the year after all transactions have bee...

Recommendation: We recommend that First Rising Mount Zion Baptist Church Housing Corporation, Inc. design and implement controls to prevent non-compliance with HUD requirements surrounding surplus cash deposits such as recalculating surplus cash at the end of the year after all transactions have been posted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: First Rising Mount Zion Baptist Church Housing Corporation, Inc. T/A Gibson Plaza Apartments will implement enhanced internal controls to ensure compliance with HUD requirements related to surplus cash calculations and deposits. Specifically: - Management will perform a final recalculation of surplus cash at year-end after all accounting transactions have been recorded and reviewed. - A standardized checklist will be developed and utilized to ensure that all required steps in the surplus cash calculation process are completed accurately. - The surplus cash calculation will be reviewed and approved by a secondary individual independent of the preparer to ensure accuracy and compliance. Name(s) of the contact person(s) responsible for corrective action: Asa Ewings Planned completion date for corrective action plan: 5/31/2026

View Audit 402124

Finding 1215475 (2025-001)

Material Weakness 2025

Tufts Medical Center Inc. and Affiliates

MA

Eligibility Student Financial Aid Reporting

RE: Funding 2025-001 – Incorrect student status, Corrective Action Plan To whom it may concern: Student Financial Assistance Cluster (ALNs: 84.063 and 84.268) Management concurs with the findings. Management acknowledges that the condition identified is primarily attributable to staff turnover assoc...

RE: Funding 2025-001 – Incorrect student status, Corrective Action Plan To whom it may concern: Student Financial Assistance Cluster (ALNs: 84.063 and 84.268) Management concurs with the findings. Management acknowledges that the condition identified is primarily attributable to staff turnover associated with the closure of the school, which resulted in disruptions to established processes and reduced the effectiveness of controls over the determination and documentation of student eligibility. Management has ensured the appropriate reporting has now been made to the NSLDS. The SFA program has been terminated and therefore will not impact future audits. Leadership Responsible: Colleen Walsh Dean, Student and Alumni Services Lawrence Memorial/Regis College (781) 979-3000 Anticipated Completion date: May 30, 2026

View Audit 402115

Finding 1215463 (2025-006)

Material Weakness 2025

Delta Research and Educational Foundation

DC

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.430

Views of Responsible Officials: All the Foundation's employees now complete an excel timesheet that is then submitted to their supervisor for review and approval. Payroll is processed only after all employee timesheets are approved and received by the Senior Accountant who processes payroll.

View Audit 402102

Finding 1215411 (2025-001)

Material Weakness 2025

Baltimore Regional Housing Partnership, Inc.

MD

Reporting Subrecipient Monitoring HUD Housing Programs

Audit Finding Reference: 2025 - 001 Planned Corrective Action: BRHP continues weekly reporting of all 50058 actions to identify any files where the 60-day deadline is approaching. PIC uploads continue to occur weekly. Starting this year and going forward, if any files approach or exceed the 60-day s...

Audit Finding Reference: 2025 - 001 Planned Corrective Action: BRHP continues weekly reporting of all 50058 actions to identify any files where the 60-day deadline is approaching. PIC uploads continue to occur weekly. Starting this year and going forward, if any files approach or exceed the 60-day submission threshold, the effective date will be revised as necessary, and any associated costs will be absorbed by BRHP to ensure that clients are held harmless. Name of Contact Person: FaShaunDa Walton, Housing Mobility Director, fwalton@brhp.org Anticipated completion date: December 31, 2026

View Audit 402021

Finding 1215405 (2025-003)

Material Weakness 2025

Association House of Chicago

IL

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

MATERIAL WEAKNESS Finding 2025-003 – Allocation and Documentation of Payroll Costs Recommendation: Management should develop a process whereby payroll costs allocated to federal grants; are supported by a system of internal controls which provides reasonable assurance that the charges are accurate, ...

MATERIAL WEAKNESS Finding 2025-003 – Allocation and Documentation of Payroll Costs Recommendation: Management should develop a process whereby payroll costs allocated to federal grants; are supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable and properly allocated, reasonably reflect the total activity for which the employee is compensated and support the distribution of the employee’s wages among specific activities or cost objectives if the employee woks on more than one federally funded program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As corrective action, management implemented a new system to track time and effort effective July 1, 2025, using the Forms Assembly platform for federally funded DHS programs. For other grants, the Agency has continued to maintain supporting time and effort documentation through Excel-based records. Management recognizes that the implementation of the Forms Assembly system has presented operational challenges, particularly due to the need to reconcile information separately with the payroll system. As a result, since October 2025, management has been evaluating and vetting alternative systems that can fully integrate time and effort reporting with payroll processing. Beginning in fiscal year 2027, the Agency plans to implement a new integrated software solution that will record employee time, grant allocations, and payroll information within a single system integrated directly with payroll processing. Management believes this integrated approach will strengthen internal controls, improve the accuracy and timeliness of reporting, reduce manual reconciliation processes, and enhance compliance with federal time and effort requirements. Name of contact person responsible for corrective action: Margarita Rosas, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2026

View Audit 401983

Finding 1215356 (2025-007)

Material Weakness 2025

City of New Haven

CT

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Suspension and Debarment Description of Finding 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. During our audit, we noted that the Board ...

Suspension and Debarment Description of Finding 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. During our audit, we noted that the Board of Education Finance Office / City Purchasing Department did not have documentation to support that it verified vendors selected for testing against the SAM to ensure that they were not suspended or debarred from federally funded purchases. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action The Board of Education Finance Office, in conjunction with the City Purchasing Department, will review and enhance their processes and controls over the verification that vendors are not suspended or debarred. Name of Contact Person Amilcar Hernandez, Board of Education Chief Financial Officer Projected Completion Date June 30, 2026

View Audit 401899

Finding 1215198 (2025-007)

Material Weakness 2025

City Of Wakefield

MI

Material Weakness Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The City acknowledges the finding. The City will continue developing and maintaining written policies and procedures appropriate to its federal award activity and the terms and conditions of applicable federal awards. Policies and procedures will address internal controls, reporting responsibilities...

The City acknowledges the finding. The City will continue developing and maintaining written policies and procedures appropriate to its federal award activity and the terms and conditions of applicable federal awards. Policies and procedures will address internal controls, reporting responsibilities, record retention, allowable costs, procurement standards, conflictof- interest requirements where applicable, and compliance monitoring procedures consistent with Uniform Guidance requirements.

View Audit 401866

Finding 1215158 (2025-004)

Material Weakness 2025

Grant Community Consolidated School District #110

IL

School Nutrition Programs Internal Control / Segregation of Duties Cash Management § 200.303

Finding No. 2025-004 Condition – Claims submitted for reimbursement did not reconcile with the District’s internally prepared monthly claim summary report. Plan – The District will ensure that meal counts are thoroughly reviewed prior to submission. Meal counts are entered into the computer by the F...

Finding No. 2025-004 Condition – Claims submitted for reimbursement did not reconcile with the District’s internally prepared monthly claim summary report. Plan – The District will ensure that meal counts are thoroughly reviewed prior to submission. Meal counts are entered into the computer by the FSMC, and has been a place where errors have occurred. The district secretary is responsible for entering the meal counts into the state system. She is verifying the counts from the FSMC, comparing to attendance and invoices, and ensuring correct data goes into IWAS. This was started last spring, when we became aware of FSMC inconsistencies. The current year, FY26, has been much more accurate. Anticipated Date of Completion: current – 9/1/2026 Name of Contact Person: Matt Stines, Superintendent

View Audit 401821

Finding 1215069 (2025-001)

Material Weakness 2025

Lee County, Florida

FL

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency § 200.302 § 200.303 § 200.403

Community Development Block Grants Cluster Entitlements/Special Purpose – Assistance Listing No. 14.218 Recommendation: It is recommended the County modify its procedure to include: • Improve reconciliation procedures to verify hours per pay period recorded in quarterly spreadsheet agrees to hours r...

Community Development Block Grants Cluster Entitlements/Special Purpose – Assistance Listing No. 14.218 Recommendation: It is recommended the County modify its procedure to include: • Improve reconciliation procedures to verify hours per pay period recorded in quarterly spreadsheet agrees to hours recorded in the KRONOS system. • Record grant wages using the pay rate at the beginning of the quarter if recorded on a quarterly basis or use pay rates for each pay period if recorded on a pay period basis. Explanation of disagreement with audit finding: Management concurs with the auditor’s recommendations. Action taken in response to finding: • Document the audit process in a formalized SOP and cross train all reviewers from SRGA Admin, Budget, and Fiscal. • Create a checklist to accompany each personnel draw to ensure that after rates are verified that SRGA Admin certify that no RPAs or pay adjustments were approved during the pay periods reported and if there were, a second pay rate is entered for that draw and hours are split according to accurate rates/dates. • Document the cure process in the SOP to ensure that any errors found after the fact will be corrected with HUD to remain compliant and to ensure that no funds drawn in error are retained. • Include a date verification process prior to submission of the draw to ensure that staff did not duplicate any dates. This verification will be an audit of the Time Tracking Review completed by Admin staff. Ongoing training and coaching will be administered should duplicate entries be found on final draw reports. • Audit of all personnel draws for both allocations of CDBG-DR grants will be completed using the new SOP and verification tools before the end of FY2026. Name of the contact person responsible for corrective action: Nicole Turner, Director Planned completion date for corrective action plan: The above action plan will be implemented immediately; an audit of all personnel draws will be conducted using new process and checklists by the end of FY2026.

View Audit 401782

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

Management acknowledges the finding related to student eligibility and internal controls over Direct Loan aggregate limits and agrees that enhancements are necessary to ensure full compliance with federal requirements.

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

This condition relates to the prior fiscal year and occurred before centralized oversight of Financial Aid operations was established under the Business Services division in February 2026.

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

Corrective actions implemented and in progress include:

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

· Implementation of a formal pre-disbursement review process to verify aggregate loan limits using NSLDS data

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

· Strengthening system validation procedures to ensure integrations and automated controls are functioning as intended

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

· Establishment of supervisory review for students approaching aggregate loan limits and higher-risk disbursements

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

· Review and correction of identified overawards, with coordination for any required adjustments or repayments

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

· Enhanced staff training on federal eligibility requirements and monitoring procedures

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

· Ongoing monitoring and periodic internal review to ensure continued compliance

View Audit 401488

Finding 1214765 (2025-002)

Material Weakness 2025

Carolina University

NC

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

Management is committed to strengthening internal controls over Title IV programs and ensuring sustained compliance with federal regulations.

View Audit 401488

Finding 1214693 (2025-002)

Material Weakness 2025

Catholic Charities of the Diocese of Palm Beach County, Inc.

FL

Matching / Level of Effort / Earmarking

U.S. Department of Health and Human Services-Assistance Listing No. 93.558 Recommendation: Management should strengthen internal review controls to ensure that cost-sharing expenditures are allowable, level-of-effort requirements are fully documented and reviewed, and program benchmarks are monitore...

U.S. Department of Health and Human Services-Assistance Listing No. 93.558 Recommendation: Management should strengthen internal review controls to ensure that cost-sharing expenditures are allowable, level-of-effort requirements are fully documented and reviewed, and program benchmarks are monitored throughout the grant period to ensure compliance with grant requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Catholic Charities of the Diocese of Palm Beach is strengthening its grant compliance procedures for the Homeless Challenge Grant. Management is implementing formal processes to separately track allowable match sources, verify that proposed cost-sharing expenditures are non-federal and otherwise allowable prior to inclusion in grant reporting, and maintain supporting documentation for all level-of-effort calculations and compliance measures. In addition, management will conduct periodic grant compliance meetings between program and finance personnel to review benchmark attainment, cost-sharing requirements, and reporting obligations. Program leadership will certify compliance with applicable benchmarks and level-of-effort requirements prior to submission of related grant reports. These measures are intended to improve grant compliance oversight and reduce the risk of future noncompliance. Name(s) of the contact person(s) responsible for corrective action: Carol Rodriguez, Program Development & Quality Director; Marc Hopin, Finance Director; and Rocio Lopez, Program Director Planned completion date for corrective action plan: June 30, 2026

View Audit 401440

Finding 1214688 (2025-001)

Material Weakness 2025

Congregation Ymh

NY

Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

Corrective Action Plan: NSLDS Reporting Institution: Congregation YMH d/b/a Yeshiva Meor Hatalmud Audit Period: Year Ended August 31, 2025 Finding 2025:001: Noncompliance with NSLDS Enrollment Reporting Requirements Views of Responsible Officials The Organization acknowledges a misunderstanding duri...

Corrective Action Plan: NSLDS Reporting Institution: Congregation YMH d/b/a Yeshiva Meor Hatalmud Audit Period: Year Ended August 31, 2025 Finding 2025:001: Noncompliance with NSLDS Enrollment Reporting Requirements Views of Responsible Officials The Organization acknowledges a misunderstanding during the initial year of the program regarding the necessity of NSLDS reporting when student loans are not present. Upon clarification, management prioritized resolving this reporting requirement. Corrective Action Taken • System Registration: The institution successfully finalized its registration with the National Student Loan Data System (NSLDS). • Technical Resolution: Initial attempts to resolve technical access issues began on March 30, 2026. These issues, tracked under Case #260330-000528, were fully resolved on April 29, 2026. • Reporting Compliance: The Organization completed its initial enrollment reporting at both the Campus and Program levels to the Department of Education on April 29, 2026. • Verification of Proof: Official confirmation of the successful registration and enrollment reporting has been provided to auditors. • Internal Controls: To ensure ongoing compliance with 2 CFR §200.303(a), the Organization established formal procedures. These include monthly monitoring of enrollment changes, maintaining an audit trail of NSLDS communications, and assigning specific reporting responsibilities to the administrative office. Completion Status: Resolved/ Completed Responsible Person: Mr. Frisch, Administrator

View Audit 401420

Corrective Action Plans

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