Corrective Action Plans

Finding 1226089 (2025-002)

Material Weakness 2025

IN

Subrecipient Monitoring Questioned Costs Material Weakness § 200.1 § 200.303

FINDING 2025-002 Sherry Lockard, 812-283-1500, slockard@townofclarksville.com A. Coronavirus State and Local Fiscal Recovery Funds The Town concurs with the finding. The Town was not aware contracts had to be signed by December 2024 for all “obligations”. The Town was under the impression the obliga...

FINDING 2025-002 Sherry Lockard, 812-283-1500, slockard@townofclarksville.com A. Coronavirus State and Local Fiscal Recovery Funds The Town concurs with the finding. The Town was not aware contracts had to be signed by December 2024 for all “obligations”. The Town was under the impression the obligations were submitted on the annual SLRF report, and that only the funds had to be spent for submitted obligations on the SLRF page by December 31, 2026. The Town was not able to obtain a contract that far in advance of the work to start, let alone be completed. At this time, we will await instructions from the Federal Agency as to what the Town needs to do regarding the expenses made after the ambiguous “obligation deadline”. For all future grants, the Town will designate the staff member who is in charge of that specific grant to create a checklist of requirements and to maintain that list until the grant is complete. (ATTACHMENT A)

View Audit 408741

Finding 1226085 (2025-026)

Material Weakness 2025

State of California

CA

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

Special Tests and Provisions California Governor’s Office of Emergency Services On December 10, 2025, Cal OES implemented communication protocol improvements by reemphasizing correct threshold applicability prior to payment during team meetings. In addition, by August 31, 2026, Cal OES will revise i...

Special Tests and Provisions California Governor’s Office of Emergency Services On December 10, 2025, Cal OES implemented communication protocol improvements by reemphasizing correct threshold applicability prior to payment during team meetings. In addition, by August 31, 2026, Cal OES will revise its Project Threshold standard operating procedure to include a review control that verifies the applicability of project thresholds, specifically the Large Project threshold, based on the appropriate timing criteria. Cal OES will also provide training to all grants processing and support staff on the revised procedure, including how to correctly identify and enter Large Project Thresholds, verify disaster data against approved sources, and apply the appropriate thresholds for specific declaration dates. Refresher training will be provided as needed thereafter. Furthermore, guidance on Large Project Thresholds will be incorporated into the onboarding process for all new staff. Estimated Implementation Date: August 2026 Contact: - Heidi Palchik, Chief, Recovery Financial Administration Branch, lnteragency Recovery Coordination Section

View Audit 408731

Finding 1226082 (2025-023)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Eligibility California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS wo...

Eligibility California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS would leverage data to monitor application processing times. The data will be used to select counties for focused reviews targeting application processing times and procedures to ensure counties are performing eligibility determinations timely and accurately. DHCS has implemented multiple monitoring activities to address the recommendation and strengthen oversight of county processing of Medi-Cal applications. In May 2024, DHCS issued Medi-Cal Eligibility Division Letter (MEDIL) 24-12, ending the temporary hold harmless provisions and resumed standard county performance accountability. Subsequently, DHCS issued ACWDL 24-17, which established the Department's transition to using system-generated eligibility data, rather than county self-certification, to monitor application timeliness. Under this approach, DHCS evaluates county performance using statewide eligibility data, publishes application timeliness performance through statewide dashboards, and uses the data to identify counties for focused reviews. Focused reviews evaluate both the timeliness and accuracy of county eligibility determinations. Counties that do not meet established performance expectations are subject to corrective actions consistent with the Welfare and Institutions Code (WIC) section 14154 performance monitoring framework, including the application of statutory performance corrective action plans (CAPS), and financial penalties where applicable. Collectively, these actions establish an ongoing oversight process that enables DHCS to monitor county compliance with Medi-Cal application timeliness requirements, identify performance issues, require counties to implement corrective actions to address any deficiencies identified through focused reviews, and promote continued improvement in the timely and accurate processing of Medi-Cal applications. In 2025, DHCS issued MEDIL I 25-19, Reinstatement of the Aid Code Clean-Up Effort, which reinstated the Department's statewide process for identifying beneficiaries assigned to obsolete pre-Affordable Care Act (ACA) aid codes, transitional aid codes, or other records that may require reevaluation of eligibility. As part of this effort, DHCS provides counties with standardized reports on a bi-monthly basis to assist in identifying records that require review and action. Counties are required to review records, and either transition beneficiaries to the appropriate Medi-Cal aid code or discontinue eligibility, as applicable. Through the reinstated Aid Code Clean-Up process, DHCS performs ongoing statewide monitoring of aid code usage, identifies obsolete or inappropriate aid codes, and requires counties to take the appropriate action to ensure these beneficiaries are enrolled under the correct Medi-Cal aid category. Estimated Implementation Date: Fully Implemented Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226080 (2025-022)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Questioned Costs Allowable Costs / Cost Principles § 200.303

Activities Allowed and Unallowed California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL noti...

Activities Allowed and Unallowed California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS would leverage data to monitor application processing times. The data will be used to select counties for focused reviews targeting application processing times and procedures to ensure counties are performing eligibility determinations timely and accurately. DHCS has implemented multiple monitoring activities to address the recommendation and strengthen oversight of county processing of Medi-Cal applications. In May 2024, DHCS issued Medi-Cal Eligibility Division Letter (MEDIL) 24-12, ending the temporary hold harmless provisions and resumed standard county performance accountability. Subsequently, DHCS issued ACWDL 24-17, which established the Department's transition to using system-generated eligibility data, rather than county self-certification, to monitor application timeliness. Under this approach, DHCS evaluates county performance using statewide eligibility data, publishes application timeliness performance through statewide dashboards, and uses the data to identify counties for focused reviews. Focused reviews evaluate both the timeliness and accuracy of county eligibility determinations. Counties that do not meet established performance expectations are subject to corrective actions consistent with the Welfare and Institutions Code (WIC) section 14154 performance monitoring framework, including the application of statutory performance corrective action plans (CAPS), and financial penalties where applicable. Collectively, these actions establish an ongoing oversight process that enables DHCS to monitor county compliance with Medi-Cal application timeliness requirements, identify performance issues, require counties to implement corrective actions to address any deficiencies identified through focused reviews, and promote continued improvement in the timely and accurate processing of Medi-Cal applications. In 2025, DHCS issued MEDIL I 25-19, Reinstatement of the Aid Code Clean-Up Effort, which reinstated the Department's statewide process for identifying beneficiaries assigned to obsolete pre-Affordable Care Act (ACA) aid codes, transitional aid codes, or other records that may require reevaluation of eligibility. As part of this effort, DHCS provides counties with standardized reports on a bi-monthly basis to assist in identifying records that require review and action. Counties are required to review records, and either transition beneficiaries to the appropriate Medi-Cal aid code or discontinue eligibility, as applicable. Through the reinstated Aid Code Clean-Up process, DHCS performs ongoing statewide monitoring of aid code usage, identifies obsolete or inappropriate aid codes, and requires counties to take the appropriate action to ensure these beneficiaries are enrolled under the correct Medi-Cal aid category. Estimated Implementation Date: Fully Implemented Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226073 (2025-020)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Eligibility California Department of Health Care Services DHCS is currently in the process of reevaluating its Medi-Cal Eligibility Data System (MEDS) monitoring process by taking the following steps: Research and Data Collection - DHCS will initiate the revised MEDS alert hierarchy process by condu...

Eligibility California Department of Health Care Services DHCS is currently in the process of reevaluating its Medi-Cal Eligibility Data System (MEDS) monitoring process by taking the following steps: Research and Data Collection - DHCS will initiate the revised MEDS alert hierarchy process by conducting targeted research. This effort will include obtaining the total number of records associated with each MEDS Alert, encompassing the entire universe of MEDS alerts. - As part of this research, DHCS will review the highest volume alerts and identify the root causes. County Staff Workgroup: DHCS will form a workgroup with County Staff to collaborate on refining the MEDS Alerts process. The objectives of this workgroup are to: - Determine whether certain alerts can be streamlined to improve efficiency. - Assess if additional functionality can be added to CalSAWS to address issues that lead to high volume alerts. - Develop strategies to ensure counties have sufficient support to resolve MEDS alerts both accurately and timely. Hierarchy Revision and Implementation - DHCS will use the findings from the research phase and the input provided by the workgroup to revise the MEDS Alerts Hierarchy and ACWDL. - The Program Review Branch will update the BI tool to incorporate all MEDS alerts that affect eligibility, and pertinent high-volume alerts. - We are considering amendments to WIC section 14154.5 to reflect any changes in calculating performance standards for MEDS alerts. - DHCS will postpone posting MEDS Alerts performance data to the public facing dashboard until the end of this process. DHCS does not resolve MEDS Alerts. The purpose of the above process is to reduce the number of MEDS alerts created because of caseworker action by providing additional guidance to counties and potentially adding functionality to CalSAWS that would reduce the number of alerts created due to system discrepancies. This is anticipated to reduce the number of MEDS alerts, which would ease the county staff workload and allow counties to better manage the MEDS alerts workload. Focused reviews will continue to assist the department in identifying counties that do not act upon newly reported information that negatively impacts eligibility. DHCS will require counties to submit a corrective action plan and emphasize implementing ongoing trainings to mitigate inappropriate continuation of benefits. DHCS will continue to monitor progress until the identified issues no longer persist. Estimated Implementation Date: June 2027 Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226037 (2025-006)

Material Weakness 2025

State of California

CA

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

Special Tests and Provisions Employment Development Department EDD has current policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the ...

Special Tests and Provisions Employment Development Department EDD has current policies, procedures, and training in place instructing employees to include applicable penalty amounts when establishing overpayments in the database. When the overpayment for the sample in question was established, the employee did not follow proper procedure to include the penalty. EDD accepts this oversight and is committed to reviewing its applicable policies and procedures to ensure they are clear, and the penalty requirements are emphasized. Regarding internal controls, EDD leverages a process known as the Field Office Basic Evaluation System (FOBES). This process includes a standardized form that is utilized by leadership to evaluate the quality of their employees’ work in a variety of processes, including overpayment processing. EDD continues to review and modernize the existing assessment form and FOBES process to ensure effectiveness and consistency while evaluating employee compliance with policies and procedures. EDD will enhance current procedures to outline the steps for reviewing claimant eligibility and applying disqualification penalties by: - Updating procedures in the various resources available for our determination false statement processes to include more comprehensive guidance. - Providing updated training for employees on any changes to procedures. Milestones: - Update UI Manuals by 8/14/2026. - Engage with UIB training team to update overpayment-related training and create a new refresher training by 8/14/2026. - Evaluate when a refresher training can be presented to determination trained employees by 8/14/2026. - Provide updated milestone to DOL by 9/30/2026. Estimated Implementation Date: September 2026 Contact: - Diane Underwood, Division Chief, Unemployment Insurance Branch

View Audit 408731

Finding 1226009 (2025-005)

Material Weakness 2025

Washington County Ambulance District

MO

Reporting Questioned Costs

Washington County Ambulance District agrees with the finding and has implanted additional reminders and levels of review to ensure reports are submitted timely. This will be overseen by Amber Coleman, Chief Administrative Officer, with a target date of completion of December 31, 2026.

View Audit 408687

Finding 1226008 (2025-004)

Material Weakness 2025

Washington County Ambulance District

MO

Cash Management Questioned Costs § 200.305

Washington County Ambulance District agrees with the reported finding. The underlying cause was a clerical error that was determined after reimbursement had been requested. Upon identifying the issue, additional acceptable expenses were substituted for this clerical error. Additional review will be ...

Washington County Ambulance District agrees with the reported finding. The underlying cause was a clerical error that was determined after reimbursement had been requested. Upon identifying the issue, additional acceptable expenses were substituted for this clerical error. Additional review will be completed on each required submission. This will be overseen by Amber Coleman, Chief Administrative Officer, with a target date of completion of December 31, 2026.

View Audit 408687

Finding 1226002 (2025-001)

Material Weakness 2025

Meadow Lane Housing Development Fund Company, Inc.

NY

Eligibility Questioned Costs HUD Housing Programs

An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail. Antici...

An age waiver has been submitted to HUD and is currently being reviewed. We are awaiting their decision. While we await a decision, Meadow Lane will review all existing application for eligibility and advise any existing applicants who are not of age that they are no longer eligible via mail. Anticipated Completion Date: Pending HUD approval of age waiver

View Audit 408679

Finding 1226000 (2025-002)

Material Weakness 2025

Piedmont Health Services, Inc.

NC

Questioned Costs Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Actions – Management agrees that the Sliding scale has been incorrectly applied on patient accounts and intends to do the following: A root cause analysis should determine whether the errors resulted from: • Staff calculation errors when annualiz...

Views of Responsible Officials and Planned Corrective Actions – Management agrees that the Sliding scale has been incorrectly applied on patient accounts and intends to do the following: A root cause analysis should determine whether the errors resulted from: • Staff calculation errors when annualizing income. • Failure to properly verify income documentation. • Incorrect data entry in the practice management system. • Inadequate training on sliding fee eligibility determination procedures. • Lack of secondary review or quality assurance monitoring by the revenue cycle team. In addition to the root cause analysis Piedmont Health Services will do the following: 1. Correct the three identified patient accounts and process any necessary refunds, adjustments, or account corrections. 2. Conduct a targeted review of a broader sample of recent sliding fee determinations to identify any additional errors and implement corrective action where necessary. 3. Retrain registration, eligibility, and financial counseling staff on income verification requirements, family-size determination, documentation standards, and sliding fee calculation procedures. 4. Implement secondary review procedures for sliding fee determinations until system enhancements are in place. 5. Continue monthly quality assurance audits of sliding fee eligibility determinations and monitor error rates. 6. Transition to OCHIN Epic in August 2026. The new EMR platform is expected to significantly strengthen internal controls through enhanced workflow automation, improved documentation, standardized eligibility processes, and expanded reporting capabilities. These features will provide greater visibility into sliding fee eligibility determinations, improve management's ability to monitor compliance, and reduce the risk of manual calculation and data-entry errors. 7. Following Epic implementation, management will conduct post-go-live validation testing to confirm that sliding fee determinations are functioning as designed and that eligibility calculations are accurate and compliant with HRSA requirements. Expected Outcome The combination of staff retraining, enhanced monitoring, and migration to OCHIN Epic is expected to improve the accuracy of sliding fee eligibility determinations, strengthen compliance oversight, and reduce the risk of future errors. The Director of Revenue and the CFO will monitor error rates through periodic audits and leverage Epic reporting tools to support ongoing compliance and quality assurance efforts. Individuals Responsible Beth Moseley, Chief Financial Officer and Daniella Jaimes-Colina, Chief Executive Officer

View Audit 408670

Finding 1225992 (2025-004)

Material Weakness 2025

City of Osseo

WI

Internal Control / Segregation of Duties Questioned Costs Procurement, Suspension & Debarment

To Federal Awarding Agency The City of Osseo, Wisconsin respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: January 1, 2025 - December 31, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings ...

To Federal Awarding Agency The City of Osseo, Wisconsin respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: January 1, 2025 - December 31, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESSES 2025-001 Limited Segregation of Duties Recommendation: The City should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will continue to work to achieve segregation of duties whenever cost effective. Name(s) of the contact person(s) responsible for corrective action: Stephanie Nelson, Clerk/Treasurer. Planned completion date for corrective action plan: The activities outlined above will be completed by December 31, 2025. 2025-002 Material Audit Adjustments Recommendation: The City should continue to evaluate its internal control processes to determine if additional internal control procedures should be implemented to ensure that accounts are adjusted to their appropriate year end balances in accordance with Generally Accepted Accounting Principles (GAAP). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will continue to rely upon the audit firm to propose audit adjustments necessary to adjust accounts in accordance with GAAP. Management will review and approve these entries prior to recording them. Name(s) of the contact person(s) responsible for corrective action: Stephanie Nelson, Clerk/Treasurer. Planned completion date for corrective action plan: The activities outlined above will be completed by December 31, 2025. 2025-003 Annual Financial Reporting under Generally Accepted Accounting Principles (GAAP) Recommendation: The City should continue to evaluate its internal staff and expertise to determine if an internal control policy over the annual financial reporting is beneficial. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will continue to rely upon the audit firm to prepare the annual financial statements and related footnote disclosures in accordance with GAAP. Management will review, approve and accept responsibility for these financial statements and related footnote disclosures prior to issuance. Name(s) of the contact person(s) responsible for corrective action: Stephanie Nelson, Clerk/Treasurer. Planned completion date for corrective action plan: The activities outlined above will be completed by December 31, 2025. 2025-004 Procurement Policy Recommendation: The City should be familiar with compliance requirements outlined by Uniform Guidance and design controls to ensure procurement requirements are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will review procurement policies and procedures and adopt necessary changes to meet the requirements of Uniform Guidance. Name(s) of the contact person(s) responsible for corrective action: Stephanie Nelson, Clerk/Treasurer. Planned completion date for corrective action plan: The activities outlined above will be completed by December 31, 2025. Any questions regarding these corrective action plans can be directed to Stephanie Nelson, Clerk/Treasurer, 13712 8th Street, Osseo, WI 54758 or 715-597-2207.

View Audit 408648

Finding 1225991 (2025-001)

Material Weakness 2025

Genesis Nonprofit Housing Corporation

MI

Questioned Costs Eligibility HUD Housing Programs

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...

The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the project. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its project and document evidence in the files.

View Audit 408647

Finding 1225990 (2025-003)

Material Weakness 2025

Shawnee Christian Healthcare Center, Inc.

KY

Questioned Costs Reporting

Management will review their process and policy for retaining supporting documentation.

View Audit 408644

Finding 1225979 (2025-003)

Material Weakness 2025

Chicago Survivors, Inc.

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.203 § 200.430

Finding Number: 2025-003 Name of Responsible Party: JaShawn Hill, Executive Director Corrective Action: Management acknowledges and agrees with the finding. This issue resulted from a reduction in force during which various employees’ final workday coincided with the end of a payroll period. While e...

Finding Number: 2025-003 Name of Responsible Party: JaShawn Hill, Executive Director Corrective Action: Management acknowledges and agrees with the finding. This issue resulted from a reduction in force during which various employees’ final workday coincided with the end of a payroll period. While employees typically have around one week to submit their timesheets after the end of a pay period, the employees that were let go from the organization did not finalize their information before leaving. In the future, management will ensure that all timesheets are submitted on the final day of employment as a part of the last day procedures. Anticipated Completion Date: July 31, 2026

View Audit 408618

Finding 1225978 (2025-002)

Material Weakness 2025

Chicago Survivors, Inc.

IL

Allowable Costs / Cost Principles Questioned Costs § 200.303

Finding Number: 2025-001 & 2025-002 Name of Responsible Party: JaShawn Hill, Executive Director Corrective Action: Management acknowledges and agrees with the finding. The issue resulted in a variety of issues: 1) invoices for recurring transactions set up on automatic payment were not downloaded an...

Finding Number: 2025-001 & 2025-002 Name of Responsible Party: JaShawn Hill, Executive Director Corrective Action: Management acknowledges and agrees with the finding. The issue resulted in a variety of issues: 1) invoices for recurring transactions set up on automatic payment were not downloaded and approved by the appropriate party, resulting in a lack of adequate documentation, 2) a former employee was granted access to make ACH payments directly from the organization’s bank account, allowing payments to be made without proper oversight or approval, and 3) access to the organization’s Amazon account was limited to one employee, allowing inappropriate purchases to be made without proper oversight or approval. To ensure that proper processes and documentation is followed going forward, management will: 1) provide adequate training to the individual tasked with collecting invoices and approval for all transactions, including recurring transactions, and will perform a periodic review of various transactions to ensure approvals and documentation is obtained; 2) no longer allow any employee to make ACH payments directly from the organization’s bank account, and instead will implement a bill payment software that ensures that all ACH payments must be approved by an appropriate party, other than the individual initiating payment, before payment can be made; and 3) ensure that multiple parties have access to the organization’s Amazon account, and that the transactions and receipts are reviewed and approved as dictated by the organization’s existing policies and procedures (and are subject to the periodic review noted in item 1 above). Anticipated Completion Date: July 31, 2026

View Audit 408618

Finding 1225977 (2025-001)

Material Weakness 2025

The Boys & Girls Clubs of Boston, Inc.

MA

Questioned Costs Procurement, Suspension & Debarment § 200.318

Finding 2025-001 - Procurement: During the FY25 audit, it was noted that the Organization did not maintain a written procurement policy that included all the required elements. Corrective Actions Taken or Planned: Corrective action has been taken during FY26. The Organization updated the spending po...

Finding 2025-001 - Procurement: During the FY25 audit, it was noted that the Organization did not maintain a written procurement policy that included all the required elements. Corrective Actions Taken or Planned: Corrective action has been taken during FY26. The Organization updated the spending policy to reflect federal requirements and best practices and provided the document to the Audit & Finance Committees of the Board for review and comment. The updated spending policy is now in place. Completion date: 6/30/2026 Person responsible for corrective action: Nathan Kuder, Chief Financial Officer

View Audit 408612

Finding 1225861 (2025-005)

Material Weakness 2025

Housing Authority of the City of Durham

NC

Cash Management HUD Housing Programs Internal Control / Segregation of Duties § 200.305

Finding 2025-005 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public Housing Capital Fund Program Federal Assistance Listing Numbers: 14.872 Noncompliance - C. Cash Management Non Compliance Material to the Financial Statements: No Significant deficiency i...

Finding 2025-005 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public Housing Capital Fund Program Federal Assistance Listing Numbers: 14.872 Noncompliance - C. Cash Management Non Compliance Material to the Financial Statements: No Significant deficiency in Internal Control over Compliance for Cash Management Criteria: In accordance with 2 CFR 200.305, payment methods for federal awards must minimize the time elapsing between the transfer of federal funds and the disbursement of those funds by the recipient. Federal funds drawn under the Public Housing Capital Fund Program should be limited to amounts needed to meet the Authority’s immediate cash requirements for allowable program expenditures. Accordingly, the Authority should implement procedures to ensure grant funds are not drawn in advance of actual or imminent eligible expenditures. Condition: The Authority drew down federal funds in advance of immediate cash needs for allowable program expenditures. As of year end, a portion of the funds drawn remained unexpended and was reported as unearned revenue in the financial statements. This indicates that federal funds were received prior to the incurrence of eligible expenditures. Context: During review of the financial statements, the Authority was noted to have unexpended federal funds on hand at year end that had been drawn prior to the disbursement of allowable program costs. Specifically, amounts recorded as unearned revenue represented federal funds received in advance of immediate cash needs. This condition was identified through review of drawdown activity, general ledger balances, and year end financial reporting records. Known Questioned Costs: $134,883. Cause: The Authority did not have adequate internal controls in place to monitor the timing of grant drawdowns in relation to actual program cash needs and allowable expenditures. As a result, federal funds were requested and received prior to the incurrence of eligible costs under the Public Housing Capital Fund Program. Effect: The Authority was not in compliance with federal cash management requirements governing the timing of federal fund drawdowns. As a result, federal funds were held in advance of immediate cash needs, increasing the risk of improper cash management and noncompliance with Uniform Guidance and HUD requirements. Recommendation: We recommend the Authority strengthen its internal controls over cash management to ensure federal funds are drawn only for immediate cash needs related to allowable program expenditures. Management should implement monitoring and review controls over grant drawdown activity, including periodic reconciliation of drawdowns to incurred expenditures, to ensure compliance with 2 CFR 200.305 and HUD requirements. Authority's Response: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ralph Staley, CFO is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring and is expected to be completed by December 31, 2026.

View Audit 408551

Finding 1225860 (2025-004)

Material Weakness 2025

Housing Authority of the City of Durham

NC

HUD Housing Programs Questioned Costs Eligibility

Finding 2025-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in...

Finding 2025-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Public and Indian Housing Program Federal Catalog Numbers: 14.850 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 733 units. Of a sample size of twenty-one (21) tenant files, the following was noted: • Citizenship declaration was missing in 1 file • Original application was missing in 1 file • HUD Form 9886 was missing in 1 file • Lead based paint form was missing in 1 file • HUD form 50058 was missing in 1 file • Verification of income was missing in 1 file • Verification of assets was missing in 1 file Our sample size is statistically valid. Known Questioned Costs: $11,005 Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority experienced high turnover and did not properly train employees in the Public and Indian Housing department, which resulted in the Authority having a limited capacity to perform the required maintenance of tenant files, and properly maintain and monitor a system of internal controls that reasonably assures the program is in compliance. Effect: The Authority is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files in the Public and Indian Housing Program. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are hired and trained on tenant file maintenance so that documents are accumulated, stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the deficiencies in the Public and Indian Housing Program and has implemented a quality control program. The Authority will continue to train staff on the proper maintenance of tenant files and implement additional internal control procedures that will ensure compliance with federal regulations. Sean Buchanan, Deputy Operating Officer is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring and is expected to be completed by December 31, 2026.

View Audit 408551

Finding 1225859 (2025-003)

Material Weakness 2025

Housing Authority of the City of Durham

NC

HUD Housing Programs Questioned Costs Special Tests & Provisions

Finding 2025-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871 & 14.879 Noncompliance – N. Special Tests and Provisions – HQS Enforcement Non Compliance Material to the Financial Statements: Yes Mater...

Finding 2025-003: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Catalog Numbers: 14.871 & 14.879 Noncompliance – N. Special Tests and Provisions – HQS Enforcement Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: HQS Enforcement. The PHA must inspect the unit leased to a family at least annually to determine if the unit meets the Housing Quality Standards (HQS) and the Authority must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussions with management, the Authority did not properly abate (6) housing assistance payments. Context: Of a sample size of twenty-five (25) failed inspections, the Authority did not properly abate six (6) out of twenty-five (25) housing assistance payments. As a result, the Authority was not in compliance with the HQS as required by 24 CFR sections 982.158(d) and 982.405(b). Known Questioned Costs: $75,656. Cause: There is a material weakness in internal controls over compliance for the special tests and provisions type of compliance related to HQS enforcement, due to high turnover. This, in addition to software limitations, has resulted in the Authority having a limited capacity to properly maintain and monitor a system of internal controls that reasonably assures program compliance. Effect: The Authority is in material non-compliance with the special tests and provisions type of compliance related to HQS enforcement in the Housing Voucher Cluster. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are hired and trained on HQS enforcement that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the deficiencies in the administration of programs within the Housing Voucher Cluster and has implemented a process to prevent the same issues from occurring. The Authority will also continue to train staff on HQS enforcement and enhance its internal control procedures that will ensure compliance with federal regulations. Tonya Crawley, HCV Program Director is responsible for ensuring proper internal controls are in place to prevent material weaknesses from occurring and is expected to be completed by December 31, 2026.

View Audit 408551

Finding 1225858 (2025-002)

Material Weakness 2025

Housing Authority of the City of Durham

NC

HUD Housing Programs Questioned Costs Eligibility

Finding 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 & 14.879 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in I...

Finding 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Numbers: 14.871 & 14.879 Non Compliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 2,208 units. Of a sample size of thirty-four (34) tenant files, the following was noted: • HUD form 9886 was unable to be provided in 2 files • Citizen Declaration Section 214 form was unable to be provided in 4 files • Signed lease was unable to be provided in 4 files • Lead based paint form was unable to be provided in 1 file Known Questioned Costs: $19,212 Cause: There is a material weakness in internal controls over the eligibility type of compliance related to the maintenance of tenant files in the Housing Voucher Cluster. The Authority experienced high turnover and did not properly train employees in the HCV department, which resulted in the Authority having a limited capacity to perform the required maintenance of tenant files, and properly maintain and monitor a system of internal controls that reasonably assures the program is in compliance. Effect: The Authority is in material non-compliance with the eligibility requirements of the Housing Voucher Cluster programs. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are hired and trained on tenant file maintenance so that documents are accumulated, stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the deficiencies related to the administration of Housing Voucher Cluster and will train staff on the proper maintenance of tenant files and implement internal control procedures that will ensure compliance with federal regulations. Tonya Crawley, HCV Program Director is responsible for ensuring proper internal controls are in place to prevent material weaknesses from occurring and is expected to be completed by December 31, 2026.

View Audit 408551

Finding 1225678 (2025-001)

Material Weakness 2025

Wyoming Valley Sanitary Authority

PA

Questioned Costs Subrecipient Monitoring Reporting

Condition The Authority's Single Audit and reporting package was delayed for the year ended December 31, 2024 beyond the nine-month due date, as a result of delays in reconciling federal and state award activity with the Commonwealth. Corrective Action Plan Corrective Action Planned: Fiscal year 202...

Condition The Authority's Single Audit and reporting package was delayed for the year ended December 31, 2024 beyond the nine-month due date, as a result of delays in reconciling federal and state award activity with the Commonwealth. Corrective Action Plan Corrective Action Planned: Fiscal year 2024 represented a significant transition period for the Authority. During the year, the Board of Directors appointed a new Chief Financial Officer and engagement a new auditor. The transition required substantial effort to transfer institutional knowledge, review historical accounting records, reconcile significant grant activity and establish a new audit process. As a result of these transition activities, the Authority’s 2024 financial statements were not certified until September 29, 2025, leaving insufficient time to complete and submit the required Single Audit reporting package by the required due date. The Authority’s 2025 Audit was presented to the Board of Directors for acceptance during the July board meeting and will be filed shortly thereafter. Management has implemented the necessary procedures and revised its audit timeline to ensure compliance with all future reporting requirements. Accordingly, the Authority expects to remain fully compliance with the filing deadlines prescribed under the Uniform Guidance for the 2025 and all subsequent audit periods. Name(s) of Contact Person(s) Responsible for Corrective Action: Chief Financial Officer Anticipated Completion Date: August 2026

View Audit 408539

Finding 1225618 (2025-005)

Material Weakness 2025

White Bird Clinic

OR

Questioned Costs Special Tests & Provisions Material Weakness

2025-005 Special Tests Corrective action planned: WBC Management agrees with this finding. WBC has created and hired for a new position, Revenue Cycle Manager (RCM). The RCM has oversight of Revenue generated through the FQHC Clinics. As part of this oversight, the RCM is implementing training for F...

2025-005 Special Tests Corrective action planned: WBC Management agrees with this finding. WBC has created and hired for a new position, Revenue Cycle Manager (RCM). The RCM has oversight of Revenue generated through the FQHC Clinics. As part of this oversight, the RCM is implementing training for Front Office staff that are responsible for gathering and inputting client data related to calculation of the Slide. In addition to internal training of Front Office staff, WBC will be engaging an external expert to review and revise applicable policies and procedures to ensure alignment with best practices. The RCM is also responsible for conducting periodic internal reviews of documentation supporting Slide calculations to ensure support matches with the calculated Slide rate. Anticipated completion date: 2026, July Contact person responsible for corrective action: Amee Markwardt, Executive Director

View Audit 408513

Finding 1225617 (2025-004)

Material Weakness 2025

White Bird Clinic

OR

Questioned Costs Allowable Costs / Cost Principles Material Weakness

2025-004 Reporting Corrective action planned: WBC Management agrees with this finding. WBC had to switch EHRs during 2023 and 2024, which required our Dental, Medical, and Behavioral Health programs to use their own separate EHR to alleviate critical functional and capacity deficiencies that were ca...

2025-004 Reporting Corrective action planned: WBC Management agrees with this finding. WBC had to switch EHRs during 2023 and 2024, which required our Dental, Medical, and Behavioral Health programs to use their own separate EHR to alleviate critical functional and capacity deficiencies that were caused by our previous EHR. This resulted in significantly more complexity when calculating our UDS numbers. The process involved combining all of our patient demographics and accounting for overlapping (duplicate encounters) by hand. This was made all the more difficult by name misspellings and other errors during data entry. Relating to our prior year finding, WBC had contracted with a third party to implement a custom population health tool to automate our UDS reporting. The contractor did not meet specified deliverable requirements, so reporting was again done manually, which resulted in the errors. White Bird Clinic has been working to evaluate population health tools to aggregate patient data to provide more accurate UDS and clinical quality reporting. In 2026, through the help of our HCCN, Health Efficient, we contracted with Relevant Health to implement their population health tool to streamline and accurately report our population health and our UDS reporting. The Relevant platform is in use by over 100 FQHCs across the country. This tool will aggregate patient data from each EHR, account for duplicates, and accurately report combined UDS demographics from all our systems. They are very experienced with UDS and UDS+ reporting, so the system is designed to seamlessly provide accurate and consistent UDS metrics and address duplicate clients from multiple EHRs. Anticipated completion date: 2026, July Contact person responsible for corrective action: Tyler Stewart, Director of IT

View Audit 408513

Finding 1225606 (2025-003)

Material Weakness 2025

Madison County District School Board

FL

Questioned Costs Allowable Costs / Cost Principles

Planned Corrective Action: The District recognizes and understands the incorrect calculation of the Federal indirect cost rate applicable to the 2024-25 fiscal year and has prepared subsequent indirect rate calculations for the fiscal years 2025-26 and 2026-27 that included other expenditures (i.e. ...

Planned Corrective Action: The District recognizes and understands the incorrect calculation of the Federal indirect cost rate applicable to the 2024-25 fiscal year and has prepared subsequent indirect rate calculations for the fiscal years 2025-26 and 2026-27 that included other expenditures (i.e. charter school expenditure) that were incorrectly omitted in the rate for the 2024-25 fiscal year. Anticipated completion date: July 1, 2025 Responsible Contact Person: Walter Copeland, CFO

View Audit 408491

Finding 1225603 (2025-001)

Material Weakness 2025

INTERCAMBIOS PUERTO RICO, INC

PR

Questioned Costs Subrecipient Monitoring Reporting § 200.512

Views of Reasonable Officials and Corrective Actions Organization will engage in assessing specific staffing needs (FY26), seeking additional funds (FY26 & FY27),and increasing the capacity of the team in charge of providing services in accounting and organizational funds(FY27) in order to achieve a...

Views of Reasonable Officials and Corrective Actions Organization will engage in assessing specific staffing needs (FY26), seeking additional funds (FY26 & FY27),and increasing the capacity of the team in charge of providing services in accounting and organizational funds(FY27) in order to achieve accurate and timely reporting. Name(s) of the Contact Person(s) Responsible for Corrective Action Rafael A Torruella, Ph.D.- Executive Director Anticipated Completion Date During FY 2025-2026 & FY2026-2027

View Audit 408485

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