Corrective Action Plans

Finding 1168731 (2025-005)

Material Weakness 2025

IL

Questioned Costs Reporting

Finding Type: Non-Compliance (84.010). Name of Contact Person: Greg Frehner, Superintendent. Recommendation: We recommend the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will be...

Finding Type: Non-Compliance (84.010). Name of Contact Person: Greg Frehner, Superintendent. Recommendation: We recommend the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-annual certifications or time and effort distribution records. Proposed Completion Date: Immediately.

View Audit 380780

Finding 1168728 (2025-004)

Material Weakness 2025

Vienna Public School District #55

IL

Questioned Costs

Finding Type: Material Weakness (10.553 and 10.555). Name of Contact Person: Greg Frehner, Superintendent. Recommendation: We recommend the District monitor the profit made by the food service program. All expenditures used to operate the food service program should be charged to the program. In add...

Finding Type: Material Weakness (10.553 and 10.555). Name of Contact Person: Greg Frehner, Superintendent. Recommendation: We recommend the District monitor the profit made by the food service program. All expenditures used to operate the food service program should be charged to the program. In addition, the District needs to adopt a plan to spend the accumulated cash reserves. Corrective Action: The District will continue to allocate indirect costs to eliminate the surplus. Proposed Completion Date: Immediately.

View Audit 380780

Finding 1168716 (2025-001)

Material Weakness 2025

City of Raleigh

NC

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2025-001, Significant Deficiency – Reporting - ERA Corrective Action Plan: Goal: To ensure required reporting to grantors has a defined review process including a preparer, reviewer and an approver to validate accuracy and compliance with data and information submitted to maintain compliance...

Finding 2025-001, Significant Deficiency – Reporting - ERA Corrective Action Plan: Goal: To ensure required reporting to grantors has a defined review process including a preparer, reviewer and an approver to validate accuracy and compliance with data and information submitted to maintain compliance with federal requirements. Plan: Staff is finalizing a formal written review policy which includes compliance components such as timely draft circulation, an independent review, checklists and documented approvals. Once the policy is finalized, training will be provided to staff on the new requirements to ensure consistent application across all grantor reporting cycles. Responsible Party: Housing and Community Development Timeframe: All elements of the Corrective Action Plan will be implemented by March 31, 2026.

View Audit 380751

Finding 1168705 (2025-002)

Material Weakness 2025

Casper Community College District

WY

Questioned Costs Student Financial Aid Reporting § 200.208 § 200.339

2025-002: Student Financial Audit Cluster - Reporting (Significant Deficiency) Corrective Action: The College has taken the following actions to implement the required additional control and ensure accurate tuition and fees reporting in the FISAP. • Systemic Data Isolation Control: The College has c...

2025-002: Student Financial Audit Cluster - Reporting (Significant Deficiency) Corrective Action: The College has taken the following actions to implement the required additional control and ensure accurate tuition and fees reporting in the FISAP. • Systemic Data Isolation Control: The College has collaborated with its Institutional Research and Business Office staff to develop and implement a new report or query within the Student Information System (SIS). – This new control will automatically isolate and extract tuition and fees revenue only for students who meet the Section D criteria (regular students enrolled in credit-bearing classes). – This ensures that non-eligible tuition (e.g., non-credit, high school) is systematically excluded from the FISAP input data. • Segregation of Duties and Dual Review: The process for FISAP preparation has been revised to include a required dual-review step: – The Financial Aid Office will prepare the draft FISAP data using the new controlled data isolation report. – The Controller will perform a mandatory secondary verification of the total tuition and fee revenue reported in Part II, Section E, against the specific data extracted by the new systemic report. • Training and Procedure Documentation: Financial Aid and Business Office staff involved in the reporting process have been trained on the updated FISAP instructions and the mandatory use of the new systemic control to calculate Section E tuition and fees. The new control procedure has been documented in the College’s official FISAP preparation manual. Each different entity has the detailed instructions from the FISAP information. Anticipated Completion Date: 9/30/2025 Contact Person: Joyce Lubeck-Sonenberg

View Audit 380705

Finding 1168662 (2025-001)

Material Weakness 2025

Sullivan Community Unit School District 300

IL

Questioned Costs Reporting School Nutrition Programs

Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will conduct a documented review of monthly claim reports.

View Audit 380636

Finding 1168655 (2025-005)

Material Weakness 2025

Village of Beverly Hills

MI

Questioned Costs Allowable Costs / Cost Principles Material Weakness

2025-005 - Material Weakness and Material Noncompliance - Allowable Costs Condition: Federal revenues and expenses reported on the Schedule of Expenditures of Federal Awards should only include eligible expenses that occurred within the current fiscal year. Corrective Action Plan: The Village experi...

2025-005 - Material Weakness and Material Noncompliance - Allowable Costs Condition: Federal revenues and expenses reported on the Schedule of Expenditures of Federal Awards should only include eligible expenses that occurred within the current fiscal year. Corrective Action Plan: The Village experienced some staff turnover in the prior fiscal year. In addition, the Village has not historically been subject to single audits, which created some challenges with the preparation of the Schedule of Expenditures of Federal Awards. Going forward, the Village has a better understanding of the requirements for completing the Schedule.

View Audit 380616

Finding 1168641 (2025-002)

Material Weakness 2025

Associates for Human Services, Inc.

MA

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

Recommendation: Management should reinforce the requirement for supervisor approval of all timecards prior to payroll processing. This should include training for supervisors and payroll staff on federal timekeeping requirements and implementation of system controls or checklists to ensure approvals...

Recommendation: Management should reinforce the requirement for supervisor approval of all timecards prior to payroll processing. This should include training for supervisors and payroll staff on federal timekeeping requirements and implementation of system controls or checklists to ensure approvals are documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reinforce supervisor approval of all timecards prior to payroll processing. Name(s) of the contact person(s) responsible for corrective action: Judy Thomas, CFO Planned completion date for corrective action plan: June 2026

View Audit 380595

Finding 1168593 (2025-001)

Material Weakness 2025

McPhs University

MA

Student Financial Aid Questioned Costs Special Tests & Provisions

Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Condition Enrollment information, including the effective date of separation from the institution, must be accurately rep...

Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Condition Enrollment information, including the effective date of separation from the institution, must be accurately reported to NSLDS within 30 days whenever attendance changes for a student, unless a roster will be submitted within 60 days. May 2025 graduates were reported to NSLDS outside of the maximum 60-day window. Corrective Actions Ellucian has since released a patch to address the known defect, and it has been successfully deployed by the University. Additionally, the University will continue to monitor subsequent submissions to NSC where errors were initially noted, to ensure status changes have been transmitted by the NSC in a timely manner to NSLDS. Responsible Official: Taylor Horner, University Registrar Completion Date: August 2025

View Audit 380486

Finding 1168589 (2025-006)

Material Weakness 2025

City of Detroit, Michigan

MI

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

Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the program...

Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the programs in a manner that did not align with the allocation methodology outlined in the 2022–2023 cost allocation plan submitted to MDHHS. Furthermore, the plan lacked explicit certification and contained minor errors and omissions. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Regina Greear Terri Daniels Anticipated completion date: July 2026 Planned Corrective Action: Upon identification, the City worked with the Michigan Department of Health and Human Services (MDHHS) and obtained approval and acceptance of the indirect cost calculation. The City will continue to work with MDHHS to ensure full compliance. The City has initiated a review of its indirect cost allocation methodology to ensure compliance. Management is updating the cost allocation calculation to document the approved allocation method and ensure the method is in accordance with the approved plan. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements.

View Audit 380442

Finding 1168587 (2025-005)

Material Weakness 2025

City of Detroit, Michigan

MI

Subrecipient Monitoring Questioned Costs Cash Management § 200.303 § 200.305

Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specif...

Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specifically for payments made to subrecipients. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Denise Fair Razo Regina Greear Terri Daniels Anticipated completion date: March 2026 Planned Corrective Action: The three payments made were paid one to two days after the 30 day reimbursement requirement. The City will review its subrecipient payment terms and implement additional processes to help ensure compliance with federal payment requirements.

View Audit 380442

Finding 1168586 (2025-004)

Material Weakness 2025

City of Detroit, Michigan

MI

Internal Control / Segregation of Duties Eligibility Questioned Costs § 200.303

Finding Number 2025-004 Federal Program, Assistance Listing Number and Name: ALN 14.239, Department of Housing and Urban Development, Home Investment Partnerships Program Condition: Original Finding Description: The City lacked adequate controls to ensure annual reviews were conducted in accordance ...

Finding Number 2025-004 Federal Program, Assistance Listing Number and Name: ALN 14.239, Department of Housing and Urban Development, Home Investment Partnerships Program Condition: Original Finding Description: The City lacked adequate controls to ensure annual reviews were conducted in accordance with its policy, limiting its ability to exercise proper oversight of eligibility determinations performed by the program’s contractor. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Julie Schneider Anticipated completion date: July 2025 Planned Corrective Action: This finding is timing related and was resolved by the City during fiscal year. The City reviewed and updated its policies and procedures to help ensure proper segregation of duties and proper oversight of eligibility determination. Additional processes now have independent review of inspections after the program’s contractor to further support program compliance. Review responsibilities were put in place to help ensure determinations receive an independent secondary review by City staff. These changes were in place by year-end. The City will continue to monitor the program and review procedures to ensure continued compliance and to prevent the recurrence of similar timing-related issues. The City will continue to monitor the program and review procedures to ensure continued compliance and to prevent the recurrence of similar timing-related issues.

View Audit 380442

Finding 1168582 (2025-003)

Material Weakness 2025

City of Detroit, Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Questioned Costs § 200.303

Finding Number: 2025-003 Federal Program, Assistance Listing Number and Name: ALN 14.239, Department of Housing and Urban Development (HUD), Home Investment Partnerships Program Condition: Original Finding Description: The requirements mandate that units be inspected, deficiencies communicated, and ...

Finding Number: 2025-003 Federal Program, Assistance Listing Number and Name: ALN 14.239, Department of Housing and Urban Development (HUD), Home Investment Partnerships Program Condition: Original Finding Description: The requirements mandate that units be inspected, deficiencies communicated, and corrective actions taken promptly. However, controls over housing quality standards are not effectively designed, reflecting a persistent lack of segregation of duties necessary to ensure compliance. Furthermore, existing controls were insufficient to guarantee that HQS inspection requirements were met and that identified deficiencies were addressed in a timely manner. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Julie Schneider Anticipated completion date: July 2025 Planned Corrective Action: During the fiscal year, the City reviewed and enhanced its internal controls over HQS inspections to strengthen oversight and segregation of duties. Process changes were implemented to ensure that inspections, documentation of deficiencies, follow-up actions, and certifications of completion have independent review and approval. In addition, management implemented monitoring procedures to track inspection schedules to help ensure HQS requirements are met in a timely manner.While corrective actions were initiated during the fiscal year, they were not fully implemented throughout the entire period. By year-end, the controls were in place. The City will continue to monitor these controls to ensure ongoing compliance and to prevent similar issues from recurring.

View Audit 380442

Finding 1168578 (2025-003)

Material Weakness 2025

Lawrence Technological University

MI

Procurement, Suspension & Debarment Questioned Costs Significant Deficiency § 200.319

Condition: The University supported full and open competition when testing Research and Development procurement contracts but did not support rationale for utilizing the selected contractor for 12 of the 23 samples tested. The University supported full and open competition when testing Coronavirus S...

Condition: The University supported full and open competition when testing Research and Development procurement contracts but did not support rationale for utilizing the selected contractor for 12 of the 23 samples tested. The University supported full and open competition when testing Coronavirus State and Local Fiscal Recovery Funds procurement contracts but did not support rationale for utilizing the selected contractor for 5 of the 5 samples tested. Planned Corrective Action: Management will reinforce its existing procurement procedures to ensure that competitive selections are not only conducted appropriately but also consistently documented. Management will implement a standardized documentation protocol that captures the rationale, evaluation criteria, and selection process for each procurement decision. The Procurement Policy will be revised, training will be provided to relevant staff, and periodic reviews will be conducted to ensure compliance. Contact person responsible for corrective action: Luba Kagan Anticipated Completion Date: June 30, 2026

View Audit 380438

Finding 1168572 (2025-002)

Material Weakness 2025

Lawrence Technological University

MI

Equipment & Real Property Management Questioned Costs § 200.313

Condition: The University did not complete a physical inventory of the property within the last two years. Planned Corrective Action: Management will establish a formal inventory schedule that mandates physical inventory and reconciliation at least once every two years. Designated personnel will be ...

Condition: The University did not complete a physical inventory of the property within the last two years. Planned Corrective Action: Management will establish a formal inventory schedule that mandates physical inventory and reconciliation at least once every two years. Designated personnel will be assigned responsibility for executing and documenting the inventory process. Additionally, internal controls will be enhanced through periodic monitoring and reminders to ensure timely completion and proper recordkeeping. Contact person responsible for corrective action: David Dettloff, Staff Accountant Anticipated Completion Date: February 26, 2026

View Audit 380438

Finding 1168544 (2025-001)

Material Weakness 2025

Welsh Mountain Health Centers, INC

PA

Questioned Costs

We agree and plan to address this with improved processes, procedures, and training.

View Audit 380429

Finding 1168543 (2025-003)

Material Weakness 2025

Towner County Hospital Authority

ND

Special Tests & Provisions Questioned Costs Significant Deficiency § 200.303

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Nome: Community Facilities Loans andGrants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the program reserve fund. Corrective Action Plan: Management w...

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Nome: Community Facilities Loans andGrants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the program reserve fund. Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliationfor the program's reserve fund is completed with formal documentation notingthe review. The CFO will reconcile the bank statement and will sign off on the bank statement, alongwith the CEO for the reserve accounts. Responsible Individuals: Tammy Larson, CFO Anticipated Completion Date: January 1, 2026

View Audit 380424

Finding 1168533 (2025-001)

Material Weakness 2025

Maple-Claremont, Inc.

NY

Questioned Costs HUD Housing Programs

Finding 2025-001, The federal program 14.181 requires that all receipts of the project shall be deposited in the name of the project in a bank, and the funds must be used exclusively for the benefit of the project Condition and Context: Resident rents collected by the Sponsor were not transferred to...

Finding 2025-001, The federal program 14.181 requires that all receipts of the project shall be deposited in the name of the project in a bank, and the funds must be used exclusively for the benefit of the project Condition and Context: Resident rents collected by the Sponsor were not transferred to the Organization monthly. Persons Responsible: Irene Math, CFO and WJCS staff member (to be determined) Management acknowledges the finding and confirms that corrective measures are being implemented to ensure compliance. - A catch-up adjustment will be made to transfer previously unremitted resident rents to the Organization. - Monthly transfers of resident rent collections will be established. - The Financial Close and Compliance Checklist for Maple-Claremont has been updated to include this process, ensuring that transfers are reconciled and reviewed quarterly. - Staff training has been initiated to reinforce awareness of HUD compliance requirements and the importance of timely and accurate fund transfers. Management is committed to maintaining full compliance with HUD regulations under Program 14.181. The implemented procedures are designed to prevent recurrence and ensure that all project receipts are properly deposited and used exclusively for the benefit of the project. Management will continue to monitor this process and make adjustments as necessary, especially during annual contract renewals. Estimated completion date: February 2026

View Audit 380384

Finding 1168469 (2025-002)

Material Weakness 2025

Town of Amite City

LA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.318

All payments to contractors and vendors for the Water Sector Program are reviewed and approved by the outside consulting firm prior to payment. The outside consultant directs the Clerk as to the amount to pay and who to pay. The outside consultant acknowledged that they made the error in instructing...

All payments to contractors and vendors for the Water Sector Program are reviewed and approved by the outside consulting firm prior to payment. The outside consultant directs the Clerk as to the amount to pay and who to pay. The outside consultant acknowledged that they made the error in instructing the Town to make the payment. The State of Louisiana was contacted by the outside consultant to discuss the corrective action plan. The State advised the consultant to not make any corrections to the pay request that they would “bagout” the overpayment. Before the next pay request, the contractor returned the overpayment which was deposited into the Town’s Water Sector grant bank account.

View Audit 380288

Finding 1168390 (2025-001)

Material Weakness 2025

The Conservation Innovation Fund

DC

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.430

CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented a system for documenting time and effort in a manner that complies with Federal requirements w...

CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented a system for documenting time and effort in a manner that complies with Federal requirements which involves timesheets that record actual time spent on a funding source and are accompanied by supervisory approvals. This system has been formally documented in the FY 26 update to the CIF Financial Policy and includes annual training for staff responsible for managing payroll allocations and Federal reporting. Charges to Federal awards for salaries and wages are now based on records that accurately reflect the work performed. The records are supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The records support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity.

View Audit 380212

Finding 1168368 (2025-006)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During ...

Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC conducted quarterly internal audit reviews of fifty (50) samples self-pay patients to review for sliding fee discount determination. However, we noted that the findings or exceptions identified in the quarterly internal audit review remained uncorrected. Recommendation: We recommend that LBUCC establish a process for communicating, investigating and correcting all internal audit findings or exceptions on a timely manner. Additionally, we recommend that management identify the potential cause of such findings or exceptions and that necessary corrective actions be taken to address such cause. For example, LBUCC may conduct periodic training of all employees involved in the patient intake and screening process. Action Taken: The internal audit process has been redesigned and expanded to include weekly reviews and all exceptions/errors will be corrected and the cause determined. Additional training will be provided with the expectation that the exceptions/errors will reduce going forward. Effectivity Date: This will be fully implemented by 1/31/2026

View Audit 380161

Finding 1168365 (2025-005)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.430

Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 Dur...

Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC charged salaries to the Section 330 grant based on pre-determined allocations or budget rather than actual hours worked. LBUCC utilized timesheets that reflect the allocations as its time and effort documentation. Recommendation: We recommend that LBUCC implement a time and effort reporting system that tracks actual hours worked on each program or grant. We recommend that they require supervisors to review and approve the actual time spent on grant activities and that such review and approval be documented. Action Taken: LBUCC will implement a time and effort reporting system to include a semi-annual certification for all employees funded by the HRSA 330 grant and a time card reporting system for those funded by multiple grants. Effectivity Date: Time and effort reporting will be implemented in January 2026 and fully in place by 1/31/2026

View Audit 380161

Finding 1168356 (2025-002)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Special Tests & Provisions Questioned Costs Cash Management

Material Weakness Item 2025-002 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our a...

Material Weakness Item 2025-002 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our audit, we noted that LBUCC did not properly determine the sliding fee discount provided to certain eligible patients based on information provided during the patient registration process. Additionally, we could not ascertain if the sliding fee discount provided to certain eligible patients were correct as LBUCC did not maintain documentation of the proof of income of those eligible patients. Recommendation: We recommend that LBUCC conduct training of all of its personnel who are involved in determining and applying the sliding fee scale of patients. We also recommend LBUCC to maintain complete and auditable documentation supporting each patient's eligibility for sliding fee discount. Action Taken: Eligibility was provided additional training which included training on a tool to assist them in determining the proper sliding fee discount. Effectivity Date: Training was held on October 28, 2025, and the tool to assist them was reviewed and provided at that time and implemented immediately thereafter.

View Audit 380161

Finding 1168335 (2025-001)

Material Weakness 2025

Bishop (csi) Non-Profit Housing Corporation

MI

HUD Housing Programs Questioned Costs Procurement, Suspension & Debarment

Name of auditee: Bishop (CSI) Non-Profit Housing Corporation HUD auditee identification number: 044-11134 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Anne Sackrison Position: Chief Executive Officer Telephone number: 5...

Name of auditee: Bishop (CSI) Non-Profit Housing Corporation HUD auditee identification number: 044-11134 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Anne Sackrison Position: Chief Executive Officer Telephone number: 586-753-9052 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding #2025-001: Effective May 1, 2025, the required monthly deposit to the reserve for replacements increased from $12,539 to $63,106 based on the capital needs assessment and replacement reserve analysis. The Corporation did not increase the monthly deposits and as of June 30, 2025, the reserve for replacements account is underfunded by $99,135. Comments on the Finding and Each Recommendation: Management should transfer $99,135 from the operating account in order to bring the reserve for replacements account current. Action(s) taken or planned on the finding: Agreed. On July 1, 2025, management transferred $99,135 to the reserve for replacements account.

View Audit 380148

Finding 1168323 (2025-001)

Material Weakness 2025

Navarro College District

TX

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs

Corrective Action Plan 1. Implement Automated Notifications (New and Long-Term Solutions) The institution will establish a two-phase approach to ensure timely and compliant Title IV disbursement notifications. New Process: A weekly report will be generated for Title IV loan disbursements with the co...

Corrective Action Plan 1. Implement Automated Notifications (New and Long-Term Solutions) The institution will establish a two-phase approach to ensure timely and compliant Title IV disbursement notifications. New Process: A weekly report will be generated for Title IV loan disbursements with the corresponding notifications sent to students. Financial aid staff will review the report to confirm that each required notification was issued within the regulatory timeframe. Any missing notifications will be immediately sent and documented. This interim process will remain in effect until full automation is implemented. Long-Term Automated Solution: The student information system will be configured to automatically generate and send Title IV disbursement notifications to students. Each notification will be sent no earlier than 30 days before, and no later than 30 days after, the crediting of Title IV loan funds to the student’s ledger account, as required by 34 CFR §668.165(a)(2). The system will also store a timestamped record of each notification in the student’s electronic file for audit and compliance verification. 2. Develop Written Procedures A formal institutional policy and procedural guide will be developed to define the timing, content, and method of Title IV disbursement notifications. This documentation will explicitly address regulatory requirements under 34 CFR §668.165(a) and outline staff responsibilities for monitoring and documentation. 3. Staff Training Financial Aid staff will receive training on the new automated notification process, including policy updates, system functionality, and documentation requirements. Completion of training will be tracked to ensure all relevant personnel are fully informed and able to implement the new procedures consistently. 4. Periodic Compliance Reviews Quarterly internal audits will be conducted to confirm that required notifications are being issued as scheduled and properly documented in each student’s record. Any discrepancies identified will result in immediate corrective measures and additional staff coaching as needed. Responsible Party Director of Financial Aid Timeline for Completion - New System Implementation: Immediate - Long-Term Solution: Work with software provider and IT for options to implement this process - Policy Documentation & Staff Training: Within 90 days - First Compliance Review: Within 90 days

View Audit 380118

Finding 1168316 (2025-001)

Material Weakness 2025

Episcopal Community Services of San Francisco

CA

Subrecipient Monitoring Eligibility Reporting

Significant Deficiency Finding: 2025-001 Certification of Tenants Criteria and Condition The grant agreement requires ECS to (1) maintain complete tenant files in the San Francisco HMIS ONE System with hard-copy eligibility documents; (2) apply changes to tenant rent portions based on City and Count...

Significant Deficiency Finding: 2025-001 Certification of Tenants Criteria and Condition The grant agreement requires ECS to (1) maintain complete tenant files in the San Francisco HMIS ONE System with hard-copy eligibility documents; (2) apply changes to tenant rent portions based on City and County of San Francisco Department of Homelessness and Supporting Housing (HSH) notifications; and (3) perform required initial, annual, and interim recertifications under the Housing First program model. We noted instances where tenant files did not contain complete eligibility documentation and/or where required recertifications or updates to tenant rent portions were not performed or documented in accordance with the grant requirements. Context ECS provides rental assistance under the program described in Appendix A-2, which requires full documentation of tenant eligibility and strict adherence to rent-portion updates and recertification timelines. Of our 31 selections, we noted 6 instances where homelessness verification was missing, 6 instances where the rent portions based on HSH notifications were incorrect and 10 instances where the recertifications were not completed for the grant period under audit. Questioned Cost There are no questioned costs regarding this finding. Cause The exceptions result from inconsistent file maintenance and monitoring procedures, including insufficient review over documentation completeness and timeliness of recertifications. The issues were centered on tenant files managed by a third-party service provider. Effect Incomplete tenant files and untimely recertifications increase the risk of noncompliance with grant requirements and may result in incorrect tenant rent portions being charged or insufficient support for program eligibility. Repeat Finding This finding is not a repeat finding. Recommendation We recommend that ECS enhance its documentation and monitoring processes with its third-party property managers by implementing a standardized tenant file checklist, conducting periodic supervisory reviews to confirm that all eligibility documents and recertifications are completed and retained, and establishing a tracking process to ensure tenant rent portions are updated promptly based on HSH notifications. View of responsible officials Management agrees with the recommendation. Corrective Action Planned ECS has taken and will continue to take the following steps in the 2026 fiscal year to correct this deficiency. Step 1: Resources ECS began addressing Certificate of Tenancy errors with the hiring an Associate Chief of Real Estate and Asset Management in August, a Director of Property Management in October and a Property Management Compliance Manager in September. Step 2: Best Practices ECS has hired a consulting firm to correct Certificate of Tenancy errors at its one of its sites and will apply the best practices learned to all the affiliate and master lease sites. In addition, ECS has put together policies and procedures and has offered training to both ECS and subcontracted staff on Certificate of Tenancy. ECS will continue to offer compliance training as it takes over property management across all Master Lease sites and the affiliate portfolio. Step 3: Take control of property management Replace outsourced property management with ECS staff to better control Tenant documentation at all master lease and affiliate sites. Step 4: Quality and Compliance ECS has started in a few sites to review Tenant documentation and will expand this review to all sites across its entire portfolio. Implementation Date ECS will fully correct Certificate of Tenancy errors by June 30, 2026. Responsible Personnel The Chief Operating Officer and the Associate Chief of Real Estate and Asset Management.

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