Corrective Action Plans

Finding 1159414 (2024-002)

Material Weakness 2024

OH

Questioned Costs Reporting

Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. ...

Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Additionally, the Organization will implement policies and procedures surrounding file retention of the underlying data that supports federal reports submitted. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Angelita Thomas, Chief Financial Officer

View Audit 370139

Finding 1159411 (2024-001)

Material Weakness 2024

Center for Asbestos Related Disease

MT

Reporting Questioned Costs § 200.516

Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm...

Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Rudd & Company, PLLC 3805 Valley Commons Drive, Ste. 7 Bozeman, MT 59718 Audit Period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below: Federal Award Findings and Questioned Costs Finding 2024-001 Department of Health and Human Services Libby, Montana’s Public Health Emergency, Asbestos Health Screening, CFDA #93.534 5NU61TS000295-05 Finding Summary: Final Financial report for the grant period end was not submitted by the due date. Responsible Individuals: Executive Director, Tracy McNew and Financial Officer, Janine Price Corrective Action Plan: Management has added all report due dates to their calendars beginning two weeks before the due dates to ensure reports are filed in a timely manner even if difficulties are encountered with the filing process. In addition, case numbers with PMS’s help desk will be recorded and other communications will be saved to ensure that proper documentation is maintained for any reports rejected and refiled at a later date. Anticipated Completion Date: Ongoing

View Audit 370138

Finding 1159410 (2024-001)

Material Weakness 2024

Grady Memorial Hospital Corporation

GA

Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.303

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting

View Audit 370132

Finding 1159406 (2024-008)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, Nati...

Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, National Science Foundation, Department of Veteran Affairs, Environment Protection Agency, Department of Energy, Department of Health and Human Services, U.S. Agency for International Development Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. Due to a system failure, vendor payment files from January through September 2024 were not transmitted to Mount Sinai’s sanction screening vendor. Mount Sinai has taken corrective actions to address this issue. All current vendors in our vendor master file, as well as all new vendors added through our new vendor credentialing process, are now processed through our sanction screening vendor on a monthly basis. In addition, a new manual control has been implemented to review, confirm, and reconcile to ensure that the vendor master file has been transmitted successfully, and all vendors are screened for sanctions, and a report thereof is provided each month. Our process will also document and maintain evidence that unverified vendors or those that were indicated as excluded were investigated and evaluated by the Health System. We will also periodically perform independent sanction screening checks on a sample of our vendors to validate the accuracy of the results of our third-party sanction screening vendor. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: Our vendor credentialing process was establishing with our ERP implementation on October 7, 2024. Our enhanced procedures to reconcile our file transmissions to our independent third-party and perform screening checks on samples of vendors verified by our independent third-party is expected to be implemented by December 31, 2025.

View Audit 370128 Questioned Costs: $1

Finding 1158856 (2024-007)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Questioned Costs Procurement, Suspension & Debarment

Finding 2024-007 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, Nati...

Finding 2024-007 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, National Science Foundation, Department of Veteran Affairs, Environment Protection Agency, Department of Energy, Department of Health and Human Services, U.S. Agency for International Development Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. In October 2024, Mount Sinai transitioned to Oracle Cloud for its Enterprise Resource Planning (ERP) and general ledger system. During this transition, Deputy Buyer transactions of $10,000 and above were not routed to the Purchasing Team for review, allowing purchase orders to be completed without the required documentation, including Sole Source Justifications, Directed Source Justifications, or multiple quotes as required under Uniform Guidance. Corrective actions, including a system enhancement, have been implemented to remediate this issue. Mount Sinai’s enhanced process ensures Deputy Buyer transactions of $10,000 and above are routed appropriately to the Purchasing Team for validation and documentation review. In addition, a quarterly manual review process, supported by reports developed in partnership with Mount Sinai’s technology team, will be fully implemented as a compensating control in the fourth quarter of 2025. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: Our enhanced procedures for ensuring the necessary documentation is completed on Deputy Buyer transactions of $10,000 and above is expected to be implemented by December 31, 2025.

View Audit 370128 Questioned Costs: $1

Finding 1158306 (2024-006)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not c...

Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not correctly populated. Management has since corrected the data and submitted a revised FISAP. Management notes there was turnover in the PSON’s Office of Student Financial Aid during the year and an employee was not properly trained on the FISAP preparation. Training has since been implemented and new employees in the department will be trained accordingly. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158301 (2024-005)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Questioned Costs

Finding 2024-005 N. Special Tests and Provisions - Disbursement to or on Behalf of Students Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective ac...

Finding 2024-005 N. Special Tests and Provisions - Disbursement to or on Behalf of Students Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that certain credit refunds were not issued timely. PSON and ISMMS’ Offices of Student Financial will implement a control that ensures communication related to refunds is enhanced when a student withdraws. ISMMS has ensured compliance with the Department of Education’s 14-day credit balance requirement by contracting with Nelnet, an external financial management vendor, to administer the credit refund process, supported by ongoing monitoring and periodic internal reviews. The control will ensure that all credit refunds are issued timely. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org LaVerne Walker Director of Student Financial Services, Icahn School of Medicine at Mount Sinai Laverne.walker@mssm.edu Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158291 (2024-003)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Questioned Costs

Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees wit...

Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON’s Office of Student Financial Aid will implement a process that ensures all required documentation is retained. Employees of the Student Financial Aid Office will be trained and PSON will be in compliance with the requirements in the Federal Student Aid Handbook. Name of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158252 (2024-004)

Material Weakness 2024

Providence St. Joseph Health

WA

Questioned Costs Reporting Special Tests & Provisions

Management acknowledges the audit finding regarding deficiencies in the reporting of student status changes to COD. These discrepancies were primarily due to limitations in our staffing and review procedures. We are revising our enrollment reporting policies to clearly define roles, responsibilities...

Management acknowledges the audit finding regarding deficiencies in the reporting of student status changes to COD. These discrepancies were primarily due to limitations in our staffing and review procedures. We are revising our enrollment reporting policies to clearly define roles, responsibilities, and timelines for processing student status changes. This includes an additional layer of review to verify the accuracy of effective dates prior to COD submission. These additional policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158250 (2024-003)

Material Weakness 2024

Providence St. Joseph Health

WA

Subrecipient Monitoring Questioned Costs

Management acknowledges the findings related to compliance with GLBA requirements. The missing elements were primarily due to existing policies and procedures not specifically covering the information technology system utilized by the School of Nursing. Management will update their information techn...

Management acknowledges the findings related to compliance with GLBA requirements. The missing elements were primarily due to existing policies and procedures not specifically covering the information technology system utilized by the School of Nursing. Management will update their information technology policies and procedures to ensure full compliance with the 7 required elements outlined by the GLBA. This will include updating risk assessment procedures, designing safeguards based on risk assessments procedures, monitoring these safeguards, and documenting the results. These policy and procedure updates will be implemented by December 31, 2025.

View Audit 370126

Finding 1158248 (2024-002)

Material Weakness 2024

Providence St. Joseph Health

WA

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

Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying an...

Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying and documenting disbursement and enrollment dates, academic year parameters, and cost of attendance calculations prior to COD submission. This will include additional layers of review to ensure timely and accurate reporting. These policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158246 (2024-001)

Material Weakness 2024

Providence St. Joseph Health

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158233 (2024-001)

Material Weakness 2024

Hawaii Public Health Institute

HI

Subrecipient Monitoring Questioned Costs Reporting

Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the sub...

Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the subrecipient's name, subaward date, and subaward amount on SAM.gov website prior to the completion of this federal grant, which ended on June 30, 2025. The funder confirmed receipt of our reporting and did not specify any implications for late submission. As recommended by the auditors, HIPHI has developed a process to help identify the subawards subject to the FFATA reporting requirements prior to the start of the grant, and to ensure that reporting is reviewed, approved for completeness and accuracy, and filed in a timely manner. The Director of Finance, Finance and Accounting Manager, Program Managers and contract signers will be responsible for implementing these corrective actions by the end of 2025.

View Audit 370124

Finding 1158231 (2024-002)

Material Weakness 2024

New York College of Traditional Chinese Medicine

NY

Questioned Costs Student Financial Aid Special Tests & Provisions

Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balan...

Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balance Authorization Form was on file, the refund was processed after the award year had ended, rather than within the required timeframe. In the past, students were always allowed to keep funds in their Populi accounts for future use regardless of the loan award year, and it had not previously been indicated that this practice was not allowed. Actions Taken or Planned: We have reviewed our internal procedures and will strengthen oversight of award year deadlines to ensure that all credit balances are refunded within the required timeframe. Moving forward, the financial aid and accounting teams will implement a compliance checklist and establish calendar reminders to prevent similar delays. Additionally, we will revise the wording on our Credit Balance Authorization Form to read: “Leave the funds in my account and any remaining funds from the current award year in my account up to the end of the loan period.” Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu

View Audit 370123 Questioned Costs: $1

Finding 1158227 (2024-002)

Material Weakness 2024

Native Sun Community Power Development

MN

Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking § 200.303

Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to b...

Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to be Completed by October 1, 2025

View Audit 370119

Finding 1158226 (2024-001)

Material Weakness 2024

Native Sun Community Power Development

MN

Allowable Costs / Cost Principles Questioned Costs § 200.303

Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of nonc...

Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of noncompliance since using this platform. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: Done ‐ July 31, 2024

View Audit 370119

Finding 1158225 (2024-004)

Material Weakness 2024

St Bernard Parish Government

LA

Questioned Costs Procurement, Suspension & Debarment

Name of contact person responsible for corrective action plan: Justin Frank Corrective action planned: The Parish will review all policies and procedures to ensure that proper internal controls are in place, with an emphasis on Federal procurement guidelines. Anticipated Completion Date: December 31...

Name of contact person responsible for corrective action plan: Justin Frank Corrective action planned: The Parish will review all policies and procedures to ensure that proper internal controls are in place, with an emphasis on Federal procurement guidelines. Anticipated Completion Date: December 31, 2025

View Audit 370116 Questioned Costs: $1

Finding 1158222 (2024-004)

Material Weakness 2024

The Family Place

TX

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.320

Auditor’s Recommendation: “We recommend management implement internal controls to ensure ﬁnancial reports are submitted accurately, with supporting documentation retained.” Management response: The Family Place has reviewed its ﬁnancial reporting procedures and concurs with the ﬁnding. During the au...

Auditor’s Recommendation: “We recommend management implement internal controls to ensure ﬁnancial reports are submitted accurately, with supporting documentation retained.” Management response: The Family Place has reviewed its ﬁnancial reporting procedures and concurs with the ﬁnding. During the audit period, staffing deﬁciencies in grants management and compliance oversight contributed to supporting documentation of ﬁnancial reports submitted not having been retained. In 2025, The Family Place created a new internal compliance department and hired a Grants Manager to provide dedicated oversight of grant drawdowns and reporting. These changes, together with updated procedures and training, are designed to ensure all future ﬁnancial reports comply with Uniform Guidance requirements and supporting documentation is retained. Corrective actions: The Executive Leadership Team has prioritized strengthening reporting controls and has already implemented several measures: The newly hired Grants Manager and internal compliance department are responsible for reviewing and approving all ﬁnancial reports to conﬁrm that expenditures have been incurred and liquidated prior to request. Finance sta􀀁 and program managers are being trained on reporting requirements under 2 CFR 200.320. All ﬁnancial reports will be reconciled to the general ledger with supporting documentation and will be reviewed by the Grants Manager and The Chief Financial Officer or Chief Executive Officer before submission. These processes will receive additional oversight by the Chief Financial Officer, the Chief Executive Officer, and the Board of Trustees. Responsible parties for corrective actions: The Grants Manager, working within the internal compliance department, will have direct responsibility for ensuring ﬁnancial reports are accurate and supporting documentation is retained. The Chief Financial Officer will review and approve reconciliations prior to drawdown. The Chief Executive Officer, Tiffany A. Tate, with assistance from the newly established Compliance Department, will conﬁrm timely compliance and will receive regular status updates. Separately, the Chief Financial Officer will report progress to the Audit & Finance Committee of the Board of Trustees. Anticipated completion date: The new internal compliance department and Grants Manager began operating together in September 2025. Full compliance monitoring is currently in place.

View Audit 370113

Finding 1158217 (2024-002)

Material Weakness 2024

The Family Place

TX

Procurement, Suspension & Debarment Cash Management Reporting § 200.303

Auditor’s Recommendation: “We recommend management ensure sufficient staffing and oversight to abide by internal processes and procedures which require prior approval of expenditures and reports prior to drawdown or submission.” Management response: The Family Place has reviewed its award compliance...

Auditor’s Recommendation: “We recommend management ensure sufficient staffing and oversight to abide by internal processes and procedures which require prior approval of expenditures and reports prior to drawdown or submission.” Management response: The Family Place has reviewed its award compliance procedures and concurs with the ﬁnding. During the period, responsible departments—including the ﬁnance and accounting and human resources teams—experienced unexpected turnover, a signiﬁcant shortage of staffing, and a time reporting system conversion. As a result, certain compliance procedures were not performed consistently and timely, resulting in unintentional noncompliance with respect to allowable costs, cash management, and reporting controls. Corrective actions: The Executive Leadership Team reviewed the staffing needs of the ﬁnance and accounting and human resources teams in 2024. Hiring and training staff to achieve a full team was established as key objectives for the Executive Leadership Team in early 2025. As of September 2025, all vacant positions in both teams have either been ﬁlled or have been posted and are in active hiring process. The Chief Financial Officer and Chief of Human Resources have reviewed all internal procedures related to award compliance and will ensure that compliance is timely and well documented going forward. Speciﬁcally, the Chief Financial Officer will ensure that purchase orders, invoices, ﬁnancial reports, and performance reports are completed, reviewed, and approved prior to submission and funding. These processes will have additional oversight by the Chief Executive Officer, with assistance from the newly established Compliance Department, and the Board of Trustees. Responsible parties for corrective actions: The Chief Financial Officer will have direct responsibility for award compliance and will be supported by Chief of Human Resources. The Chief Executive Officer, Tiffany A. Tate, with assistance from the newly established Compliance Department, will conﬁrm that compliance occurs on a timely basis and prior to submission and funding. Separately, the Chief Financial Officer will report on progress to the Audit & Finance Committee of the Board of Trustees. The Executive Leadership Team will be responsible for ensuring the ﬁnance and accounting and human resources teams achieve and maintain full staffing levels. Anticipated completion date: The organization is actively implementing the corrective actions by ensuring sufficient staffing as mentioned above and training to ensure prior approval of all grant reports and drawdown requests. As of October 1, 2025, all grant reports will be appropriately approved and documented as such.

View Audit 370113

Finding 1158212 (2024-003)

Material Weakness 2024

Jesuit Refugee Service/usa, INC

DC

Reporting Questioned Costs

Finding Tax Disclosure Submission. Per the grant agreements to the above awards section 19 Reporting Taxes on Foreign Assistance Funds. The Recipient is required to submit a report detailing foreign taxes assessed under this award during the prior U.S. Government fiscal year (10/01 - 09/30). The rep...

Finding Tax Disclosure Submission. Per the grant agreements to the above awards section 19 Reporting Taxes on Foreign Assistance Funds. The Recipient is required to submit a report detailing foreign taxes assessed under this award during the prior U.S. Government fiscal year (10/01 - 09/30). The report must be submitted to the Grants Officer on an annual basis by February 15. Management had processes in place to submit each tax report on a timely basis; however these processes did not occur. Grant countries impacted: Cameroon, South Sudan, Uganda, Ethiopia, Iraq, and Thailand. Corrective Action Plan Management concurs with the findings. Although internal procedures for timely submission of the foreign tax reports were previously in place, the organization experienced significant turnover in key management positions during the reporting period. This transition disrupted the continuity of compliance processes and led to failure to meet the tax disclosure reporting deadlines. To prevent recurrence of this compliance lapse, JRS/USA is taking the following corrective measures: 1. Formalized Tax Reporting SOP A formal Standard Operating Procedure (SOP) will be developed for the Foreign Tax Disclosure Reporting Process, outlining: a) Roles and responsibilities (JRS/USA and country offices) b) Required data sources c) Timeline for data collection and submission d) Review and approval workflows This SOP will be distributed to all relevant compliance, finance, and grant management staff. 2. Centralized Calendar and Tracker A centralized compliance calendar and submission tracker will be implemented, incorporating the February 15 foreign tax report deadline. Automated reminders will be sent to responsible staff beginning in January each year to initiate the reporting process well in advance. 3. Designated Focal Point A single point of contact at JRS/USA has been assigned as the Tax Disclosure Focal Point, responsible for: a) Coordinating data collection from field offices b) Ensuring timely submission to the Grants Officer c) Maintaining documentation of the submission and confirmation of receipt 4. Training and Onboarding Updates Compliance and finance staff, both at JRS/USA and in the field, will be trained on the tax disclosure requirements and the new SOP. This training will also be integrated into the onboarding process for new hires in relevant roles to reduce the risk of future disruptions due to staff turnover. 5. Quarterly Internal Compliance Check-ins Although the report is submitted annually, quarterly check-ins will be held by the JRS/USA Compliance Team to review upcoming deadlines, including the tax report, to ensure ongoing visibility and proactive planning. Timeline for Implementation All corrective actions have been implemented or will be fully in effect by October 30, 2025. Responsible Party Samira Ahmed, Senior Grants and Compliance Specialist, will be responsible for overseeing the tax disclosure process and ensuring timely and accurate submissions going forward.

View Audit 370111

Finding 1158202 (2024-002)

Material Weakness 2024

National Council for Community Development, Inc.

NY

Questioned Costs Subrecipient Monitoring Reporting

Finding No. 2024-002 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-t...

Finding No. 2024-002 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-through Entity (if applicable): Nassau County Condition: During our testing, we noted that the Organization did not provide the required monthly reports to Nassau County. Recommendation: We recommend that the Organization establish policies, procedures, and controls to ensure that the required information is submitted on a timely basis. Action Taken: Management has incorporated procedures into our grant compliance and administration policies and procedures to ensure that a Project Director reviews, understands and takes the necessary steps to comply with reporting requirements or other, as set forth by the client agreements. This step includes but is not limited to the Project Director completing a Grant Award File Checklist. Anticipated completion date: Immediately.

View Audit 370110

Finding 1158192 (2024-006)

Material Weakness 2024

Atrium Health, Inc.

NC

Questioned Costs Student Financial Aid Cash Management

Corrective Action Plan: Atrium Health CMHA management in the future will ensure that all correspondence, including notes from review meetings and approvals of key decisions, will be documented and retained as part of the support records for FEMA related awards. Proposed Completion Date: No further a...

Corrective Action Plan: Atrium Health CMHA management in the future will ensure that all correspondence, including notes from review meetings and approvals of key decisions, will be documented and retained as part of the support records for FEMA related awards. Proposed Completion Date: No further action is required until future needs arise for Atrium Health CMHA to obtain FEMA funding awards at which time management will ensure all documentation supporting the process and key decisions are retained.

View Audit 370096

Finding 1158190 (2024-004)

Material Weakness 2024

Atrium Health, Inc.

NC

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

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT sys...

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

View Audit 370096

Finding 1158188 (2024-002)

Material Weakness 2024

Atrium Health, Inc.

NC

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

Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign various processes and w...

Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign various processes and work flows. This project is expected to address the gap in SFA transactional review and approval internal controls that are arising due to the SFA program size, limited number of subject matter experts, and the management turn; and result in mitigating controls and policies being implemented to ensure the accuracy and completeness of all SFA transactions. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

View Audit 370096

Finding 1158174 (2024-002)

Material Weakness 2024

Washington Tourism Alliance

WA

Questioned Costs Subrecipient Monitoring Reporting

FINDING 2024-002 – Reporting; Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance The grant contract conditions require that applicable reports be filed quarterly. State of Washington Tourism initially submitted performance reports monthly, but in Q4 of 2024 adju...

FINDING 2024-002 – Reporting; Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance The grant contract conditions require that applicable reports be filed quarterly. State of Washington Tourism initially submitted performance reports monthly, but in Q4 of 2024 adjusted the performance reports to quarterly in accordance with award agreement timeframe. The Accounting Manager will complete the report and provide documented support at the end of each quarter in the future. The reports will be reviewed, approved, and submitted by the Director of Strategic Partnership and Tourism Development. These changes took effect April 2025.

View Audit 370086

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