Corrective Action Plans

Finding 1223284 (2023-003)

Material Weakness 2023

CITY OF FRANKLIN

WI

Reporting Cash Management Material Weakness § 200.512

Recommendation: We recommend that the City implement a system of internal controls over the financial close and reporting process that will mitigate the risk of misstatement in accordance with Uniform Guidance, the Wisconsin State Single Audit Guidelines, and the Wisconsin Department of Health Servi...

Recommendation: We recommend that the City implement a system of internal controls over the financial close and reporting process that will mitigate the risk of misstatement in accordance with Uniform Guidance, the Wisconsin State Single Audit Guidelines, and the Wisconsin Department of Health Services Audit Guide. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City is actively working with their auditors to become current with required single audit filings. Name(s) of the contact person(s) responsible for corrective action: Danielle Brown, Director of Finance & Treasurer Planned completion date for corrective action plan: September 30, 2026

View Audit 406785

Finding 1223216 (2023-013)

Material Weakness 2023

Williston Basin Public School District #7

ND

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303 § 200.403

2023-013 – EDUCATION STABILIZATION FUND - LACK OF SUPPORT OVER ESSER FUNDS – ALN 84.425 - MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Williston Basin Public School District No. 7 was unable to provide supporting documentation for journal entries that were done to reallocate payroll. There ...

2023-013 – EDUCATION STABILIZATION FUND - LACK OF SUPPORT OVER ESSER FUNDS – ALN 84.425 - MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Williston Basin Public School District No. 7 was unable to provide supporting documentation for journal entries that were done to reallocate payroll. There were 3 journal entries totaling $6,391,442 that were completed at year end to move salaries into the Education Stabilization Fund program that did not have documentation to support the salary expenditures. Management’s Response: We agree. WBSD#7 created a new Grants Coordinator position in July 2023 with one of the specific responsibilities for that position being oversight of all Federal programs. This oversight responsibility includes monitoring expenditures to ensure all expenditures are allowable within the parameters of each program and also that proper documentation for those expenditures has been maintained. It has taken the district some time to get this area cleaned up. Anticipated Completion Date: FY 2025

View Audit 406705

Finding 1223215 (2023-012)

Material Weakness 2023

Williston Basin Public School District #7

ND

Material Weakness Reporting § 200.327 § 200.329

2023-012– EDUCATION STABILIZATION FUND - REPORTING – ALN 84.425 - MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Williston Basin Public School District No. 7 did not maintain documentation for the data that was submitted to the North Dakota Department of Public Instruction (NDDPI) for the sta...

2023-012– EDUCATION STABILIZATION FUND - REPORTING – ALN 84.425 - MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Williston Basin Public School District No. 7 did not maintain documentation for the data that was submitted to the North Dakota Department of Public Instruction (NDDPI) for the state’s completion of the Annual Report for the Education Stabilization Fund program. We were able to obtain the information that was submitted from NDDPI; however, due to issues identified with the accuracy of underlying accounting records we were unable to determine if the information included in the report is accurate. Management’s Response: We agree. The District will work to ensure that all federal programs reporting requirements are met going forward. The district has implemented new documentation retention requirements. Anticipated Completion Date: FY 2025

View Audit 406705

Finding 1223162 (2023-002)

Material Weakness 2023

CENTRO DE CUIDADO AMOR, INC

PR

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.305 § 200.328 § 200.329 § 200.334

VIEWS OF RESPONSIBLE OFFICIALS In response to the single audit finding we will take the following actions. We will establish internal controls that provide certainty, effective monitoring data validation and accountability for those employees who approved expenditures. We will prepare written proces...

VIEWS OF RESPONSIBLE OFFICIALS In response to the single audit finding we will take the following actions. We will establish internal controls that provide certainty, effective monitoring data validation and accountability for those employees who approved expenditures. We will prepare written process in accordance with both state and federal regulations. We will prepare written process in accordance with both state and federal regulations. We will require relevant staff (Staff interacting with procurement, expenditures approval) a comprehensive training program on the requirements of CFR 200. IMPLEMENTATION DATE September 30, 2026 RESPONSIBLE PERSON Ivan Rentas, President

View Audit 406682

Finding 1223142 (2023-006)

Material Weakness 2023

MERCER COUNTY

ND

Reporting Subrecipient Monitoring Material Weakness § 200.303

2023-006 – CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS – IMPROPER AND UNTIMELY REPORTING OF EXPENDITURES & OBLIGATIONS – ALN 21.027 – MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Mercer County did not properly report total cumulative and current period expenditures and obligations on ...

2023-006 – CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS – IMPROPER AND UNTIMELY REPORTING OF EXPENDITURES & OBLIGATIONS – ALN 21.027 – MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Mercer County did not properly report total cumulative and current period expenditures and obligations on the March 31, 2023, Project and Expenditure Report for the Coronavirus State and Local Fiscal Recovery Funds program. The total reported cumulative expenditures and obligations were overstated by $37,577 and $484,435. The total reported current period expenditures were understated by $345,365, and the total current period obligations were overstated by $780,000. In addition, the 2023 report was submitted on May 15, 2023, roughly two weeks after the April 30, 2023 deadline. Corrective Action Plan: We agree. We will ensure the future obligation reports that are sent are proper. Anticipated Completion Date: FY 2026

View Audit 406671

Finding 1223128 (2023-013)

Material Weakness 2023

St. Croix Chippewa Housing Authority

CA

Material Weakness

2023-013 Support for Payroll Material Weakness Recommendation: Auditor’s recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Housing Authority agrees with this finding and will...

2023-013 Support for Payroll Material Weakness Recommendation: Auditor’s recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 406660

Finding 1223127 (2023-012)

Material Weakness 2023

St. Croix Chippewa Housing Authority

CA

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.327

2023-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as de...

2023-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as defined under policy. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 406660

Finding 1223126 (2023-011)

Material Weakness 2023

St. Croix Chippewa Housing Authority

CA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management § 200.305

2023-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this fi...

2023-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 406660

Finding 1223122 (2023-007)

Material Weakness 2023

St. Croix Chippewa Housing Authority

CA

Eligibility HUD Housing Programs Material Weakness

2023-007 Tenant Eligibility Material Weakness Recommendation: In general, we continue to recommend a review of the re-certification process to determine areas of weakness. Specifically, we recommend the use of a standard checklist in the re-certification process. We further recommend that each re-ce...

2023-007 Tenant Eligibility Material Weakness Recommendation: In general, we continue to recommend a review of the re-certification process to determine areas of weakness. Specifically, we recommend the use of a standard checklist in the re-certification process. We further recommend that each re-certification clerk’s work be routinely audited. We also recommend more standardization in resident files organization of information, and procedures established to make sure all files are maintained adequately in order to be compliant. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 406660

Finding 1223121 (2023-006)

Material Weakness 2023

St. Croix Chippewa Housing Authority

CA

Subrecipient Monitoring Material Weakness Internal Control / Segregation of Duties

2023-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the a...

2023-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the auditor. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 406660

Finding 1223120 (2023-005)

Material Weakness 2023

St. Croix Chippewa Housing Authority

CA

Cash Management Material Weakness

2023-005 Timely Bank Reconciliations Material Weakness Recommendation: Implement currently adopted policies over bank reconciliations. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 406660

Finding 1223119 (2023-004)

Material Weakness 2023

St. Croix Chippewa Housing Authority

CA

Cash Management Material Weakness

2023-004 Cash Management Material Weakness Recommendation: Auditors recommend filing documentation for grant draws along with payment vouchers throughout the year. Action Taken: Documentation for grant draws and expenditures to support the request for funding is vouchered along with wire transaction...

2023-004 Cash Management Material Weakness Recommendation: Auditors recommend filing documentation for grant draws along with payment vouchers throughout the year. Action Taken: Documentation for grant draws and expenditures to support the request for funding is vouchered along with wire transaction documentation that requires the signature of 3 Tribal Council for processing.

View Audit 406660

Finding 1223117 (2023-002)

Material Weakness 2023

St. Croix Chippewa Housing Authority

CA

Questioned Costs Procurement, Suspension & Debarment Material Weakness

2023-002 Support for Expenditures Material Weakness Recommendation: Auditors recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Tribal Chairperson has been a designated check ...

2023-002 Support for Expenditures Material Weakness Recommendation: Auditors recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Tribal Chairperson has been a designated check signer as well as the St. Croix Tribal Council reviews revenue and expenditures on a monthly basis.

View Audit 406660

Finding 1221450 (2023-001)

Material Weakness 2023

Lawrence County School District

MS

Questioned Costs Subrecipient Monitoring Material Weakness § 200.512

Corrective Action Plan Details: A. Contact person responsible for corrective action: Name: Alicia Smith Title: Chief Financial Officer B. Description of corrective action planned: The district will strengthen its internal control systems over reporting to ensure single audit reporting package and da...

Corrective Action Plan Details: A. Contact person responsible for corrective action: Name: Alicia Smith Title: Chief Financial Officer B. Description of corrective action planned: The district will strengthen its internal control systems over reporting to ensure single audit reporting package and data collection form are submitted to the Federal Audit Clearinghouse within established timeframe and financial statements are prepared timely. C. Anticipated completion date of corrective action: Immediately

View Audit 405738

Finding 1218727 (2023-002)

Material Weakness 2023

Benton County

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Questioned Costs

The County has since implemented corrective actions to strengthen internal controls and ensure compliance moving forward, including: Providing targeted staff training on eligibility requirements, including self-attestation limitations. Implementing a secondary review process for eligibility determin...

The County has since implemented corrective actions to strengthen internal controls and ensure compliance moving forward, including: Providing targeted staff training on eligibility requirements, including self-attestation limitations. Implementing a secondary review process for eligibility determinations and payment calculations when clients self-certify income. Establishing ongoing monitoring procedures, including periodic file reviews. Benton County is committed to maintaining strong internal controls and ensuring compliance with all applicable federal and state requirements. These enhancements are designed to prevent recurrence and support consistent application of program guidelines.

View Audit 404788

Finding 1218459 (2023-003)

Material Weakness 2023

Southeast Idaho Council of Governments, INC

ID

Material Weakness Reporting

SICOG hired an internal Director of Fiscal Operations responsible for the reconciliations instead of a consultant, also simplified the reconciliation process by consolidating accounts and financial institutions whenever possible.

View Audit 404750

Finding 1217561 (2023-001)

Material Weakness 2023

Jumoke Academy, Inc.

CT

Reporting Internal Control / Segregation of Duties Material Weakness

The Organization has agreed to the recommendation to maintain appropriately trained and experienced personnel and has hired a new Director of Finance. This will ensure that the accounting processes and internal controls over Federal Reporting will be functioning properly.

View Audit 403718

Finding 1217387 (2023-004)

Material Weakness 2023

The Wellness Plan Medical Centers

MI

Questioned Costs Special Tests & Provisions Material Weakness § 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 1215750 (2023-005)

Material Weakness 2023

Harvest Hope Food Bank

SC

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

2023-005 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake...

2023-005 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635

View Audit 402412

Finding 1215745 (2023-004)

Material Weakness 2023

Harvest Hope Food Bank

SC

Subrecipient Monitoring Eligibility Material Weakness

2023-004 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@har...

2023-004 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635

View Audit 402412

Finding 1214959 (2023-004)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF LITTLE ROCK, ARKANSAS

CA

Allowable Costs / Cost Principles HUD Housing Programs Questioned Costs

Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.01...

Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.019 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements regarding Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2023.

View Audit 401728

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 1214453 (2023-006)

Material Weakness 2023

COUNTY OF GALLATIN

MT

Questioned Costs Material Weakness Reporting

Reporting – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: Various amounts reported as expended or obligated did not agree with amounts supported by the County’s accounting records. Responsible Individuals: Aaron Mitchell, Chief Financial Officer Corrective Action Plan: The Count...

Reporting – Coronavirus State and Local Fiscal Recovery Funds Finding Summary: Various amounts reported as expended or obligated did not agree with amounts supported by the County’s accounting records. Responsible Individuals: Aaron Mitchell, Chief Financial Officer Corrective Action Plan: The County is strengthening review and reconciliation procedures for federal reporting to ensure amounts reported agree with underlying accounting records and supporting documentation prior to submission. Additional supervisory review procedures are being implemented for future federal reporting submissions. Anticipated Completion Date: Ongoing

View Audit 401154

Finding 1214452 (2023-005)

Material Weakness 2023

COUNTY OF GALLATIN

MT

Questioned Costs Cash Management Material Weakness

Reporting – Airport Improvement Program Finding Summary: Adequate supporting documentation for the amount requested for reimbursement with reporting form SF-271 was not available. Responsible Individuals: Aaron Mitchell, Chief Financial Officer Corrective Action Plan: The County is implementing enha...

Reporting – Airport Improvement Program Finding Summary: Adequate supporting documentation for the amount requested for reimbursement with reporting form SF-271 was not available. Responsible Individuals: Aaron Mitchell, Chief Financial Officer Corrective Action Plan: The County is implementing enhanced documentation retention and review procedures to ensure supporting documentation for reimbursement requests is maintained, reviewed, and readily accessible prior to submission. Anticipated Completion Date: Ongoing

View Audit 401154

Finding 1213858 (2023-004)

Material Weakness 2023

Knoxville Knox County Community Action Committee

TN

Questioned Costs Material Weakness Matching / Level of Effort / Earmarking

U.S. Department of the Treasury Internal Control Over General Disbursements Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: Implement a formal way to document the review and approval of transportation costs charged from the Knox County garage to prov...

U.S. Department of the Treasury Internal Control Over General Disbursements Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: Implement a formal way to document the review and approval of transportation costs charged from the Knox County garage to provide evidence that internal controls are effectively designed and implemented. Explanation of disagreement with audit finding: There is no disagreement with the finding regarding the formal documentation of the services and approval of transportation cost charged from the Knox County Service Center (garage.) Action taken in response to finding: Agency vehicles are serviced at the Knox County Service Center (garage), with services billed monthly. Although transportation charges from the County were reviewed monthly, documentation of that review was not formally retained. CAC is implementing the following corrective actions: • Monthly Transportation Costs will be signed and dated by reviewer. • Establish grant compliance documentation retention protocol. • Establish Centralized federal grant compliance documentation repository. Management will perform periodic review to ensure documentation controls are consistently applied. Name(s) of the contact person(s) responsible for corrective action: Misty Goodwin, Chief Executive Officer, Anna Roeder, Chief Financial Officer. Planned completion date for corrective action plan: Documentation procedures were implemented in February 2026 and remain operational with ongoing monitoring.

View Audit 400695

Corrective Action Plans

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