Corrective Action Plans

Finding 1153133 (2024-002)

Material Weakness 2024

NY

Questioned Costs

The School already has implemented a formal process to work with outside auditor to develop an appropriate time line for the completion of future audits on schedule that allows for timely filing of the Single Audit.

View Audit 366365 Questioned Costs: $1

Finding 1153132 (2024-001)

Material Weakness 2024

Career School of Ny, Inc.

NY

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

The School will put additional resources in place to ensure monthly reconciliation going forward. Anticiapted date of completion by November 2025

View Audit 366365 Questioned Costs: $1

Finding 1153131 (2024-004)

Material Weakness 2024

Cibecue Community Education Board, Inc. Dba Dishchii'bikoh Comm School

AZ

Questioned Costs Material Weakness Reporting § 200.512 § 200.520

2024-004: Reporting Type of Finding: Noncompliance, Material Weakness Condition: The School did submit their audit for the fiscal year ending June 30, 2024 timely. The audit was submitted September 15, 2025, which was 168 days past the March 31, 2025 deadline. Action planned in response to finding: ...

2024-004: Reporting Type of Finding: Noncompliance, Material Weakness Condition: The School did submit their audit for the fiscal year ending June 30, 2024 timely. The audit was submitted September 15, 2025, which was 168 days past the March 31, 2025 deadline. Action planned in response to finding: Management will implement procedures to ensure that all audit documentation, is available for the audit in a timely manner and the audit report is completed and submitted within the appropriate timeframe. Repeat Finding: Similar to prior year finding 2023-005. Planned completion date for corrective action plan: June 30, 2025 Name of the contact person responsible for corrective action: Dolores Silva, Chief Financial Officer

View Audit 366362

Finding 1153126 (2024-003)

Material Weakness 2024

Cibecue Community Education Board, Inc. Dba Dishchii'bikoh Comm School

AZ

Special Tests & Provisions Questioned Costs Material Weakness

2024-003: Special Tests and Provisions Type of Finding: Noncompliance, Material Weakness Context: For three of 20 employees tested, the School did not maintain a current and full background check and character investigation on file. Repeat Finding: Similar to prior year finding 2023-004. Action plan...

2024-003: Special Tests and Provisions Type of Finding: Noncompliance, Material Weakness Context: For three of 20 employees tested, the School did not maintain a current and full background check and character investigation on file. Repeat Finding: Similar to prior year finding 2023-004. Action planned in response to finding: Management will implement procedures to ensure that all employees have a current character investigation and background check on file. Planned completion date for corrective action plan: June 30, 2025 Name of the contact person responsible for corrective action: Dolores Silva, Chief Financial Officer

View Audit 366362

Finding 1153102 (2024-002)

Material Weakness 2024

Cascadia Behavioral Healthcare, Inc.

OR

Questioned Costs Procurement, Suspension & Debarment § 200.320

Corrective action planned – Management recognizes that procurement is a material concern of the organization both from an operational efficiency and regulatory compliance perspective. During the audited time period, procurement responsibilities were decentralized, resulting in inconsistent complianc...

Corrective action planned – Management recognizes that procurement is a material concern of the organization both from an operational efficiency and regulatory compliance perspective. During the audited time period, procurement responsibilities were decentralized, resulting in inconsistent compliance. In April 2025, Management decided to create a dedicated Procurement Department and began staffing the department. The new Procurement team is tasked with reviewing all current procurement policies and procedures, revising and creating new processes as needed, and partnering with the compliance team to monitor compliance going forward. The policy and procedure revisions will be implemented by the end of the fourth quarter of 2025. Staff will receive training by the first quarter of 2026, and after the training rollout, we will begin internal audits to ensure successful training, implementation and compliance with the new policies and procedures. Name(s) of contact person(s) responsible for corrective action – Alison Spens, Senior Director of Project Management and Procurement Anticipated completion date – August 15, 2025

View Audit 366335 Questioned Costs: $1

Finding 1153083 (2024-012)

Material Weakness 2024

Milwaukee Public Schools

WI

Questioned Costs Subrecipient Monitoring Material Weakness § 200.302 § 200.303

Finding 2024-012 – Material Weakness – Maintenance of Effort Condition The Maintenance of Effort (MOE) calculation is calculated annually by the Wisconsin Department of Public Instruction (WI DPI) based on the information submitted in the PI-1505 report. There was a $16,977,949 variance between what...

Finding 2024-012 – Material Weakness – Maintenance of Effort Condition The Maintenance of Effort (MOE) calculation is calculated annually by the Wisconsin Department of Public Instruction (WI DPI) based on the information submitted in the PI-1505 report. There was a $16,977,949 variance between what was reported in the PI-1505 and the District's accounting records for the revenue source code 751. Due to this variance, we recalculated the MOE based on the District's accounting records. The MOE on a per pupil basis would have still been met. Corrective Action Plan The Office of Finance is committed to timely and accurate financial reporting. As we aim to improve our financial reporting due to DPI, our ACFR preparation and our SEFSA preparation, we will ensure that our reporting reconciles and there are no variances. We are working to improve, as mentioned in all the findings above, related to financial reporting. We recognize that this is critical for funding purposes for our district and it is our intent that this finding is remedied for FY25 reporting. Name(s) of Contact Person(s) Responsible for Corrective Action: Chief Financial Officer Anticipated Completion: 06.30.2026

View Audit 366326

Finding 1153080 (2024-011)

Material Weakness 2024

Milwaukee Public Schools

WI

Questioned Costs Subrecipient Monitoring Cash Management

Finding 2024-011 – Material Weakness – Reporting Condition In 22 of the 25 providers tested, there were issues related to incorrectly reporting the provider’s salaries and benefits in the quarterly cost reports. • In quarters ended December 2022 and March 2023 there were 21 instances where the provi...

Finding 2024-011 – Material Weakness – Reporting Condition In 22 of the 25 providers tested, there were issues related to incorrectly reporting the provider’s salaries and benefits in the quarterly cost reports. • In quarters ended December 2022 and March 2023 there were 21 instances where the providers’ salaries and benefits were not reported even though they worked providing services to eligible students. • In quarters ended March 2023 and June 2023 there were eight instances where the providers’ salaries and benefits were overstated when compared to the District’s payroll records. Seven of the eight individuals were included in the 21 instances above that were not reported in the quarters ended December 2022 and March 2023. Corrective Action Plan Central office will be improving processes and procedures to ensure that teachers are reminded to enter their hours worked on a regular basis. Controls will be implemented for timely reviews to ensure completeness and accuracy. Training of key staff on an annual or semi-annual basis is key. It is the intent of the Office of Finance to create and implement a robust training plan in place for the summer of 2026. Name(s) of Contact Person(s) Responsible for Corrective Action: Chief Financial Officer, Central Office leadership Anticipated Completion: 06.30.26

View Audit 366326 Questioned Costs: $1

Finding 1153079 (2024-010)

Material Weakness 2024

Milwaukee Public Schools

WI

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403 § 200.430

Finding 2024-010 – Material Weakness – Allowable Costs/Cost Principles Condition The District supports time charged to federal awards via semi-annual certifications which are approved by the grant administrator or the building principal. In order for a cost to be supported at the time of final reimb...

Finding 2024-010 – Material Weakness – Allowable Costs/Cost Principles Condition The District supports time charged to federal awards via semi-annual certifications which are approved by the grant administrator or the building principal. In order for a cost to be supported at the time of final reimbursement, the semi-annual certifications should be approved by the grant administrator or the building principal. Title I Grants to Local Educational Agencies (ALN 84.010) The final reimbursement claim for the Title I Grants to Local Educational Agencies (Title I) program were due to Wisconsin Department of Public Instruction (DPI) on September 30, 2024; however, the final reimbursement claim for the Part A award was not submitted to DPI until November 18, 2024, and the CSI award was not submitted to DPI until October 1, 2024, due to an extension. Five of the 40 individuals sampled had their semi-annual certifications not approved timely and were approved after the due date of the final reimbursement claim, but before the date of the actual submission of the final reimbursement claim. An additional two individuals of the 40 sampled had their semi-annual certifications approved after the final reimbursement claims were submitted. Upon further review of all the spring semi-annual certifications for the Title I awards, there were an additional 50 individuals that had their semi-annual certifications approved by the principal after the due date of the final reimbursement claim but before the submission of the final reimbursement. Additionally, nine individuals had their semi-annual certifications approved after the final reimbursement date of the Part A award and another 59 individuals from Part A did not have their semi-annual certifications approved at all. Head Start Cluster (ALN 93.600) The final reimbursement claim for the program was submitted to the Federal agency on November 22, 2024. Four of the 40 individuals sampled had their semi-annual certifications approved by the Head Start administrator after the submission date of the final reimbursement claims. Upon further review of the all the spring semi-annual certifications, there was an additional individual that had their semi-annual certifications approved by the principal after the due date of the final reimbursement claim and another four individuals that did not have their semi-annual certifications approved at all. The samples were not statistically valid. Corrective Action Plan The Office of Finance agrees that it is important that certifications be completed in a timely manner and award reimbursements are submitted within the deadlines. The Office of Finance and the District as a whole is working on improving its internal controls system wide. We are committed to developing sound processes and procedures that are in full compliance with federal and state regulations. An example of a process improvement is to send out reminders on a regular schedule to school leaders and central office employees for programmatic compliance. These activities will be completed in advance of due dates going forward to ensure timely submission of grant claim reimbursements. Annual training for school leaders and central office staff is also part of the process improvement plan underway. Name(s) of Contact Person(s) Responsible for Corrective Action: Chief Financial Officer, State and Federal Programs Director, Comptroller, Grant Accounting Manager Anticipated Completion: 06.30.2026

View Audit 366326 Questioned Costs: $1

Finding 1153077 (2024-009)

Material Weakness 2024

Milwaukee Public Schools

WI

Allowable Costs / Cost Principles Questioned Costs § 200.303

Finding 2024-009 – Material Weakness – Allowable Costs/Cost Principles Condition The District supports time charged to federal awards via semi-annual certifications which are approved by the grant administrator or the building principal. Supporting Effective Instruction State Grants (ALN 84.367) The...

Finding 2024-009 – Material Weakness – Allowable Costs/Cost Principles Condition The District supports time charged to federal awards via semi-annual certifications which are approved by the grant administrator or the building principal. Supporting Effective Instruction State Grants (ALN 84.367) The final reimbursement claim for the program was due to Wisconsin Department of Public Instruction (DPI) on September 30, 2024; however, the final reimbursement claim was not submitted to DPI until January 9, 2025, due to an extension. Thirteen of the 40 individuals sampled did not have their semi-annual certifications approved timely and were approved after the due date of the final reimbursement claim, but before the date of the actual submission of the final reimbursement claim. COVID-19 – Education Stabilization Fund: Elementary and Secondary School Emergency Relief (ESSER II) (ALN 84.425D), American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP ESSER) (ALN 84.425U) and American Rescue Plan - Elementary and Secondary School Emergency Relief - Homelessness Children and Youth (84.425W) The final reimbursement claims for the ESSER II and the ARP ESSER programs were due to DPI on September 30, 2023, and September 30, 2024, respectively; however, the final reimbursement claims were not submitted to DPI until December 8, 2023, for ESSER II and December 6, 2024, for ARP ESSER. Five of the 40 individuals sampled had their semi-annual certifications not approved timely and were approved after the due date of the final reimbursement claims, but before the date of the actual submission of the final reimbursement claim. The samples were not statistically valid. Corrective Action Plan The Office of Finance agrees that it is important that certifications be completed in a timely manner and claims for cost reimbursement are submitted within the deadlines. The Office of Finance and the District as a whole is working on improving its internal controls system wide. While we recognize the importance of adhering to the due dates for final reimbursement claims, it is important to note that all expenditures claimed were reviewed for allowability through the required WISEgrants budget approval process prior to submission. Although five of the 40 sampled individuals had semi-annual certifications approved after the official claim due date, all certifications were completed prior to the actual submission of the final reimbursement claims to DPI. Therefore, no unapproved or uncertified personnel costs were included in the reimbursement requests, and internal controls were maintained to ensure that only allowable costs were submitted. We are committed to developing sound processes and procedures that are in full compliance with federal and state regulations. An example of a process improvement is to send out reminders on a regular schedule to school leaders and central office employees for programmatic compliance. These activities will be completed in advance of due dates going forward to ensure timely submission of grant claim reimbursements. Annual training for school leaders and central office staff is also part of the process improvement plan underway. Name(s) of Contact Person(s) Responsible for Corrective Action: Chief Financial Officer, Comptroller, State and Federal Programs Director, Grant Accounting Manager Anticipated Completion: 06.30.2026

View Audit 366326

Finding 1153064 (2024-001)

Material Weakness 2024

County of Westchester

NY

Student Financial Aid Questioned Costs Special Tests & Provisions

Corrective Action Plan (CAP) Institution: Westchester Community College New York Program Audited: Assistance Listing Number & Title: 84.063 – Federal Pell Grant Prepared for: Submission to Single Audit reporting package through the Federal Audit Clearinghouse (FAC) and Aid, Director, Financial Manag...

Corrective Action Plan (CAP) Institution: Westchester Community College New York Program Audited: Assistance Listing Number & Title: 84.063 – Federal Pell Grant Prepared for: Submission to Single Audit reporting package through the Federal Audit Clearinghouse (FAC) and Aid, Director, Financial Management Group – Federal Student Aid Date: August 27, 2025 1. Finding Reference • Audit Report Section: [Insert Finding Number/Reference] Finding 2024-001: Refunds of Title IV Funds Calculation and Disbursement Errors (Significant Deficiency - Special Tests and Provisions) • Description of Finding: Summarize the audit finding clearly as stated in the audit report. During the Fall 2023-2024 semester, 125 Pell Grant refund checks totaling $144,576 were issued incorrectly due to failures in the newly implemented student financial aid reporting system. • Errors Identified: 1. 10 checks totaling $11,087 were cashed, with only $1,233 returned to the college. The remaining $9,854 is considered questioned costs. 2. 51 checks totaling $56,263 were cashed, and accounts were later adjusted with student cooperation. 3. 64 checks totaling $77,226 were stopped before payment. 2. Root Cause Analysis • Cause of Noncompliance: Explain why the issue occurred (e.g., lack of internal controls, insufficient training, system error). System and operational failures due to inadequacy of the new student financial aid reporting system. • Contributing Factors: List any secondary factors (e.g., staff turnover, policy misinterpretation). 1. Data integrity issues – Automatic updates resulted in unauthorized entries and inaccurate data. 2. Communication failures – Early reports by staff of system errors were not addressed in a timely manner, resulting in delayed communication. 3. Disbursement errors – Scheduled disbursement dates canceled and rescheduled as a result of system’s inability to package students correctly. 4. SFP processing was inconsistent with US DOE COD system data. 5. Compliance date reporting errors due to SFP processing. 6. Training on the new SFP system was insufficiently provided by the vendor. In-person and self-paced training modules also not provided by the vendor. 7. SFP system contributed to incorrect financial aid packaging, requiring manual reprocessing 8. The SFP system was not aligned with unique community college scheduling features (e.g. parts of term such as winter session, 8-week semesters). 3. Corrective Action Plan Planned Corrective Measures: Detail the specific steps WCC management will take to correct the deficiency. To mitigate further damage, WCC reinstated the prior software system in April 2024, however, since the ISIRs were already determined, manual adjustments were made to students. This required additional corrective action steps: • Manual Data Corrections – Financial aid counselors manually reviewed data on approximately 6400 students and made corrections, student by student. • Reconciliation with G5 Data – Financial aid data had to be manually reconciled with G5, the federal payment system. • Compliance Adjustments – Transaction dates for compliance reporting were corrected. • Award Authorization – Student award amounts required manual verification, authorization, and approval. • Bursar’s Office Delays – Due to system errors, Bursar’s Office delayed processing refunds to prevent further financial discrepancies. • Parallel setup of on-prem financial aid system in March 2024 to prepare for the 2024-25 academic year. • Extraction of 2023-24 academic year financial aid data from SFP system and import into on-prem financial aid system. • Discontinue use of SFP on approximately 7/1/2025. • Responsible Party: Name/Title of the person(s) responsible for implementing corrective action. Garrett McAlister, Vice President of Information Technology; Dawn Gillins, Acting Vice President of Administrative Services/CFO; Dr. Erik Fortune, Assistant Vice President of Administration; Dr. Sandra Ramsey, Director of Enrollment Services; Nicola Howard-Brown, Acting Director of Financial Aid; Richard Cruz, Manager of Fiscal Operations; Garth Walcott, Program Administrator- Bursar Operations; Brian Murphy, former VP of Administrative Services/CFO; Dante Cantu, VP of Student Affairs; Anita Cook, former Director of Financial Aid. • Resources Required: Identify resources such as additional staff, training, IT system upgrades. Additional financial aid professional staff, IT/SFP system consultants. • Timeline: Expected completion date(s) for each corrective measure. Financial aid system remediation and awarding is complete. 2023-24 student financial aid data extraction/import for future reference in process. 4. Monitoring & Follow-Up • Ongoing Oversight - Describe how WCC will monitor to ensure corrective actions remain effective: WCC has a fully documented academic year financial aid project plan that is followed to ensure the timely implementation of tasks. • Internal Review Mechanisms: WCC will include periodic reviews aligned with standard DOE reporting timelines. Increase reconciliation frequency between G5 and COD. Increase periodic reviews, reports to leadership, and internal audit spot checks. 5. Evidence of Implementation • Documentation: List the types of evidence that will be maintained (e.g., revised policies, training logs, updated system reports). Project plan to revert back to previous system, training schedules, policy updates as they occur, and relevant updated system reports. • Retention: Confirm that documentation will be retained in accordance with federal regulations. WCC confirms that documentation will be retained in accordance with federal regulations. 6. Management Certification I certify that the corrective actions described above will be implemented as stated and monitored to ensure full compliance with federal requirements. Signed: Belinda S. Miles Name: Belinda S. Miles, Ed. D. Title: President Date: August 29, 2025

View Audit 366317

Finding 1153060 (2024-001)

Material Weakness 2024

Trinity Academy for the Performing Arts

RI

Material Weakness Period of Performance Reporting

August 26, 2025 CORRECTIVE ACTION PLAN Cognizant or Oversight Agency for Audit Trinity Academy for the Performing Arts respectfully submits the followinbg correction action plan for the year ended June 30, 2025 Name and address of independent public accounting firm: AAFCPAs 160 Federal Street 16th F...

August 26, 2025 CORRECTIVE ACTION PLAN Cognizant or Oversight Agency for Audit Trinity Academy for the Performing Arts respectfully submits the followinbg correction action plan for the year ended June 30, 2025 Name and address of independent public accounting firm: AAFCPAs 160 Federal Street 16th Floor Boston, MA 02110 Audit Period: July 1, 2023, thru June 30, 2024 The findings from June 30, 2024, schedul fo findings and questioned cost are discussed below. The findigns are numbered consistently with the numbers assgined in the schedule. FINDINGS - FINANCIAL STATEMENT AUDIT FINDINGS SIGNIFICANT DEFICIENCY 2024-001 Payroll Reccomendation: The Scheool implements a standardized checklist and conducts preiodic internal reviews of onboarding documentation to ensure all required forms are properly completed and retained in accordance with Federal Regulations.. Action Taken: The School is implementing a standardized onboarding checklist; all personnel folders will now included a printed version to ensure required forms, including Form I-9 and Form W-4 are completed in full a the time of hire. In addition, periodic interal review of personnel files are completed in full at the time of hire. In addition, periodic internal reviews of personnel files will be conducted to verify ongoing compliance. HR staff will also receive additional training to reinforce proper documentation procedures and retention requirements. We are committe to strengthening interal controls and ensuring full compliance moving forward. If there are any questions regarding this plan, please call Harold Sands at 401-432-7881. Sincerely yours, Harold Sands

View Audit 366314

Finding 1153058 (2024-001)

Material Weakness 2024

Turning Point of Central California, Inc.

CA

Questioned Costs Material Weakness Reporting § 200.512

Finding 2024-001 Corrective Action: We have evaluated the operations of the business office and are in the process of reorganizing our FloQast software to include all balance sheet accounts with check-off reconciliation lists to be assigned to bookkeeping and accounting staff for monthly reconciliat...

Finding 2024-001 Corrective Action: We have evaluated the operations of the business office and are in the process of reorganizing our FloQast software to include all balance sheet accounts with check-off reconciliation lists to be assigned to bookkeeping and accounting staff for monthly reconciliations. These assigned tasks will be tracked and signed off by the Finance Director and the Chief Financial Officer to keep all staff accountable. Person Responsible: Interim CFO - Bruce Tyler and Finance Director - Jason Phillips Timing for Implementation: Complete and caught up by October 15, 2025

View Audit 366313

Finding 1153056 (2024-007)

Material Weakness 2024

Children's Home of Kingston

NY

Questioned Costs Allowable Costs / Cost Principles

The Agency’s management agrees with this finding. During the upcoming fiscal year, the Chief Financial Officer will work with various departments within the Agency including the HR and ORR program directors to identify items that are direct charges or allocated based on percentages to the Unaccompan...

The Agency’s management agrees with this finding. During the upcoming fiscal year, the Chief Financial Officer will work with various departments within the Agency including the HR and ORR program directors to identify items that are direct charges or allocated based on percentages to the Unaccompanied Alien Children (UAC) grant where possible. Allocation methods, that are allowable under the funding sources, will be reviewed for implementation. Methods, such as quarterly time studies, direct recording of time or other methods will be considered to ensure there is supporting documentation. The approved budget is also being monitored on a monthly and/or quarterly basis and compared to the UAC approved budget. The allocation process as well as other accounting process relating to New Horizons are being reviewed and the Accounting which had been outsourced is being brought internally. The Agency will be performing reviews of the internal allocation methodology, at least every other quarter-end.

View Audit 366307

Finding 1153054 (2024-006)

Material Weakness 2024

Children's Home of Kingston

NY

Internal Control / Segregation of Duties Questioned Costs Reporting

The Agency’s management agrees with this finding and is committed to the development of a solid internal control system that will enable timely reports to government sources. The Agency, under the oversight of a newly hired Chief Financial Officer, will develop monthly and quarterly closing procedur...

The Agency’s management agrees with this finding and is committed to the development of a solid internal control system that will enable timely reports to government sources. The Agency, under the oversight of a newly hired Chief Financial Officer, will develop monthly and quarterly closing procedures to aid in the timely closing and filing of reports.

View Audit 366307

Finding 1152938 (2024-002)

Material Weakness 2024

Community Foundation of Northern Nevada

NV

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

Finding 2024-002 Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the prepa...

Finding 2024-002 Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer of the quarterly financial reports. Corrective Action Plan: Previous reports were compiled by the Foundation’s vendors and submitted by the prior CFO. Future reports will be prepared by the Accountant and reviewed by the CFO prior to submission. Responsible Individuals: Alisha Kinnison, Accountant and Matt Lazar, CFO Anticipated Completion Date: July 2025

View Audit 366274

Finding 1152911 (2024-003)

Material Weakness 2024

Prime Healthcare Foundation, Inc. and Subsidiaries

CA

Questioned Costs Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.317 § 200.318 § 200.319

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the fed...

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company will update the procurement policy to ensure it complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest, governing the actions of its employees who select, award and administer procurement contracts. This policy will include procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised to demonstrate compliance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with were not included on the SAM Exclusions listing. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: The procurement policy will be updated by September 30, 2025, and training will be provided to all employees who are relevant to the procurement process of federal contracts by December 31, 2025.

View Audit 366228 Questioned Costs: $1

Finding 1152910 (2024-002)

Material Weakness 2024

Prime Healthcare Foundation, Inc. and Subsidiaries

CA

Questioned Costs Cash Management Subrecipient Monitoring § 200.303 § 200.305

The Company acknowledges non-compliance with 2 CFR § 200.305 that the entity must minimize the time elapsing between the transfer of funds from the U.S. Treasury or the pass-through entity and the disbursement of funds by the recipient or subrecipient. However, the questioned costs that were transfe...

The Company acknowledges non-compliance with 2 CFR § 200.305 that the entity must minimize the time elapsing between the transfer of funds from the U.S. Treasury or the pass-through entity and the disbursement of funds by the recipient or subrecipient. However, the questioned costs that were transferred in advance were ultimately deemed reasonable because they were disbursed during the grant period for allowable costs as part of the federal contract awarded. The Company will ensure a proper understanding of the compliance requirements for all federal contracts prior to requesting funds and will ensure funds transferred are compliant with the requirement that the Company minimize the time elapsed from the time of transfer and the disbursement of funds in accordance with the grant terms. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: This will be implemented on new federal contracts awarded subsequent to August 28, 2025.

View Audit 366228 Questioned Costs: $1

Finding 1152909 (2024-001)

Material Weakness 2024

Prime Healthcare Foundation, Inc. and Subsidiaries

CA

Questioned Costs Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.317 § 200.318 § 200.319

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the fed...

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company will update the procurement policy to ensure it complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest, governing the actions of its employees who select, award and administer procurement contracts. This policy will include procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised to demonstrate compliance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with were not included on the SAM Exclusions listing. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: The procurement policy will be updated by September 30, 2025, and training will be provided to all employees who are relevant to the procurement process of federal contracts by December 31, 2025.

View Audit 366228 Questioned Costs: $1

Finding 576337 (2024-002)

None 2024

City of Fort Lauderdale

FL

Questioned Costs Subrecipient Monitoring Cash Management

Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and s...

Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and send reminders to the Project Managers no less than 15 days before the reporting deadline.

View Audit 366205

Finding 576336 (2024-001)

Significant Deficiency 2024

City of Fort Lauderdale

FL

Questioned Costs Subrecipient Monitoring Cash Management § 200.303 § 200.328

Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and s...

Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and send reminders to the Project Managers no less than 15 days before the reporting deadline.

View Audit 366205

Finding 576328 (2024-002)

None 2024

Greensboro College, Inc. and Affiliates

NC

Questioned Costs Student Financial Aid Reporting

Contact Person: Travis Mickey, Registrar Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College will collaborate with NSC to evaluate the errors in the file transmissions and to develop procedures to minimize further errors in ...

Contact Person: Travis Mickey, Registrar Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College will collaborate with NSC to evaluate the errors in the file transmissions and to develop procedures to minimize further errors in the future. More specifically, the College will review the reporting procedures for withdrawn and graduating students to ensure the correct information is transmitted to NSLDS. Anticipated Completion Date: 6/30/2025

View Audit 366195

Finding 576323 (2024-001)

Significant Deficiency 2024

Greensboro College, Inc. and Affiliates

NC

Questioned Costs Special Tests & Provisions

Contact Person: Regina Elliott, Chief Information Officer Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College updated and implemented a comprehensive information security program on 1/19/25 that meets all requirements. And w...

Contact Person: Regina Elliott, Chief Information Officer Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College updated and implemented a comprehensive information security program on 1/19/25 that meets all requirements. And we will continue to review and update our IT policies and procedures on a regular basis. Furthermore, the College has strengthened our internal controls in order to ensure we are aware of new regulatory requirements and enhance our process for addressing them in a timely manner. Anticipated Completion Date: 1/19/2025

View Audit 366195

Finding 576312 (2024-002)

Material Weakness 2024

Yakama Nation Housing Authority

WA

Allowable Costs / Cost Principles Eligibility Questioned Costs § 200.303

Persons responsible for this corrective action plan: Phylistine Alexander, Housing Manager and Jana Kent, Executive Director Corrective Action Plan: YNHA will work with the NwONAP Grant Evaluation Director to evaluate our current tenant file documentation and eligibility determination process an...

Persons responsible for this corrective action plan: Phylistine Alexander, Housing Manager and Jana Kent, Executive Director Corrective Action Plan: YNHA will work with the NwONAP Grant Evaluation Director to evaluate our current tenant file documentation and eligibility determination process and will implement recommendations from HUD. Estimated Completion Date: December 31, 2025

View Audit 366187

Finding 576234 (2024-003)

Material Weakness 2024

Opening Doors, Inc.

CA

Questioned Costs Allowable Costs / Cost Principles § 200.403

Auditor's Recommendation: Strengthen policies and procedures to ensure proper authorization and documentation of payroll changes. Management Response: While ODI does not disagree with the audit finding, the Agency does clarify the context of the finding. ODI has a policy for setting, processing, an...

Auditor's Recommendation: Strengthen policies and procedures to ensure proper authorization and documentation of payroll changes. Management Response: While ODI does not disagree with the audit finding, the Agency does clarify the context of the finding. ODI has a policy for setting, processing, and approving staff wage rates as follows: Sr. HR Manager or Payroll Assistant process new hires and sets them up in the timekeeping system (NOVAtime). Any salary changes are also processed by DHR (may also be processed by supervisor) on a change status form and approved by CEO. The auditors performed tests to determine if the CEO approved the change status form. As mentioned in the audit finding, of the audit sample of employees tested in the 16 pay periods from more than 250 pay periods, six employees did not have their change of status forms signed by the CEO. Audit requirements for federal awards require the auditors to assign a value to specific instances of noncompliance as “known questioned costs”. The known questioned costs for this finding are $14,112 and are comprised of the transactions the auditors tested for allocated wages of the six employees to specific grants. The auditors further calculate “likely questioned costs” by extrapolating the auditor’s sample across the entire population from which the sample is drawn and is $553,607. Is it important to note that the “known questioned costs” and the “likely questioned costs” are not calculations of errors or misstatement in the financial statements. All six employees' pay rates were processed correctly despite missing CEO signatures on the change status forms. Corrective Action: -Conduct comprehensive internal audit of all current staff to verify proper processing and CEO approval of change status forms -Implement dual-filing system: approved forms will be maintained in both personnel folders and financial accounting folders to verify that approved pay rates are used when charging labor costs to any grant. Responsible Personnel: Karen Dickson, Sr. Finance Director; Lisa Tucker, Sr. HR Manager Implementation Date: Immediate implementation

View Audit 366160 Questioned Costs: $1

Finding 576212 (2024-006)

None 2024

Orleans Parish School Board

LA

Questioned Costs Reporting Special Tests & Provisions

2024-006: Timely Filing of the Federal Data Collection Cause: Delay from financial turnover and incomplete data documentation. Corrective Actions: Initiate year-end closeout schedule mid-May each year Implement internal deadline two months before Federal Programs deadline Timeline for Resolution: De...

2024-006: Timely Filing of the Federal Data Collection Cause: Delay from financial turnover and incomplete data documentation. Corrective Actions: Initiate year-end closeout schedule mid-May each year Implement internal deadline two months before Federal Programs deadline Timeline for Resolution: December 31, 2025 Responsible Positions: Chief Financial Officer - Nyesha Veal Executive Director of Grants Management - Debra Dean Comptroller - Jennifer Celestain Executive Direct of Finance Dejon Stewart

View Audit 366148

Corrective Action Plans

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