Corrective Action Plans

Finding 1205529 (2025-002)

Material Weakness 2025

Alpha One

ME

Questioned Costs Procurement, Suspension & Debarment

Management concurs with this finding. Maintaining complete and accurate receipt documentation is essential for ensuring proper expense coding, supporting auditability, and maintaining compliance with organizational policies and funding requirements. Upon identification of this exception, management ...

Management concurs with this finding. Maintaining complete and accurate receipt documentation is essential for ensuring proper expense coding, supporting auditability, and maintaining compliance with organizational policies and funding requirements. Upon identification of this exception, management initiated corrective actions to reinforce our internal controls over receipt retention and documentation. Accounting staff have been re-trained on our receipt-tracking procedures, with an emphasis on the requirement that receipts must be obtained and retained for all meal expenses. We will continue to monitor compliance with these updated procedures to ensure their effectiveness. The anticipated completion date for this corrective action is 11/1/2025.

View Audit 397202

Finding 1205506 (2025-002)

Material Weakness 2025

Susquehanna Workforce Network INC

MD

Allowable Costs / Cost Principles Questioned Costs § 200.334 § 200.403

SWN will develop additional review procedures over contracts to ensure proper adjustments are proposed to allocate expenses between proper periods. Procedure for approval of the Finance Committee by May 21, 2026. This procedure may include implementation of official listing of SWN's written contract...

SWN will develop additional review procedures over contracts to ensure proper adjustments are proposed to allocate expenses between proper periods. Procedure for approval of the Finance Committee by May 21, 2026. This procedure may include implementation of official listing of SWN's written contracts and vendor contracts. Additionally, the Organization plans to work with vendors to align contracts with the fiscal reporting period.

View Audit 397189

Finding 1205502 (2025-004)

Material Weakness 2025

Oregon Cascades West Council of Governments

OR

Questioned Costs Matching / Level of Effort / Earmarking

Reporting issues with the USDA lending program have been resolved as of March 2025. Steps have been identified to validate and verify information being reported prior to submission. USDA, CCD and Lending staff are working cooperatively on this effort.

View Audit 397187

Finding 1205484 (2025-007)

Material Weakness 2025

Las Vegas City Schools

NM

School Nutrition Programs Equipment & Real Property Management Internal Control / Segregation of Duties § 200.303

Recommendation We recommend the District implement documented daily edit checks reconciling meal counts to attendance records and maintain records of this review. For food inventory, the District should establish a formal inventory system, including perpetual inventory records, monthly physical coun...

Recommendation We recommend the District implement documented daily edit checks reconciling meal counts to attendance records and maintain records of this review. For food inventory, the District should establish a formal inventory system, including perpetual inventory records, monthly physical counts, and supervisory review. Staff involved in Child Nutrition operations should receive training on USDA and federal compliance requirements Management Response Corrective Action The Food Service Director will implement the federally required daily edit check process. This will include comparing daily meal counts against the attendance and enrollment figures to ensure that claims do not exceed the number of students present. Any discrepancies identified during this process will be investigated and documented prior to submission of the monthly claim. The District will also change the tracking of meals served by using an official meal tracking device or by having students use their badge/ID cards to get a more accurate meal count each day. The District has a formal inventory process for all food service supplies including canned goods, dry goods, and freezer items. This system tracks items from receipt through consumption. The District conducts monthly physical inventory counts of all food service assets. These counts are reconciled and any significant variances are reviewed by the Food Service Director and reported to the Business Manager. The District will ensure that all nutrition staff is trained on these procedures as well. Due Date of Completion: June 30, 2026 Responsible Party Business Manager, Food Service Director

View Audit 397169

Finding 1205477 (2025-001)

Material Weakness 2025

Town of Avon, Ma

MA

Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.430

Finding 2025-001 Condition: Semi-annual time and effort certifications were not maintained for grant employees whose salaries and wages were not supported by detailed time records. Corrective Action Planned: Controls will be implemented to ensure all time and effort certifications are completed and ...

Finding 2025-001 Condition: Semi-annual time and effort certifications were not maintained for grant employees whose salaries and wages were not supported by detailed time records. Corrective Action Planned: Controls will be implemented to ensure all time and effort certifications are completed and maintained by the appropriate grant administrators for all grant employees. Anticipated Completion Date: June 30, 2026 Contact: Larry Azer, School Business Manager

View Audit 397156

Finding 1205465 (2025-002)

Material Weakness 2025

Vocational Education and Extension Board of the County of Nassau, Ny

NY

Questioned Costs Special Tests & Provisions Student Financial Aid

Management acknowledges the audit finding related to the absence of a formally documented written information security program. While VEEB has implemented certain administrative and technical safeguards to protect sensitive information, these practices have not been consolidated into a single, writt...

Management acknowledges the audit finding related to the absence of a formally documented written information security program. While VEEB has implemented certain administrative and technical safeguards to protect sensitive information, these practices have not been consolidated into a single, written information security program as required. Management is committed to addressing this matter and plans to formalize its existing information security practices into a written information security program that is appropriate to the size, complexity, and risk profile of the organization. Management expects to complete the development and implementation of the written program during the upcoming fiscal year. Management believes that this condition does not reflect a failure to safeguard information, but rather a documentation gap that will be remedied through the actions described above.

View Audit 397139

Finding 1205464 (2025-001)

Material Weakness 2025

Vocational Education and Extension Board of the County of Nassau, Ny

NY

Student Financial Aid Questioned Costs Subrecipient Monitoring

Management agrees with the finding and has indicated that corrective actions will be implemented to improve monitoring and timeliness of R2T4 returns. Management’s corrective action plan is included in the accompanying schedule.

View Audit 397139

Finding 1205456 (2025-002)

Material Weakness 2025

Housing Authority of the County of Dauphin

PA

Questioned Costs Special Tests & Provisions HUD Housing Programs

Finding Number: 2025-002; Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all client files contain documentation ensuring complia...

Finding Number: 2025-002; Planned Corrective Action: Applicable staff will be briefed on the finding and training will be provided on both written policy and procedure. The Housing Authority has a quality assurance program to monitor and ensure all client files contain documentation ensuring compliance with Rent Reasonableness requirements. Anticipated Completion Date: 6/30/26; Responsible Contact Person: Kristen Runion, HCV Supervisor

View Audit 397134

Finding 1205450 (2025-003)

Material Weakness 2025

Notre Dame of Maryland University, INC

MD

Questioned Costs Special Tests & Provisions Student Financial Aid

Management Response The University concurs with this finding. Management has initiated a review of all relevant institutional academic calendars to ensure that the correct payment period start and end dates are accurately configured within the Colleague system. The Spring 2025 withdrawal population ...

Management Response The University concurs with this finding. Management has initiated a review of all relevant institutional academic calendars to ensure that the correct payment period start and end dates are accurately configured within the Colleague system. The Spring 2025 withdrawal population is being reviewed to determine whether additional R2T4 recalculations and returns of Title IV funds are required. Necessary corrections will be processed promptly. Going forward, the University will implement procedures to verify that system-configured term dates agree to the officially approved academic calendar prior to each academic term to ensure compliance with federal R2T4 requirements. Corrective Action The University is currently reviewing all R2T4 calculations for the Spring 2025 withdrawal population to ensure calculations were accurate. Necessary corrections will be processed promptly. The University is implementing procedures to verify that system-configured term dates agree to the officially approved academic calendar. The procedures include a review and signoff process to ensure multiple individuals review the information for accuracy. Contact Person Responsible Name – Justin Pichey Title – Director of Financial Aid Phone – 410-532-5735 Email - jpichey@ndm.edu Anticipated Completion Date – April 30, 2026

View Audit 397132

Finding 1205449 (2025-002)

Material Weakness 2025

Notre Dame of Maryland University, INC

MD

Questioned Costs Special Tests & Provisions Student Financial Aid

Management Response The University concurs with this finding. Management has reviewed its processes for monitoring and issuing Title IV credit balance refunds and has implemented procedures to ensure refunds are processed within the required 14-day timeframe. The Financial Aid and Student Accounts o...

Management Response The University concurs with this finding. Management has reviewed its processes for monitoring and issuing Title IV credit balance refunds and has implemented procedures to ensure refunds are processed within the required 14-day timeframe. The Financial Aid and Student Accounts offices will review credit balance reports on a regular basis to identify students eligible for refunds and confirm timely disbursement. In addition, staff have been reminded of federal requirements related to credit balance refunds. Management will monitor this process periodically to ensure ongoing compliance. Corrective Action The University reviewed the federal requirements for refunds with applicable members of the Business Office and Financial Aid departments to ensure a thorough understanding of the refund rules. The University enhanced its weekly credit balance review process to require explicit review by the Controller and Director of Financial Aid if uncertainty exists on whether a student is eligible for a refund. This review must be completed within the 14 day period with either the refund issued or the loan removed from the student’s account. Contact Person Responsible Name – Richard Jones Title – Controller Phone – 410-532-5367 Email – rjones13@ndm.edu Anticipated Completion Date – April 30, 2026

View Audit 397132

Finding 1205448 (2025-001)

Material Weakness 2025

Notre Dame of Maryland University, INC

MD

Questioned Costs Special Tests & Provisions Student Financial Aid

Management Response The University concurs with this finding and has implemented corrective actions to prevent recurrence. The entrance counseling loan processing rule parameters within the Colleague financial aid module have been updated to prevent loan authorization and disbursement if entrance co...

Management Response The University concurs with this finding and has implemented corrective actions to prevent recurrence. The entrance counseling loan processing rule parameters within the Colleague financial aid module have been updated to prevent loan authorization and disbursement if entrance counseling has not been received and posted to the student's loan record. The system update was implemented in February 2026. In addition, the University reviewed loans processed during the affected period to confirm no additional instances of noncompliance occurred. Financial aid staff have been reminded of federal entrance counseling requirements, and management will periodically monitor system controls to ensure continued compliance. Corrective Action In February 2026, the University updated the entrance counseling loan processing rule parameters within the Colleague financial aid module. From February 2026 forward, the rule parameters would prevent a loan from disbursing if the entrance counseling was not performed. The University reviewed loans processed during the period July 2024 – Feb 2026 to ensure there were no additional loans processed without entrance counseling. Contact Person Responsible Name – Justin Pichey Title – Director of Financial Aid Phone – 410-532-5735 Email - jpichey@ndm.edu Anticipated Completion Date – March 31, 2026

View Audit 397132

Finding 1205443 (2025-001)

Material Weakness 2025

Marillac Community Health Centers

LA

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

The organization has implemented additional levels of review and prescreening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of mont...

The organization has implemented additional levels of review and prescreening of slide patient data to ensure accuracy and that the data is complete. Routine reviews done by front desk supervisors will be further documented in order to provide additional training to staff as needed. Results of monthly audits performed by service line leaders will be reported to senior leadership. An internal audit will be done by the compliance team and presented to leadership on a quarterly basis. All appropriate admitting staff will go through training to reinforce our slide process and review procedures for all FQHC services.

View Audit 397122

Finding 1205441 (2025-002)

Material Weakness 2025

Camden County Technical Schools

NJ

Allowable Costs / Cost Principles Questioned Costs

Grant salaries and purchase orders will be reviewed for proper accounting. Monthly review with the grant coordinator and the business office will occur to verify appropriate charges.

View Audit 397116

Finding 1205432 (2025-002)

Material Weakness 2025

Nash County

NC

Eligibility Internal Control / Segregation of Duties Questioned Costs

Finding 2025-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2025-002 Name of contact person: Corrective Action: Proposed completion date: Section IV - State Award Findings and Questioned Costs Corrective actions for Finding 2025-002 also apply to State Awards. Secti...

Finding 2025-001 Name of contact person: Corrective Action: Proposed completion date: Finding 2025-002 Name of contact person: Corrective Action: Proposed completion date: Section IV - State Award Findings and Questioned Costs Corrective actions for Finding 2025-002 also apply to State Awards. Section III - Federal Award Findings and Questioned Costs Corrective Action Plan Refresher training sessions will be fully completed for all Medicaid staff by the end of January 2026. Documentation standards and quality review processes are already in effect, with ongoing monitoring. Angel Carpenter and Goldie Davis - Medicaid Supervisors All Medicaid caseworkers will complete targeted refresher training on key eligibility and budgeting rules, including the use of online verification systems, accurate income and deduction calculations, household composition, recertification processes, and proper case documentation standards. Training will be delivered through a combination of state Learning Gateway courses, webinars, and internal sessions, with knowledge checks to confirm understanding. Staff will be reminded that “if it’s not documented, it didn’t happen.” Standardized documentation templates have been created and are now required for all cases to ensure thorough, clear, and consistent case notes. Second-party case reviews will continue and be expanded as needed to monitor ongoing accuracy. Case errors and lessons learned will be regular agenda items at monthly staff meetings, with emphasis on double-checking determinations before authorizing or releasing cases in NC FAST. Dedicated weekly time will be protected for staff to work pending verifications and system reports, with supervisory review. Section II - Financial Statement Findings 8/14/2025 Nikki Stanton, Finance Director The Nash County Finance Director was appointed effective April 14, 2025. Since that time, Finance has undertaken the following measures to strengthen operations and internal controls: • Reclassified job duties to better align responsibilities with organizational needs and improve efficiency. • Implemented additional internal controls to enhance the reliability and accuracy of financial processes. • Recruited and onboarded a dedicated Accountant to support the Accounting Manager. These changes have enabled the Accounting Manager to concentrate on performing timely reconciliations and preparing accurate journal entries, thereby improving the overall timeliness and quality of financial reporting. For the Year Ended June 30, 2025 Claude Mayo Jr. Administration Building • 120 West Washington Street, Suite 3072 • Nashville, NC 27856 Phone (252) 459-9800 • Fax (252) 459-9817 188

View Audit 397103

Finding 1205414 (2025-002)

Material Weakness 2025

University of Maryland Medical System Corporation

MD

Questioned Costs Allowable Costs / Cost Principles Cash Management

C. Cash Management; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressional...

C. Cash Management; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing Assistance Listing 93.078 – Strengthening Emergency Care Delivery in the United States Healthcare System through Health Information and Promotion Assistance Listing 16.753 – Congressionally Recommended Awards Federal Agency: Department of Health and Human Services Department of Justice Recommendation: Management should reassess the design of its controls to ensure documentation is retained that evidences the review and approval of expenditures submitted to the DOJ and DHHS for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. ORSPA and Corporate Financial Reporting are developing standard operating procedures and policies for the required review and reconciliation of grant expenditures per the accounting system to the financial submissions to the granting agency, including requirements for maintaining evidence of the review(s). A shared central repository for financial submissions was created. For each grant, this repository includes the financial submission and evidence of review and approval of the financial report submissions. The ORSPA and Corporate Financial Reporting will monitor the repository and work with grant managers to ensure evidence of financial submission review and approval is maintained. Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397091

Finding 1205411 (2025-001)

Material Weakness 2025

West River Transit Authority Dba Prairie Hills Transit

SD

Internal Control / Segregation of Duties Questioned Costs § 200.303

Condition: During our testing of controls over payroll, we identified three instances of payroll summary reports lacking an indication of review and approval. Criteria: The Uniform Guidance 2 CFR 200.303 requires auditees to establish and maintain effective internal control over federal awards that ...

Condition: During our testing of controls over payroll, we identified three instances of payroll summary reports lacking an indication of review and approval. Criteria: The Uniform Guidance 2 CFR 200.303 requires auditees to establish and maintain effective internal control over federal awards that provides reasonable assurance that the awards are being managed in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The Organization should have a system of internal control in place to provide reasonable assurance that payroll summary reports are accurate and are being reviewed. Repeat of Prior Year Finding: No. Auditor’s Recommendation: We recommend that payroll summary reports be reviewed and approved prior to completing the payroll process. If the Executive Director is unavailable, another staff member should review and approve the reports so the payroll process can be completed. Management’s Response: Payroll reports will be reviewed and approved by the Executive Director. If the Executive Director is unavailable, another staff member will review and approve the reports. The Executive Director has reviewed and approved all payroll reports to date. Completion Date: March 17, 2026

View Audit 397085

Finding 1205391 (2025-102)

Material Weakness 2025

Pima County

AZ

Cash Management Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.328 § 200.334

2025-102 The County did not develop internal control procedures over program reporting and cash management requirements, increasing risk of report errors to awarding agencies and wrongly receiving monies Cluster Name: Workforce Innovation and Opportunity Act (WIOA) Cluster Assistance Listings number...

2025-102 The County did not develop internal control procedures over program reporting and cash management requirements, increasing risk of report errors to awarding agencies and wrongly receiving monies Cluster Name: Workforce Innovation and Opportunity Act (WIOA) Cluster Assistance Listings numbers and program names: 17.258 WIOA Adult Program 17.259 WIOA Youth Activities 17.278 WIOA Dislocated Worker Formula Grants Award Numbers and years: IGA DI21-002286 July 1, 2024 through June 30, 2025 IGA DI23-002389 July 1, 2023 through June 28, 2028 Assistance Listings numbers and program name: 21.027 COVID-19—Coronavirus State and Local Fiscal Recovery Funds Award Numbers and years: 1505-0271 March 3, 2021 through December 31, 2024 CT-FM-22-149 October 1, 2024 through September 30, 2025 SLFRFP1962 January 5, 2023 through December 31, 2026 CTR069300 January 1, 2024 through December 30, 2026 GTAW-FM-23*123 October 3, 2022 through July 3, 2026 ACJC-VC-25-001A July 1, 2024 through December 31, 2024 Assistance Listings numbers and program name: 93.268 Immunization Cooperative Agreements Award numbers and years: CTR062571 July 1, 2022 through June 30, 2025 CTR059891 July 1, 2022 through June 30, 2027 Name of contact person: Art Cuaron, Director, Finance and Risk Management Anticipated completion date: June 30, 2027 The County recognizes the need to strengthen internal controls over federal reporting and cash management requirements. F&RM will complete the following actions to ensure compliance with 2 CFR Part 200: 1. Establish written internal control policies and procedures for federal program reporting. All federal financial reports will undergo an independently documented review before submission to ensure accuracy, allowability, and proper reporting periods. 2. Implement documentation standards requiring staff to retain supporting materials such as system reports, financial queries, screenshots, and reconciliations, in accordance with federal and County retention requirements. 3. Pima County has been working with each of its grant implementing entities to use Euna Grants calendaring and reminders to prompt the entities’ timely reporting activities. Grants Management and Innovation (GMI) Department sets the reminders schedule at the onset of the performance period. The reminders are then automatically emailed to the grants manager and the assigned accountant for each grant on a set schedule throughout the course of the grant. GMI and Finance – Grants will continue to work with grant implementing entities to use these reminders to trigger the necessary actions in a timely manner. Pima County was still in the process of institutionalizing this system during FY25. 4. Provide training for staff who prepare and review federal reports, focusing on reporting requirements, documentation standards, internal controls, and record retention. 5. Conduct periodic management oversight reviews to confirm that internal controls are followed and that reports are complete, accurate, and submitted on time. The County is also planning to implement the Workday Grants Module with an anticipated go-live of July 1, 2027. This solution will enhance our ability to manage the full fiscal lifecycle of grant awards and ensure compliance with federal reporting requirements. The Workday Grants Module is a native Workday solution, purpose-built to support the full fiscal grant lifecycle. The module supports the following financial grant objectives: • Grant setup and award and fiscal tracking • Cost allocation and allocability controls • Real-time grant financial reporting • Compliance with federal Uniform Guidance (2 CFR 200) • Integration with Workday Financial Management, Procurement and Human Capital Management (HCM) In addition, F&RM has submitted FY 2026/27 budget requests to fund three additional Accountant III positions in our Finance – Grants Division. These positions will expand our capacity to manage our grant portfolio and strengthen our reconciliation, billing and SEFA preparation processes. The contract for the Workday Grants Module is scheduled to go before the Board of Supervisors for approval in April. These new positions will be included in the County Administrator’s Recommended Budget and will be considered by the Board as part of the full budget adoption process in June.

View Audit 397080

Finding 1205380 (2025-002)

Material Weakness 2025

South Carolina State University

SC

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

Finding 2025-001 – Special Tests and Provisions: Enrollment Reporting – Status Change at Program Level Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-001 related to deficiencies in enrollment reporting at the program level under the Pell Grant, Direct ...

Finding 2025-001 – Special Tests and Provisions: Enrollment Reporting – Status Change at Program Level Corrective Action Plan I. Overview and Acknowledgment The University acknowledges Finding 2025-001 related to deficiencies in enrollment reporting at the program level under the Pell Grant, Direct Loan, and Federal Family Education Loan (“FFEL”) programs. The University concurs with the finding and recognizes the importance of accurate and timely reporting to the National Student Loan Data System (“NSLDS”) in accordance with federal requirements (OMB No. 1845-0035). The University is committed to strengthening internal controls, enhancing operational procedures, and ensuring full compliance with all enrollment reporting requirements. II. Criteria Institutions participating in federal student aid programs are required to: • Report accurate enrollment information through NSLDS, including enrollment status and program-level data elements. • Ensure that all significant data elements—including enrollment status, program begin date, and enrollment effective date—are accurate as of the reporting date. • Submit enrollment reporting updates at least every 60 days (bi-monthly). • Maintain adequate internal controls to ensure data integrity and compliance with federal regulations. III. Condition The audit identified errors in enrollment reporting for a sample of 25 students, including: • 2 instances of incorrect program enrollment effective date reporting These errors were attributed to administrative oversight and insufficient internal controls governing enrollment reporting processes. IV. Cause Analysis The University has identified the following contributing factors: • Insufficient internal controls and review mechanisms over enrollment status updates • Limited system automation and alert capabilities for tracking status changes • Inadequate staffing resources to manage reporting timelines and data verification • Lack of formalized cross-functional coordination between the Office of the Registrar and reporting entities • Absence of an independent monitoring function to ensure compliance consistency V. Corrective Actions and Implementation Plan The University will implement the following corrective actions to address the identified deficiencies: 1. Establishment of Internal Audit Function • The University will establish a formal Internal Audit function by the start of the next academic year. • This function will have broad authority to oversee compliance, enforce corrective actions, and evaluate internal controls across all relevant departments. • Internal Audit will lead ongoing reviews of enrollment reporting processes and ensure accountability. 2. Process Review and Cross-Functional Collaboration • Internal Audit will coordinate a comprehensive review of enrollment reporting processes involving the Office of the Registrar and the National Student Loan Clearinghouse. • This review will include a structured assessment of strengths, weaknesses, opportunities, and risks (SWOT analysis). • Standard operating procedures (SOPs) will be updated and formally documented. 3. Staffing and Resource Enhancements • The University will enhance staffing within the Office of the Registrar to support enrollment reporting functions. • Additional technological tools and system capabilities will be implemented to provide automated alerts, status tracking, and exception reporting. 4. Implementation of Monitoring and Control Systems • A robust monitoring system will be deployed to: o Track student enrollment status changes in real time o Generate alerts for discrepancies or missing data o Ensure timely submission of required updates to NSLDS • Data validation checkpoints will be integrated prior to submission to ensure accuracy. 5. Strengthening Reporting Protocols • Interim control measures will include the submission of transfer student status reports on a semester basis until full remediation is achieved. • All enrollment updates will undergo a secondary review and certification prior to submission. • A compliance calendar will be implemented to ensure adherence to the 60-day reporting requirement. 6. Training and Accountability Measures • Mandatory training sessions will be conducted for all personnel involved in enrollment reporting. • Training will focus on federal requirements, data accuracy standards, and system utilization. • Performance expectations and accountability metrics will be clearly defined and monitored. VI. Timeline for Implementation • Immediate (0–90 Days): o Initiate staffing enhancements o Implement interim review and validation procedures o Conduct training sessions • Short-Term (90–120 Days): o Deploy monitoring and alert systems o Formalize SOPs and compliance calendar o Begin enhanced reporting protocols • Long-Term (By Start of Next Academic Year): o Fully establish Internal Audit function o Complete comprehensive process review and continuous monitoring framework VII. Monitoring and Ongoing Compliance The Internal Audit function will conduct periodic reviews and report findings for executive leadership. Continuous monitoring will ensure that corrective actions remain effective and that compliance with federal regulations is sustained. VIII. Conclusion Through the implementation of these corrective measures, the University will address the deficiencies identified in Finding 2025-001 and significantly strengthen its internal control environment. These actions will ensure accurate and timely enrollment reporting, uphold the integrity of federal student aid programs, and reinforce the University’s commitment to regulatory compliance and operational excellence. Anticipated Completion Date: September 1, 2026

View Audit 397073

Finding 1205371 (2025-001)

Material Weakness 2025

Council for Jewish Elderly and Subsidiaries

IL

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

Finding: The company did not implement the HUD approved rent adjustments for October 2024 in a timely fashion. Corrective Actions Taken: Management subsequently made the retroactive adjustments to HUD which have been approved by and paid to HUD. In addition, management has implemented a formal revie...

Finding: The company did not implement the HUD approved rent adjustments for October 2024 in a timely fashion. Corrective Actions Taken: Management subsequently made the retroactive adjustments to HUD which have been approved by and paid to HUD. In addition, management has implemented a formal review and corss-verification process to ensure that rent adjustments are completed accurately and in a timely manner.

View Audit 397066

Finding 1205370 (2025-101)

Material Weakness 2025

Cochise County

AZ

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Cochise County Corrective Action Plan Year ended June 30, 2025 2025-101 Assistance Listings number and name: 10.557 WIC Special Supplemental Nutrition Program for Women, Infants, and Children Award number and years: CTR067930, October 1, 2023 through September 30, 2028 Federal agency: U.S. Departmen...

Cochise County Corrective Action Plan Year ended June 30, 2025 2025-101 Assistance Listings number and name: 10.557 WIC Special Supplemental Nutrition Program for Women, Infants, and Children Award number and years: CTR067930, October 1, 2023 through September 30, 2028 Federal agency: U.S. Department of Agriculture Pass-through grantor: Arizona Department of Health Services Compliance requirement: Eligibility Questioned costs: Unknown The County did not perform eligibility certification requirements, resulting in an increased risk of program participants receiving benefits they are not eligible to receive Contact: Barbara Lang Completion date: March 2026 Corrective Action: Cochise County WIC leadership and staff are committed to full adherence with WIC policy and will continue to implement training, monitoring, and communication to ensure compliance with federal and state regulation. This audit timeframe produced findings primarily related to issues that have already been corrected through the departure of staff that contributed to the findings (to include the previous Directors), hiring of new staff with a more thorough and comprehensive training plan implemented, and staff effort to retroactively collect all required signatures at subsequent appointments to ensure all WIC clients have current signatures and understanding of Rights & Obligations and Consents for their certification period. We recognize that these new processes were not put into plan until June 2025, due to the timing of the previous audit, and therefore did not reflect on the July 1, 2024 – June 30, 2025 audit period. In addition to the above resolved issues, a new WIC director was hired in September 2025 and new policies and procedures were immediately developed and put into place. These new policies and procedures that serve as our already implemented corrective action plan are as follows: Staff Training a. All staff are required to complete the full ADHS WIC-sponsored live cohort training courses upon hire, and every 3 years of their employment to ensure competencies are maintained over time. b. All staff complete their annual Civil Rights, Conflict of Interest, and Confidentiality upon hire and annually. Last annual training was completed Fall 2025. c. A staff dedicated as Training Coordinator monitors training logs and ensure all training requirements are met, with additional oversight by the WIC Director and the ADHS WIC State office. d. In-person staff meetings are held monthly, with a significant portion of time dedicated to staff training on programmatic expectations to ensure all staff obtain the same information so that tasks are carried out in a standardized method. e. Weekly team huddles to review any timely findings or discuss issues as a group. f. Weekly 1:1’s with each staff to discuss areas where the employee may need additional training or to discuss any deficiencies the WIC manager has noticed, (i.e. note-taking/documentation, single income verifications, chart review findings, etc.). Separation of Duties g. Cert List for Audits report run every 2 weeks for each clinic/staff person to review adherence to Separation of Duties. i. Follow up with certain percentage of clients per policy to assess how the certification went and verify client information. ii. Follow up with staff if any issues are identified. h. Staff have been training on during staff meetings in July 2025, August 2025, October 2025, and during new employee training on how to properly use the HANDS system to ensure the system accurately records who completed the 2nd income verification. i. Revision of Separation of Duties policy and implementation of new “protected time” procedure to ensure there is a staff person available at almost all times of day to complete the 2nd IV. *Since approval of this policy the ADHS WIC state office on 1/5/2026 and implementation of this policy/procedure, the Cert List for Audit report of single-income verifications has decreased substantially (from 60 in 2 weeks, to 5), all with documented reasons why 2nd IV was unable to be obtained during certification appointment and notes verifying 2nd IV was completed on another date. Rights and Obligations and Consent Forms a. All staff received a refresher training on 8/26/25, will be retrained annually, and are regularly reminded to obtain both required signatures at certification b. If staff are unable to obtain digital signatures due to tech issues, they are required to obtain e-document signatures via the clients email, or written signatures the staff then scans into the client file c. Chart reviews and staff observations are completed on a monthly-bimonthly basis to ensure ongoing staff compliance with policy and procedure

View Audit 397064

Finding 1205361 (2025-003)

Material Weakness 2025

City of Alexandria

VA

Questioned Costs Subrecipient Monitoring Reporting § 200.303

HeadStart Assistance Listing No. 93.600 Recommendation: We recommend that DCHS review procedures and internal controls to ensure that the required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Documentation o...

HeadStart Assistance Listing No. 93.600 Recommendation: We recommend that DCHS review procedures and internal controls to ensure that the required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Documentation of supporting compliance should be readily available for review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The reporting has been completed. New employees will be trained in the procedures and internal controls to ensure that the required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Documentation will be available for review during the audit period. Name(s) of the contact person(s) responsible for corrective action: Noah Abraham, DCHS Operations Director. Planned completion date for corrective action plan: Complete

View Audit 397053

Finding 1205356 (2025-003)

Material Weakness 2025

Health Resources in Action, INC

MA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

2025-003 Program Name: Environmental Justice Thriving Communities Grantmaking Program; Assistance Listing Number: 64.615 Compliance Requirement Affected: Reporting: Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements mad...

2025-003 Program Name: Environmental Justice Thriving Communities Grantmaking Program; Assistance Listing Number: 64.615 Compliance Requirement Affected: Reporting: Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements made with federal funds. Disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented additional controls to ensure that each program has documented procedures to submit required reports timely and accurately. The untimely filing of reports in fiscal year 2025 resulted from a change in personnel. During fiscal year 2026, management identified all applicable reporting requirements and assigned responsibility to appropriate personnel. Additional procedures were implemented to ensure reports are reviewed and submitted in accordance with required deadlines. Name of the contact person responsible for corrective action: Beth Doreian, CFO Planned completion date for corrective action plan: March 1, 2026

View Audit 397051

Finding 1205354 (2025-002)

Material Weakness 2025

Health Resources in Action, INC

MA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

2025-002 Program Name: Community-Based Violence Intervention and Prevention Initiative; Assistance Listing Number: 16.045 Compliance Requirement Affected: Reporting: Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements ma...

2025-002 Program Name: Community-Based Violence Intervention and Prevention Initiative; Assistance Listing Number: 16.045 Compliance Requirement Affected: Reporting: Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements made with federal funds. Disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented additional controls to ensure that each program has documented procedures to submit required reports timely and accurately. The untimely filing of reports in fiscal year 2025 resulted from a change in personnel. During fiscal year 2026, management identified all applicable reporting requirements and assigned responsibility to appropriate personnel. Additional procedures were implemented to ensure reports are reviewed and submitted in accordance with required deadlines. Name of the contact person responsible for corrective action: Beth Doreian, CFO Planned completion date for corrective action plan: March 1, 2026

View Audit 397051

Finding 1205352 (2025-001)

Material Weakness 2025

Health Resources in Action, INC

MA

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

2025-001 Program Name: Community-Based Violence Intervention and Prevention Initiative; Assistance Listing Number: 16.045 Compliance Requirement Affected: Procurement Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements m...

2025-001 Program Name: Community-Based Violence Intervention and Prevention Initiative; Assistance Listing Number: 16.045 Compliance Requirement Affected: Procurement Recommendation: HRIA should improve controls/processes around reporting to ensure documentation is retained related to procurements made with federal funds. Disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented additional procedures to ensure that required procurement documentation is appropriately retained for each vendor in accordance with Uniform Guidance requirements. These procedures were implemented and management considers the matter to be fully remediated during fiscal year 2026. Name of the contact person responsible for corrective action: Beth Doreian, CFO Planned completion date for corrective action plan: March 1, 2026

View Audit 397051

Finding 1205342 (2025-004)

Material Weakness 2025

The Edinburg Center, Inc.

MA

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization review controls in place to ensure expenses are approved and maintain evidence of approval. Explanation of disagreemen...

U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization review controls in place to ensure expenses are approved and maintain evidence of approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New Management has adopted a new A/P process for invoice approvals. Approved invoices are required for expenses to be paid. All autopay features on utility bills has been removed. Name(s) of the contact person(s) responsible for corrective action: Kate Mombourquette Planned completion date for corrective action plan: Completed 12/31/2025

View Audit 397046

Corrective Action Plans

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