Corrective Action Plans

Finding 1241591 (2025-002)

Material Weakness 2025

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

CORRECTIVE ACTION PLAN September 25, 2026 Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: Dece...

CORRECTIVE ACTION PLAN September 25, 2026 Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2025. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2025 The findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410 and H8N53897 for 2025 Finding 2025-002 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken and Expected Date of Correction Identified Issue: Brooklyn Plaza Medical Center identified a need to strengthen the consistent application and documentation of the Sliding Fee Discount Program (SFDP), including front-end staff processes related to patient eligibility, documentation, and collection of applicable fees, as well as back-end billing processes to ensure that sliding fee adjustments and write-offs are applied accurately and consistently. Corrective Action Brooklyn Plaza Medical Center will implement a standardized training, monitoring, and reconciliation process to ensure appropriate administration of the Sliding Fee Discount Program from patient registration through final account reconciliation. This will be implemented by December 2026. Front Desk Training and Standardization All Front Desk/Patient Services staff will receive mandatory training on the Sliding Fee Discount Program. Training will include: • Reviewing the current Sliding Fee Discount Program policy and fee schedule. • Determining and documenting household size and income in accordance with established policy. • Identifying patients who may qualify for the Sliding Fee Discount Program. • Properly completing and maintaining required eligibility documentation. • Applying the appropriate sliding fee category based on established income guidelines. • Communicating the program and applicable patient responsibility clearly and consistently to patients. • Ensuring appropriate information is entered into the electronic health record/practice management system so that billing can process the account correctly. Training will be incorporated into the onboarding process for new Front Desk staff and reinforced through periodic refresher training. Billing and Write-Off Reconciliation The Billing/Revenue Cycle team will establish a back-end review process to ensure that accounts approved for the Sliding Fee Discount Program are adjusted appropriately. Billing staff will verify that: • The correct sliding fee category has been applied. • Patient responsibility is consistent with the approved sliding fee schedule. • Applicable contractual adjustments and sliding fee write-offs are accurately posted. • Sliding fee balances are not incorrectly transferred to patient responsibility or collection activity. • Any discrepancies identified between front-end documentation and back-end billing are corrected promptly. Billing will also conduct periodic reconciliation of sliding fee accounts to identify inappropriate balances, missed adjustments, or incorrect write-offs. Monitoring and Quality Assurance Management will conduct routine audits of a sample of Sliding Fee Discount Program accounts to confirm compliance at both the front and back end. Audit findings will be reviewed with Patient Services and Billing leadership, and any identified deficiencies will result in immediate correction and additional staff education as necessary. The organization will monitor compliance on an ongoing basis to ensure that the corrective action is sustained and that eligible patients consistently receive the appropriate sliding fee discount. Responsible Parties: Practice Administration/Patient Services Leadership Revenue Cycle/Billing Leadership Finance Compliance Expected Outcome: Brooklyn Plaza Medical Center will have a standardized and auditable process that ensures Sliding Fee Discount Program eligibility is appropriately determined and documented at the front end and that corresponding billing adjustments and write-offs are accurately reflected on the back end. If the Health Resources and Services Administration has questions regarding this plan, please call Philip J. Onorato, Chief Executive Officer at 718-596-9800, ext. 205.

View Audit 415633

Finding 1241517 (2025-002)

Material Weakness 2025

City of Portsmouth

OH

Subrecipient Monitoring Material Weakness Reporting § 200.303 § 200.334

The City will implement procedures to obtain, review, reconcile, and retain supporting documentation for all Federal award activity, including costs paid on the City's behalf by the Ohio Department of Transportation. Responsibility for monitoring and documenting these activities will be assigned to ...

The City will implement procedures to obtain, review, reconcile, and retain supporting documentation for all Federal award activity, including costs paid on the City's behalf by the Ohio Department of Transportation. Responsibility for monitoring and documenting these activities will be assigned to appropriate personnel, and management will review and reconcile the amounts reported on the Schedule of Expenditures of Federal Awards to the information provided by ODOT.

View Audit 415580

Finding 1241513 (2025-005)

Material Weakness 2025

Karen Organization of Minnesota

MN

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: We recommend that the Organization strengthen controls over participant eligibility by implementing procedures to regularly monitor participant eligibility periods, track ORR...

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: We recommend that the Organization strengthen controls over participant eligibility by implementing procedures to regularly monitor participant eligibility periods, track ORR eligibility dates, and timely close cases that exceed the maximum allowable service period. In addition, the Organization should verify and document Minnesota residency prior to providing services, retain supporting eligibility documentation in participant files, and perform periodic monitoring to ensure compliance with program eligibility requirements. Management should not rely solely on system-generated notifications to identify participants approaching eligibility expiration. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KOM will strengthen its participant eligibility procedures by implementing a process to regularly monitor participant eligibility periods and track applicable ORR eligibility dates. Cases that reach or exceed the maximum allowable service period will be identified and closed timely. KOM will also establish procedures to verify and document Minnesota residency before services are provided and to retain appropriate eligibility documentation in participant files. Periodic monitoring will be performed to confirm ongoing compliance with program eligibility requirements, rather than relying solely on system-generated notifications to identify approaching eligibility expiration dates. Name of the contact person responsible for corrective action: Alice Buckner, Executive Director Planned completion date for corrective action plan: December 31, 2026.

View Audit 415577

Finding 1241510 (2025-004)

Material Weakness 2025

Karen Organization of Minnesota

MN

Internal Control / Segregation of Duties Eligibility Material Weakness

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its controls over Executive Director payroll by requiring payroll timesheets and related payroll records to be reviewed and approved by an ...

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its controls over Executive Director payroll by requiring payroll timesheets and related payroll records to be reviewed and approved by an individual with appropriate oversight authority, such as the Board Chair, Treasurer, or another designated board representative. Management should maintain documentation of such approval and periodically monitor compliance with the control. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in October 2026, KOM will implement an independent review and approval process for the Executive Director's payroll. A designated Board member will review and approve the Executive Director's payroll records. To facilitate this control, the designated Board member will be established in Paylocity with the appropriate manager-level access necessary to perform the approval. KOM will coordinate with the designated Board member to ensure that the review and approval can be completed within the organization's time-sensitive semi-monthly payroll cycle and that evidence of the approval is retained. Name of the contact person responsible for corrective action: Alice Buckner, Executive Director Planned completion date for corrective action plan: November 30 , 2026.

View Audit 415577

Finding 1241507 (2025-003)

Material Weakness 2025

Karen Organization of Minnesota

MN

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its internal controls over grant reimbursement requests by ensuring all requests are reviewed and approved by the authorized Executive Dire...

Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: The Organization should strengthen its internal controls over grant reimbursement requests by ensuring all requests are reviewed and approved by the authorized Executive Director prior to submission to the grantor. Management should maintain documentation evidencing the review and approval and perform periodic monitoring to ensure compliance with established approval and segregation of duties requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective July 2026, KOM implemented an enhanced review and approval process for RPO reimbursement invoices. Each invoice is subject to review by two executives and requires two levels of approval. The Program Director and Executive Director are primarily responsible for the review and approval process. When the Executive Director is unavailable, the Finance Director provides the required review and approval. This process is intended to ensure appropriate oversight and documented authorization before reimbursement requests are submitted. Name of the contact person responsible for corrective action: Alice Buckner, Executive Director Planned completion date for corrective action plan: November 30,2026

View Audit 415577

Finding 1241502 (2025-008)

Material Weakness 2025

City of Redondo Beach

CA

HUD Housing Programs Subrecipient Monitoring Material Weakness § 200.303

Recommendation: We recommend that the City review and update internal controls over the completion and submission of monthly program reports to ensure the accuracy of the information being reported and to ensure that supporting underlying documentation is properly retained. As part of this process, ...

Recommendation: We recommend that the City review and update internal controls over the completion and submission of monthly program reports to ensure the accuracy of the information being reported and to ensure that supporting underlying documentation is properly retained. As part of this process, the City should consider utilizing members of the Finance Department as the monthly reports contain certain financial information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The RBHA established a process by which Housing staff generate the reports required to prepare the VMS and provide the Finance Department staff a copy in order to document timing and ensure additional review. Also, the RBHA and Finance revised the City’s account structure for Housing-related expenses to align with the City’s account setup with VMS reporting. The RBHA will provide monthly reports to the Finance Department and the financial consultant to document the timing of the reports and facilitate an independent review and ensure the monthly submissions are properly reviewed, approved, and retained for audit purposes. Name(s) of the contact person(s) responsible for corrective action: Imelda Delgado, Housing Manager Planned completion date for corrective action plan: January 2026

View Audit 415572

Finding 1241383 (2025-002)

Material Weakness 2025

Afghan Cultural Society of Mn

MN

Cash Management Material Weakness Period of Performance

U.S. Department of Health and Human Services 2025-002 Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that organization improve grant tracking to ensure that on...

U.S. Department of Health and Human Services 2025-002 Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that organization improve grant tracking to ensure that only costs incurred within the period of performance are included in the reimbursement requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Expenditure trackers are being updated for ease of use and will include notes on exact end of contract dates instead of just the month and year. This will take place starting in Q4 2026. Name(s) of the contact person(s) responsible for corrective action: Nasreen Sajady Planned completion date for corrective action plan: 10/13/2026

View Audit 415503

Finding 1241254 (2025-002)

Material Weakness 2025

Davis & Elkins College

WV

Internal Control / Segregation of Duties Material Weakness Reporting § 200.512

Management acknowledges the reporting package and Data Collection Form were not submitted to the Federal Audit Clearinghouse by the required deadline due to delays in completing the audited financial statements.. Management has addressed the staffing challenges which caused the delay by evaluating r...

Management acknowledges the reporting package and Data Collection Form were not submitted to the Federal Audit Clearinghouse by the required deadline due to delays in completing the audited financial statements.. Management has addressed the staffing challenges which caused the delay by evaluating resource needs, filling key positions, and improving the assignment of financial reporting responsibilities. These actions are intended to support the timely completion of the annual audit and ensure compliance with future Federal Audit Clearinghouse reporting deadlines.

View Audit 415371

Finding 1241171 (2025-004)

Material Weakness 2025

Community Health Service, Inc.

MN

Special Tests & Provisions Allowable Costs / Cost Principles Material Weakness

Sliding Fee Documentation Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Ensure complete documentation is obtained and retained. - Implement monitoring and periodic reviews. - Provide staff training. Responsible Parties: Chief Executive Officer and Chief Financial ...

Sliding Fee Documentation Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Ensure complete documentation is obtained and retained. - Implement monitoring and periodic reviews. - Provide staff training. Responsible Parties: Chief Executive Officer and Chief Financial Officer

View Audit 415245

Finding 1241170 (2025-003)

Material Weakness 2025

Community Health Service, Inc.

MN

Cash Management Internal Control / Segregation of Duties Material Weakness § 200.305

Cash Management Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Implement reconciliation of each drawdown to actual expenditures. - Require detailed supporting documentation. - Establish supervisory approval process. Responsible Parties: Chief Executive Officer and ...

Cash Management Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Implement reconciliation of each drawdown to actual expenditures. - Require detailed supporting documentation. - Establish supervisory approval process. Responsible Parties: Chief Executive Officer and Chief Financial Officer

View Audit 415245

Finding 1240802 (2025-003)

Material Weakness 2025

Stebbins Community Association

AK

Material Weakness Reporting Internal Control / Segregation of Duties § 200.512

Finding 2025-003 Late Reporting and Noncompliance with Reporting Requirements Material Weakness Name of Contact Person: Nora Tom, President; Tribal Coordinator, Jacinta Martin Corrective Action Plan: The Stebbins Community Association will establish and implement a formal reporting compliance proces...

Finding 2025-003 Late Reporting and Noncompliance with Reporting Requirements Material Weakness Name of Contact Person: Nora Tom, President; Tribal Coordinator, Jacinta Martin Corrective Action Plan: The Stebbins Community Association will establish and implement a formal reporting compliance process to ensure that all required financial, programmatic, grant, and other regulatory reports are accurately prepared, reviewed, approved, and submitted by the applicable deadlines. Management will implement the following procedures: 1. Centralized Reporting Calendar The Association will establish a centralized reporting calendar identifying all required reports, including: • Report name and funding source; • Reporting period; • Due date; • Responsible employee; • Required management review; • Submission method; and • Date submitted. The calendar will be maintained and updated throughout the year. 2. Designated Responsibility A specific employee will be assigned responsibility for monitoring each reporting requirement. The assigned employee will be responsible for preparing the report and ensuring that it is submitted by the applicable deadline. 3. Management Review and Approval All significant financial and program reports will be reviewed by the Executive Director or designated management personnel before submission. The review will verify the accuracy and completeness of the information and compliance with applicable reporting requirements. 4. Advance Deadlines Internal deadlines will be established before the actual funding agency or regulatory deadline. Reports should generally be completed and submitted for management review sufficiently in advance to allow time for corrections or unforeseen delays. 5. Supporting Documentation Documentation supporting submitted reports will be maintained in an organized manner, including financial records, invoices, payroll records, program records, grant documentation, correspondence, and copies of submitted reports and submission confirmations. 6. Monitoring of Grant and Reporting Requirements Management will periodically review grant agreements, award documents, funding notices, and applicable regulations to identify reporting requirements and changes to reporting deadlines or submission procedures. 7. Late or Missed Reports If a report cannot be submitted by the required deadline, the responsible employee will immediately notify management. Management will contact the applicable funding agency, when appropriate, to request an extension or provide an explanation and establish a plan for bringing the reporting requirement current. 8. Follow-Up on Outstanding Reports Management will maintain a list of outstanding or pending reports and monitor them until completed and accepted by the applicable funding agency. 9. Staff Training Employees responsible for grant administration, accounting, financial reporting, and program reporting will receive training regarding reporting deadlines, applicable grant requirements, documentation standards, and submission procedures. 10. Ongoing Management Oversight The Executive Director will periodically review the reporting calendar and outstanding reports to ensure that reporting responsibilities are being completed timely and that identified deficiencies are corrected. Proposed Completion Date: The corrective action will be implemented immediately. The centralized reporting calendar and assignment of reporting responsibilities will be established for the current fiscal year.

View Audit 415173

Finding 1240728 (2025-003)

Material Weakness 2025

Ironton- Lawrence County Area Community Action Organization, Inc.

OH

Reporting Material Weakness § 200.512

Management agrees with the finding. The Director of Accounting has implemented a revised closing timeline and automated tracking for future FAC submissions.

View Audit 415103

Finding 1240715 (2025-006)

Material Weakness 2025

Nevadaworks

NV

Reporting Material Weakness § 200.303 § 200.328

Reporting Management Response: Management acknowledges this finding. The fourth-quarter FY2025 financial report submitted to the grantor was an exact duplicate of the third-quarter report and did not include fourth-quarter activity. The audit also found no evidence of an independent review before su...

Reporting Management Response: Management acknowledges this finding. The fourth-quarter FY2025 financial report submitted to the grantor was an exact duplicate of the third-quarter report and did not include fourth-quarter activity. The audit also found no evidence of an independent review before submission. Corrective Action: Nevadaworks will strengthen its federal financial reporting review process. 1. A reporting calendar will identify all required federal reports, due dates, preparer, reviewer, and approving official. 2. Each quarterly report will be reconciled to the general ledger and applicable grant accounting records before submission. 3. Management will review the FY2025 fourth-quarter reporting issue and submit any required corrected reports to the awarding agency. Responsible Party: Finance Manager/Controller. Target Completion The reporting checklist and independent review process will be implemented immediately and used for all subsequent quarterly federal financial reports. Monitoring: Management will perform quarterly compliance reviews to verify that each federal financial report was reconciled, independently reviewed, approved, and retained with supporting documentation.

View Audit 415079

Finding 1240643 (2025-004)

Material Weakness 2025

JOHNSON CREEK WATERSHED COUNCIL

OR

Cash Management Allowable Costs / Cost Principles Material Weakness § 200.302 § 200.303 § 200.305

2025-004 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance – Cash Management Recommendation: We recommend the Organization implement formal internal controls over the cash management process, including documented supervisory review and approval ...

2025-004 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance – Cash Management Recommendation: We recommend the Organization implement formal internal controls over the cash management process, including documented supervisory review and approval of all cash draw requests prior to submission. Cash draw requests should be prepared and supported using information maintained within the accounting system and reconciled to the general ledger to ensure that only allowable, properly recorded Federal expenditures are included in reimbursement requests. Additionally, management should develop and implement a written cash management policy that establishes procedures for preparing, reviewing, approving, reconciling, documenting, and retaining cash draw records in accordance with the Uniform Guidance. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: JCWC is in the process of implementing updated financial policies and procedures to strengthen internal controls over cash management and Federal reimbursement requests. The new Fiscal Policy Manual establishes a specific process for preparing, verifying, reconciling, reviewing, approving, submitting, and retaining Federal reimbursement and cash draw requests. For example, Section 7.2.1, Reimbursement Request Process, requires: 1. Prepare and Verify The Finance & Grants Manager works with Program Staff and Jitasa to identify eligible expenditures and prepares the reimbursement request, ensuring costs are allowable, appropriately allocated, within the approved budget, and supported by documentation. The request shall be prepared using financial information maintained in QuickBooks. 2. Review and Reconcile The appropriate Director reviews the request and supporting documentation for accuracy, allowability, and budget compliance. Jitasa reconciles the requested amount to the applicable QuickBooks general ledger accounts and supporting documentation. Any discrepancy shall be resolved and documented before submission. 3. Approve and Submit The appropriate Director provides documented approval through an approved electronic signature platform. By approving the request, the Director confirms that the request has been reviewed for accuracy, allowable costs, appropriate grant allocation, and compliance with the applicable grant budget and funding requirements. Once approved, the Finance & Grants Manager submits the request to the funder or partner with all required supporting documentation. 4. Retain Records The reimbursement request, supporting documentation, electronic approval, and submitted request are retained in the designated grant records in accordance with Section 10 and applicable funder requirements. The policy therefore establishes a documented supervisory approval and reconciliation process before Federal reimbursement or cash draw requests are submitted. Action Plan: JCWC will finalize and present the Fiscal Policy Manual to the Board for formal adoption and will continue implementing the procedures in the interim. The Finance & Grants Manager will work with program staff and Jitasa to prepare and verify Federal reimbursement and cash draw requests. Requests will be reconciled to the QuickBooks general ledger and supporting documentation, with any discrepancies resolved and documented before submission. The appropriate Director will review and approve each Federal reimbursement or cash draw request prior to submission. JCWC will retain the request, supporting documentation, reconciliation, and approval in accordance with its records retention requirements and applicable Federal requirements. Following Board The appropriate Director will review and approve each Federal reimbursement or cash draw request prior to submission. JCWC will retain the request, supporting documentation, reconciliation, and approval in accordance with its records retention requirements and applicable Federal requirements. Following Board

View Audit 415026

Finding 1240641 (2025-002)

Material Weakness 2025

JOHNSON CREEK WATERSHED COUNCIL

OR

Allowable Costs / Cost Principles Reporting Material Weakness § 200.302 § 200.303

2025-002 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance – Financial Management Recommendation: We recommend the Organization modify its financial management system to separately identify and track Federal award expenditures within the account...

2025-002 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance – Financial Management Recommendation: We recommend the Organization modify its financial management system to separately identify and track Federal award expenditures within the accounting records. Management should discontinue reliance on external workbooks as the primary record of Federal expenditures and ensure the accounting system provides complete, accurate, and auditable records sufficient to support Federal financial reporting and compliance with Uniform Guidance requirements. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: In September 2025, Johnson Creek Watershed Council implemented a new financial management process that separately identifies and tracks Federal award expenditures within its accounting records. JCWC transitioned its bookkeeping and accounting functions to Jitasa, an external accounting firm, with QuickBooks Online serving as the official accounting ledger. Under the new process, Federal grant expenditures are coded to the appropriate grant, project, and funding source within the accounting system. Grant expenditures are reconciled to the QuickBooks general ledger and supporting documentation as part of the grant reimbursement and financial reporting process. External grant tracking worksheets may still be used as supplemental management tools for monitoring project budgets and preparing reimbursement requests; however, they are no longer relied upon as the primary record of Federal expenditures. The new Fiscal Policy Manual formalizes these practices. Section 4.4.4, Cost Allocation, requires direct costs to be charged to the specific grant, contract, or project and shared costs to be allocated using documented methodologies. Section 10.1, Financial Records, establishes QuickBooks as the official accounting ledger, with Jitasa maintaining and reconciling the organization's financial records. Action Plan: JCWC will continue the financial management process implemented in September 2025 and incorporate the process into its formal fiscal policies and procedures. The Finance & Grants Manager will work with Jitasa to ensure Federal award expenditures continue to be appropriately coded and identifiable within QuickBooks. Federal expenditures will be reviewed and reconciled to the general ledger and supporting documentation as part of ongoing grant management and reporting. The Finance & Grants Manager and Executive Director will monitor the process to ensure that external tracking worksheets remain supplemental management tools and that the official accounting records in QuickBooks remain the primary source for Federal expenditure reporting. Name(s) of the contact people responsible for correction action: Jennifer Hamilton, Executive Director Sean Connolly, Finance & Grants Manager Jitasa Mallette Faherty, Board Treasurer Plan completion date for corrective action plan: September 5, 2025 for implementation of the new process; ongoing monitoring thereafter.

View Audit 415026

Finding 1240640 (2025-001)

Material Weakness 2025

JOHNSON CREEK WATERSHED COUNCIL

OR

Reporting Material Weakness

2025-001 Habitat Conservation – Assistance Lising #11.463 - Audited Financial Statements Late Filing – Material Weakness in Controls Over Compliance and Noncompliance Recommendation: The Organization should review the program requirements and implement contingency plans to ensure that year-end repor...

2025-001 Habitat Conservation – Assistance Lising #11.463 - Audited Financial Statements Late Filing – Material Weakness in Controls Over Compliance and Noncompliance Recommendation: The Organization should review the program requirements and implement contingency plans to ensure that year-end reporting requirements are met. The Organization should establish clear, documented processes and procedures that address compliance requirements under Uniform Grant Guidance and can be consistently followed during management transitions. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: Johnson Creek Watershed Council has taken steps to strengthen its financial management and compliance systems following the audit. The Council has transitioned its bookkeeping and accounting functions to Jitasa, an external accounting firm, and has developed a new Fiscal Policy Manual establishing clear responsibilities and procedures for financial management, grant compliance, audits, recordkeeping, and corrective actions. The Fiscal Policy Manual assigns responsibility for grant compliance and reporting to the Executive Director, with support from the Finance & Grants Manager, program staff, and Jitasa. It also establishes procedures for maintaining financial and grant documentation in organized, accessible systems and requires audit reports, corrective action plans, and related correspondence to be retained for a minimum of seven years. For example, Section 11, Independent Financial Reviews and Audits, establishes management's responsibility for monitoring Federal expenditures and determining whether a Single Audit is required. The policy also establishes Board oversight of financial reviews and audits. Section 10, Recordkeeping & Documentation, establishes requirements for maintaining financial records and supporting documentation and requires financial records, invoices, receipts, and contracts to be retained for a minimum of seven years. Action Plan: JCWC will finalize and adopt the Fiscal Policy Manual and implement a documented year-end compliance and audit reporting process. This process will identify required federal, state, and other funder reporting deadlines, assign responsibility for each filing, and provide sufficient lead time for management, Jitasa, the external accounting firm, the Board Treasurer, and the Board to complete required reviews and approvals. The Executive Director and Finance & Grants Manager will maintain a centralized schedule of financial, grant, audit, and regulatory reporting deadlines and will review the schedule regularly to ensure upcoming requirements are identified and assigned. The Executive Director will coordinate with Jitasa and the independent auditor to ensure that required financial information and supporting documentation are available in advance of filing deadlines. To address the risk created by management turnover, JCWC will maintain documented financial and compliance procedures and centralized records so that reporting responsibilities and supporting documentation can be transferred without relying on the knowledge of a single individual. Name(s) of the contact people responsible for correction action: Jennifer Hamilton, Executive Director Sean Connolly, Finance & Grants Manager Mallette Faherty, Board Treasurer Plan completion date for corrective action plan: December 31, 2026 for implementation and monitoring ongoing.

View Audit 415026

Finding 1240636 (2025-003)

Material Weakness 2025

Housing Hope and Subsidiaries

WA

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.317 § 200.318 § 200.327

Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Housing Hope adopted a P...

Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Housing Hope adopted a Procurement Policy that aligns with the Uniform Guidance following year end. The policy was communicated to all staff with purchasing and procurement responsibilities. The policy will be reviewed at least annually to ensure continued compliance with the Uniform Guidance. In addition, management conducts periodic reviews of procurement practices to verify compliance with the Policy. Anticipated completion date: The Procurement Policy was adopted November 2025 by the Board.

View Audit 415020

Finding 1240628 (2025-004)

Material Weakness 2025

Housing Hope and Subsidiaries

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility

Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Housing Hope changed pro...

Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Housing Hope changed property management companies in April 2026. The new property management company is working to bring all past due certifications for current tenants up to date. Progress towards this goal is monitored through bi-weekly reports to Housing Hope management. The new property management company maintains a schedule of all certifications due dates and tracks progress towards these dates on a schedule shared with Housing Hope management. Anticipated completion date: December 31, 2026

View Audit 415020

Finding 1240501 (2025-011)

Material Weakness 2025

Heritage University

WA

Student Financial Aid Special Tests & Provisions Material Weakness

11. 2025-011 – Special Tests and Provisions - Verification – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Recommendation: The auditors recommend the University implement the proper controls to ensure that verification of students is completed accurately and ac...

11. 2025-011 – Special Tests and Provisions - Verification – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Recommendation: The auditors recommend the University implement the proper controls to ensure that verification of students is completed accurately and according to the applicable guidance. Planned corrective actions: Heritage University agrees with the recommendation and is strengthening its processes and internal controls surrounding student verification. As part of the University's broader efforts to build capacity within the Financial Aid department, management is reviewing existing verification procedures to ensure requirements are clearly documented, consistently applied, and aligned with applicable federal guidance. The University is establishing clearer ownership of verification responsibilities, defined timelines and checkpoints for completion, and appropriate review procedures to ensure required documentation is obtained and reviewed before verification is considered complete and aid is disbursed. Management will also continue to strengthen staff training and supervisory review and will periodically review procedures as federal requirements change. These efforts are intended to provide greater consistency, accountability, and oversight while ensuring verification requirements are completed accurately and timely. Name of Responsible Party: Nancy Benavidez, Sagrario Armenta Jimenez Anticipated completion date: Most of the clean-up will happen during Fiscal Year 2026-2027. But this will always remain a project for continuous improvement.

View Audit 414959

Finding 1240480 (2025-005)

Material Weakness 2025

Heritage University

WA

Student Financial Aid Special Tests & Provisions Material Weakness

5. 2025-005 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Material Weakness in Internal Controls over Compliance and Material Noncompliance Recommendation: The auditors recommend the University review their policies and procedures to ensure all withdrawals, including unofficial ...

5. 2025-005 – Special Tests and Provisions – Return of Title IV Funds (R2T4) – Material Weakness in Internal Controls over Compliance and Material Noncompliance Recommendation: The auditors recommend the University review their policies and procedures to ensure all withdrawals, including unofficial withdrawals where the student does not give formal notification can be identified and accurately evaluated. They also recommend a control be put in place to ensure the calculations and return of funds are performed accurately and timely. Planned corrective actions: Heritage University agrees with the recommendation and is reviewing its withdrawal and Return of Title IV (R2T4) processes to strengthen both the timely identification of student withdrawals and the accurate and timely completion of required calculations and return of funds. The University is reviewing the processes and communication between Financial Aid, the Registrar, Academic Affairs, and other appropriate departments to ensure both official and unofficial withdrawals are identified timely and the information necessary to evaluate a student's withdrawal date is appropriately documented and communicated. Within Financial Aid, responsibilities and timelines will be clearly assigned for reviewing withdrawal information, completing required R2T4 calculations, and returning funds within applicable deadlines. The University will also establish documented review checkpoints to verify that calculations are accurate, required documentation is maintained, and returns are completed timely. As part of its broader efforts to build capacity within Financial Aid, management will continue to evaluate staffing, training, system access, and internal procedures to ensure these compliance responsibilities have clear ownership and appropriate oversight. Name of Responsible Party: Nancy Benavidez, Sagrario Armenta Jimenez Anticipated completion date: Most of the clean-up will happen during Fiscal Year 2026-2027. But this will always remain a project for continuous improvement.

View Audit 414959

Finding 1240416 (2025-003)

Material Weakness 2025

Wilmington Housing Authority

NC

Allowable Costs / Cost Principles Eligibility HUD Housing Programs § 200.516

Authority's Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Kinteh Darboe,...

Authority's Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Kinteh Darboe, Chief of Financial Operations & Management, is responsible for ensuring the deficiencies have been rectified by March 31, 2026.

View Audit 414907

Finding 1240415 (2025-002)

Material Weakness 2025

Wilmington Housing Authority

NC

Cash Management HUD Housing Programs Subrecipient Monitoring § 200.305 § 200.516

Authority's Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Kinteh Darboe,...

Authority's Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Kinteh Darboe, Chief of Financial Operations & Management, is responsible for ensuring the deficiencies have been rectified by March 31, 2026.

View Audit 414907

Finding 1240301 (2025-019)

Material Weakness 2025

Philander Smith College

AR

Student Financial Aid Material Weakness Reporting

Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-019 1. Finding Summary The auditor determined that the institution did not properly notify students and employees of the required annual security report. As a result, the institution could ...

Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-019 1. Finding Summary The auditor determined that the institution did not properly notify students and employees of the required annual security report. As a result, the institution could not demonstrate compliance with federal requirements governing campus security policies and crime statistics. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that while the information is posted to the institution's website, a campus-wide notification was not sent out in accordance with federal requirements. 3. Root Cause Analysis The exception was caused by insufficient procedures for distributing the data, along with the lack of formal sign-off one the completed action. 4. Corrective Action(s) Management will implement a formal management sign-off on the notification of the required annual security report, which will include maintaining documentation of the notification submission. The next required annual security report is due October 1, 2026. Description of Corrective Actions The institution has added a required supervisory review to verify timely notification is given to students and employees to ensure ongoing compliance and consistent documentation of annual campus safety and fire security disclosure requirements. 5. Risk Mitigation (Required - Even if Disagreeing) These corrective actions will mitigate the risk of noncompliance with annual campus safety and fire security disclosure requirements and ensure students and employees have adequate information. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Director of Financial Aid • Name (optional): ____________ _ 7. Implementation Timeline • Corrective action implemented: D Yes ~ No • If not fully implemented, expected completion date: October 1, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) D Fully implemented D Partially implemented D Not yet implemented Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability The corrective actions will be monitored through ongoing supervisory review to confinn required documentation is obtained and information is shared. These practices will be sustained through standardized review procedures and continued oversight to ensure long-term compliance.

View Audit 414825

Finding 1240273 (2025-012)

Material Weakness 2025

Philander Smith College

AR

Student Financial Aid Cash Management Material Weakness

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-012 1. Finding Summary The auditor determined that the institution disbursed Pell Grant funds more than 10 days prior to the first day of classes, in violation of federal Title IV disburseme...

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-012 1. Finding Summary The auditor determined that the institution disbursed Pell Grant funds more than 10 days prior to the first day of classes, in violation of federal Title IV disbursement timing requirements. As a result, the institution could not demonstrate compliance with applicable federal regulations governing the timing of Pell Grant disbursements. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that Pell Grant funds were disbursed earlier than permitted under federal Title IV disbursement timing requirements due to a miscalculation of the days. 3. Root Cause Analysis The root cause of this finding resulted from by inaccurate or prematurely scheduled disbursement dates, limited coordination between the Financial Aid and Business Offices on the approved disbursement calendar, and insufficient controls to ensure Pell Grant funds were released in accordance with federal timing requirements. 4. Corrective Action(s) Management will implement a standardized calendar of disbursement dates annually based on the academic calendar. Description of Corrective Actions Management will prepare an annual disbursement calendar based on the academic calendar, which will be reviewed by both the Business Office and Office of Financial Aid to ensure compliance to federal Title IV disbursement timing requirements. 5. Risk Mitigation (Required - Even if Disagreeing) These corrective actions reduce the risk of early federal disbursements by strengthening oversight, implementing a disbursement calendar, and reinforcing staff understanding of federal timing requirements. 6. Responsible Party • Office/Department: Business Office • Title of Responsible Official: Senior Accountant • Name (optional): ____________ _ 7. Implementation Timeline • Corrective action implemented: ~ Yes D No • If not fully implemented, expected completion date: 8. Status of Corrective Action (For Prior-Year or Repeat Findings) ~ Fully implemented D Partially implemented D Not yet implemented Evidence of Implementation Academic Year 2026-2027 Disbursement Calendar. 9. Monitoring and Sustainability The University will continue to prepare a disbursement calendar annually before any new year disbursements are made. 900

View Audit 414825

Finding 1240257 (2025-008)

Material Weakness 2025

Philander Smith College

AR

Student Financial Aid Internal Control / Segregation of Duties Subrecipient Monitoring

Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-008 1. Finding Summary The auditor identified three (3) instances in which the University did not return unearned Title IV funds within the required 45-day timeframe following a student's w...

Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-008 1. Finding Summary The auditor identified three (3) instances in which the University did not return unearned Title IV funds within the required 45-day timeframe following a student's withdrawal, with the return occurring significantly after the institution's date of determination and one (1) instance in which proper supporting documentation was not maintained. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and concurs that the return of unearned Title IV funds must occur within the required regulatory timeframe. The University recognizes the importance of timely Return of Title IV processing and is committed to strengthening internal controls, oversight, and coordination to ensure future compliance. "3. Root Cause Analysis The root cause was the absence of a formal monitoring and tracking process for Return of Title IV (R2T4) obligations, combined with limited supervisory oversight and insufficient coordination between the Office of Financial Aid, the Business Office, and Student Retention. These factors resulted in delayed identification of withdrawals and untimely processing ofrequired Title IV fund returns. 4. Corrective Action(s) Management is working to implement standardized workflows and periodic internal monitoring. Description of Corrective Actions To address this finding and prevent recurrence, the University has centralized oversight of the Return of Title IV (R2T4) process by assigning responsibility to the Director of Financial Aid and implementing a formal tracking and monitoring system to ensure all returns are completed within the required 45-day timeframe. The Director of Financial Aid now collaborates with Student Retention to receive prompt notification of student withdrawals. Once funds are removed from the student account for R2T4, the Business Office returns the funds within 3 days. In addition, supervisory review procedures have been established to verify the accuracy and timeliness ofR2T4 calculations and returns, strengthening internal controls and ensuring ongoing compliance with federal regulations. Implementing the revised process has been delayed due to personnel changes. Additionally, the University has contracted with Blue Icon Advisors, a National Association of Student Financial Aid Administrators' financial aid consulting service, to review the R2T4 process and assist with implementation. 5. Risk Mitigation (Required - Even if Disagreeing) The University recognizes the importance of proactively managing regulatory risk related to the Return of Title IV process. The corrective actions implemented are intended to improve the timely identification of student withdrawals, strengthen oversight ofR2T4 calculations and returns, and enhance coordination among responsible offices, thereby reducing the risk of delayed returns, regulatory exposure, and future audit findings. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Financial Aid Director • Name (optional): ____________ _ 7. Implementation Timeline • Corrective action implemented: D Yes ~ No • If not fully implemented, expected completion date: December 31, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) D Fully implemented D Partially implemented ~ Not yet implemented Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability The University will ensure ongoing compliance by conducting routine internal reviews of Return of Title IV activity, including verification of withdrawal notifications, calculation dates, and return confirmations. R2T4 tracking reports and supervisory oversight will be used to monitor timeliness and accuracy, and procedures will be reinforced through continued staff training and management review to support long-term sustainability.

View Audit 414825

Corrective Action Plans

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