Corrective Action Plans

Finding 1161359 (2025-002)

Material Weakness 2025

MN

Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagre...

Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Augsburg University will update its Written Information Security Program to: * More fully document the processes and procedures to dispose of customer information securely * Maintain a log of authorized users’ activity and keep an eye out for unauthorized access. Names of the contact persons responsible for corrective action: Scott Krajewski Planned completion date for corrective action plan: May 31, 2026

View Audit 371249

Finding 1161353 (2025-001)

Material Weakness 2025

Augsburg University

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreeme...

Student Financial Assistance Cluster— Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student Financial Services is working with the Registrar to update our reporting practices for students with student teaching requirements. The registrar has connected with the Clearinghouse to confirm and utilize a separate file type for this population, which should resolve the reporting date issue. Name of the contact person responsible for corrective action: Catherine Maun Planned completion date for corrective action plan: May 31, 2026

View Audit 371249

Finding 1161342 (2025-001)

Material Weakness 2025

King University

TN

Questioned Costs Student Financial Aid Reporting

2025‐001 Significant Deficiency: Working During Scheduled Class Time (U.S. Department of Education, Federal Work Study Program, ALN #84.033) Responsible Officials: Christin Mustard, Director of Financial Aid, is responsible for overseeing campus-based funding, and Melissa Tolbert, Financial Aid Offi...

2025‐001 Significant Deficiency: Working During Scheduled Class Time (U.S. Department of Education, Federal Work Study Program, ALN #84.033) Responsible Officials: Christin Mustard, Director of Financial Aid, is responsible for overseeing campus-based funding, and Melissa Tolbert, Financial Aid Office Manager, manages the work study contracts and training with supervisors and students. Kelly Pennington, Payroll and Benefits Supervisor, is responsible for paying work study students. Summary of Finding: During the audit, it was noted that a student appears to have been paid for Federal Work Study hours logged and submitted for time the student was scheduled to be in class without acceptable exemption, which contradicts guidance provided by the 2024-2025 Federal Student Aid Handbook, resulting in an over-payment of $11. Corrective Action Plan: King University has implemented a new mandatory training module for both work study students and supervisors. This training must be completed before a student is cleared to begin working, and this step will be an annual requirement for all new and returning students and supervisors. The training includes key points from the Work Study Handbook and an assessment test that must be passed in order to be cleared for work. Our Work Study Coordinator is completing individual training with all new supervisors as well as refresher training with returning supervisors. Supervisors are informed of their responsibility to verify the accuracy of all timesheets submitted and to ensure that clocked hours do not overlap with scheduled class time. They are required to meet with their work study students in advance to review the policies and expectations outlined in the Work Study Handbook. Both the student and supervisor must sign a document acknowledging that they have read the handbook. Timely communications and reminders will be sent throughout the academic year to supervisors and students as well. As an added safeguard, our IT department has created a report that compares student timesheets to their class schedules to ensure there is no overlap with class time. This report will be run by payroll or financial aid staff prior to each pay cycle to verify compliance. Anticipated Completion Date: King University has returned the overpayment of $11 to the Department via G6 in September 2025.

View Audit 371237 Questioned Costs: $1

Finding 1161290 (2025-001)

Material Weakness 2025

Presbyterian Homes

IL

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Coordinated with Illinois Emergency Management Agency to correct duplicate line items in grant cost summary. Cost summary was corrected before closing out grant. Management has implemented controls in the future to prevent duplicate invoices from being submitted.

View Audit 371213

Finding 1161274 (2025-004)

Material Weakness 2025

MacAlester College

MN

Procurement, Suspension & Debarment Significant Deficiency

Research & Development Cluster – CFDA No. 47.050 Recommendation: We recommend that the Grants Accounting team implement a control to ensure that suspension and debarment checks are both performed and formally documented prior to processing payments of $25,000 or more. Explanation of disagreement wit...

Research & Development Cluster – CFDA No. 47.050 Recommendation: We recommend that the Grants Accounting team implement a control to ensure that suspension and debarment checks are both performed and formally documented prior to processing payments of $25,000 or more. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has amended its procedures for approving federal grant expenditures to ensure that review for suspension and debarment is formally documented prior to payments of $25,000 or more. Name of the contact person responsible for corrective action: Matthew Walters, Director of Accounting Planned completion date for corrective action plan: October 31, 2025

View Audit 371195

Finding 1161273 (2025-003)

Material Weakness 2025

MacAlester College

MN

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Student Financial Assistance Cluster – CFDA No. 84.038 Recommendation: We recommend that the College review all retired/assigned Perkins loan files to ensure MPNs are present and properly retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actio...

Student Financial Assistance Cluster – CFDA No. 84.038 Recommendation: We recommend that the College review all retired/assigned Perkins loan files to ensure MPNs are present and properly retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College will review assigned and retired files for the Master Promissory Notes. Name of the contact person responsible for corrective action: Deb Schmidt, Director of Student Accounts Planned completion date for corrective action plan: February 28, 2026

View Audit 371195

Finding 1161272 (2025-002)

Material Weakness 2025

MacAlester College

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – CFDA No. 84.063, 84.268 Recommendation: We recommend the College review its reporting procedures to ensure the students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: No disagreement with t...

Student Financial Assistance Cluster – CFDA No. 84.063, 84.268 Recommendation: We recommend the College review its reporting procedures to ensure the students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: No disagreement with the audit finding. Action taken in response to finding: The College will review our reporting procedures to ensure that students’ statuses re reported accurately to NSLDS, as required by regulations. Name of the contact person responsible for corrective action: Bethany Miller, Interim Registrar; Associate Provost & Chief Data Officer. Planned completion date for corrective action plan: December 20, 2025

View Audit 371195

Finding 1161269 (2025-001)

Material Weakness 2025

MacAlester College

MN

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.303

Student Financial Assistance Cluster – CFDA No. 84.063, 84.268 Recommendation: We recommend the College review its procedures to ensure controls are in place to ensure to catch any inconsistencies that occur during the year. Explanation of disagreement with audit finding: No disagreement with the au...

Student Financial Assistance Cluster – CFDA No. 84.063, 84.268 Recommendation: We recommend the College review its procedures to ensure controls are in place to ensure to catch any inconsistencies that occur during the year. Explanation of disagreement with audit finding: No disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office will maintain documentation of monthly communication between the External Programs Manager, the Financial Aid Director and the Director of Accounting, related to the monthly reconciliation of Federal Direct Loans, Federal Pell Grant. Federal SEOG and Federal Work Study programs. Name of the contact person responsible for corrective action: Jenae Schmidt, Director of Financial Aid Planned completion date for corrective action plan: September 30, 2025

View Audit 371195

Finding 1161263 (2025-002)

Material Weakness 2025

Milligan University

TN

Questioned Costs Student Financial Aid HUD Housing Programs

Finding Reference Number: 2025-002 Working During Scheduled Class Time Summary of Finding: Students are not permitted to work in Federal Work Study positions during scheduled class times. Exceptions are permitted if an individual class is cancelled, if the instructor has excused the student from att...

Finding Reference Number: 2025-002 Working During Scheduled Class Time Summary of Finding: Students are not permitted to work in Federal Work Study positions during scheduled class times. Exceptions are permitted if an individual class is cancelled, if the instructor has excused the student from attending for a particular day, and if the student is receiving credit for employment in an internship, externship, or community workstudy experience with exemptions being appropriately documented. The University had a few instances in which appropriate documentation for exemptions had not been obtained by the supervisors. The known error is $99 with extrapolation of the error across the population at $3,115. Entity’s Corrective Action Plan: The University understands the federal guidelines and provided reminders to all students and supervisors, via email, that students are not permitted to work during scheduled class times; the reminders were sent at the end of each pay period throughout the 2024-25 year. In August 2025, the University provided a required training session for all work study supervisors and reviewed the importance of compliance with this specific aspect of managing FWS as well as all other federal requirements governing the Federal Work Study Program. Supervisors and students continue to receive bi-monthly reminders of this policy. Supervisors are expected to monitor when their students are working and to know their students’ class schedules. They are expected to request documentation if clock-in times, or any period of their work shift, falls within a scheduled class time. Additionally, for 2025-26, the Human Resource Office is developing a review process to determine that appropriate documentation has been obtained if a student meets one of the eligible exemption criteria. Anticipated Completion Date: November 1, 2025 Name and Title of Responsible Person: Gus Morgan, Interim Financial Aid Director and VP for Enrollment Services and Rebecca Proffitt, Payroll and Student Employment Coordinator

View Audit 371188 Questioned Costs: $1

Finding 1161133 (2025-001)

Material Weakness 2025

Boys & Girls Club of Weber-Davis

UT

Procurement, Suspension & Debarment Subrecipient Monitoring Cash Management

BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by th...

BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by the grant facilitator to provide member income data. However, to ensure compliance with federal reporting requirements, we will begin requesting income information from our members. In addition, we will reach out to our partner schools to determine whether they can confirm which of our members participate in the free or reduced lunch program.

View Audit 371150

Finding 1160966 (2025-001)

Material Weakness 2025

North Greenville University

SC

Student Financial Aid Allowable Costs / Cost Principles Eligibility

Need Analysis Planned Corrective Action: 1. A revised internal procedure has been implemented, requiring a secondary review of all loan award allocations prior to disbursement to confirm compliance with federal regulations. 2. Staff members responsible for loan origination and packaging have been as...

Need Analysis Planned Corrective Action: 1. A revised internal procedure has been implemented, requiring a secondary review of all loan award allocations prior to disbursement to confirm compliance with federal regulations. 2. Staff members responsible for loan origination and packaging have been assigned refresher training on federal loan awarding requirements, with specific emphasis on annual and aggregate loan limits and the prioritization of subsidized eligibility. 3. System-level reports have been created to identify potential discrepancies in loan allocation, which will be reviewed monthly by the Financial Aid Office. Ongoing Monitoring: The Director of Financial Aid will oversee the monitoring process each term to ensure compliance with 34 CFR 685.203, and 34 CFR 685.301 requirements. Any discrepancies identified will be corrected immediately and documented as part of the institution’s internal compliance log. North Greenville University believes these corrective measures address the issue identified and will prevent recurrence of similar errors. Person Responsible for Corrective Action Plan: Cindi Patterson, Director of Financial Aid Anticipated Date of Completion: October 1, 2025

View Audit 371000

Finding 1160856 (2025-004)

Material Weakness 2025

Texas Christian University

TX

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.430

To safeguard from future errors and ensure data accuracy, Human Resources partnered with Enterprise Application Services department to develop an automated process that populates earnings codes and project account codes based on employee, job record and earnings code. This enhancement streamlines da...

To safeguard from future errors and ensure data accuracy, Human Resources partnered with Enterprise Application Services department to develop an automated process that populates earnings codes and project account codes based on employee, job record and earnings code. This enhancement streamlines data entry by consolidating it into a single interface, reducing the risk of manual entry errors. Additionally, the HR Technology Manager has implemented a new monitoring report to track employees with multiple salary distribution accounts as a part of payroll process. The biweekly report will be automatically generated and sent via email to HR’s HRIS Consultants for review. The HRIS Consultants will analyze the report, resolve any discrepancies and escalate any issues to the HR Technology Manager or Lead Application Consultant as necessary. These processes will be routinely reviewed, with adjustments made as needed.

View Audit 370942 Questioned Costs: $1

Finding 1160855 (2025-003)

Material Weakness 2025

Texas Christian University

TX

Questioned Costs Student Financial Aid Eligibility

The University has found a critical breakdown in communication between the Ranch Management department and the Registrar’s Office, stemming from informal, ad hoc processes that have not scaled with institutional needs. Specifically, there is no formal mechanism to ensure that updates to student stat...

The University has found a critical breakdown in communication between the Ranch Management department and the Registrar’s Office, stemming from informal, ad hoc processes that have not scaled with institutional needs. Specifically, there is no formal mechanism to ensure that updates to student statuses for the ranch management program are consistently reported or verified. To prevent recurrence of this issue, a process is being implemented that all Non-Degree programs will now be required to perform formal degree audits within the student information system. This ensures consistency in processing and aligns with practices currently used for degree-seeking students. Targeted training and communication will be provided to all Non-Degree program administrators to ensure clarity on new expectations, tools, and timelines. The Registrar’s Office will conduct periodic audits of non-degree program records to verify compliance and identify any further process improvements.

View Audit 370942 Questioned Costs: $1

Finding 1160397 (2025-001)

Material Weakness 2025

University of Mary Hardin-Baylor

TX

Student Financial Aid Special Tests & Provisions Reporting

Finding 2025-001 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster ALN: 84.268 Finding Summary: For a small group of students with very specific circumstances, our software’s enrollment report autopopulated an effective date of enrollment change tha...

Finding 2025-001 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster ALN: 84.268 Finding Summary: For a small group of students with very specific circumstances, our software’s enrollment report autopopulated an effective date of enrollment change that did not match the actual effective date. UMHB did not realize that these specific circumstances would require manual processes to identify and correct the enrollment report prior to submission. As a result, four students had incorrect status change effective dates reported to NSLDS. Responsible Individuals: Trent Bridges, Director Data Quality and Institutional Analytics Corrective Action Plan: UMHB plans to implement the following: 1. Review all the coding on system reports used for NSLDS reporting to assess accuracy and completeness of the data based on any changes in business practice and make updates to system reports as necessary. 2. Update internal process to document any required special handling of records based on system limitations. 3. Reassess system report and processes used for NSLDS reporting prior to the beginning of each fall and spring semester. Anticipated Completion Date: Fall 2025

View Audit 370810

Finding 1160239 (2025-002)

Material Weakness 2025

Northwest University

WA

Student Financial Aid Reporting Significant Deficiency

Auditors noted that for two of the six sampled students, funds were returned to ED more than 45 days after the date the University determined the student had withdrawn. For one selection, a Return of Title IV calculation was performed timely, but an administrative error caused the disbursement to be...

Auditors noted that for two of the six sampled students, funds were returned to ED more than 45 days after the date the University determined the student had withdrawn. For one selection, a Return of Title IV calculation was performed timely, but an administrative error caused the disbursement to be delayed eight months. For the second selection, the University was notified of withdrawal in early March 2025 and student was included in registrar’s withdrawal listing, but was missed in review by Student Financial Services until late April 2025. Contact Person(s): Vickie Rekov, VP Enrollment Services; Roger Wilson, Associate Director of Financial Aid, SFS; Ryan Porter, CFO and Bernie Rundquist, Controller Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: All employees in Student Financial Services and Accounting Office involved in the reporting, distribution, drawdown and return of federal funds have reviewed the criteria under 34 CFR 668.22 The two departments involved will be meeting in the month of September 2025 to review policies and procedures to ensure controls exist and are well documented to ensure funds are returned timely. In-charge personnel will gather training resources to educate those involved in the reporting, disbursement and return of Title IV Funds. Anticipated completion date: October 2025

View Audit 370626

Finding 1159684 (2025-001)

Material Weakness 2025

Virginia Garcia Medical Health Center

OR

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration...

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration, Electronic Health Records (EHR) not operating as expected for one line of the SFDS and error not caught and corrected, and a significant process change from percentage to fixed fee SFDS causing inconsistent application during transition and training period. Planned corrective action: System Configuration:  Leaders for all service lines and Billing Department will work with EHR Support Team and vendor to review and test all possible SFDS options to verify rules are functioning as expected and as outlined in the SFDS policy.  Annual review and testing of EHR rules governing SFDS to validate ongoing compliance. Contact person: Jennifer Velez, Revenue Cycle Director Completion date for action: 10/31/2025 Staff Training and Documentation:  All staff responsible for registration and income verification in all service lines, programs, and sites will receive a review of income eligibility assessment, documentation, and application.  Registration Program Manager and EHR Trainers will work with Learning and Development Department to develop competency standard for income eligibility assessment, documentation, and application for all staff responsible for registration and income verification in all service lines, programs, and sites. All identified staff will be required to demonstrate competence annually using the Learning Management System (LMS).  The Center will audit 5 patient records for FPL (Federal Poverty Level) documentation per site or program two times annually during C-Qual (the Center’s internal audit process). This will result in 180 charts each year.  Site Managers or Department Administrators will review front office dashboard in monthly management meetings and develop site specific action plans if exceptions are identified. This was added to the standing agenda for the Primary Care Clinic Managers (PCCM) meeting in September 2025. Contact person: Angela Hurley, Director of Operations Completion date for action: 12/31/2025 Implementation Controls:  Update SFDS policy to include review and verification of EHR alignment with fee schedule following any update or change approved by the Board of Directors.  Develop checklist for roll-out of changes in SFDS that prompts change management and training team to review readiness and validation procedures before going live with changes. Contact person: Angela Hurley, Director of Operations Completion date for action: 9/30/2025

View Audit 370272

Finding 1159455 (2025-001)

Material Weakness 2025

Great Falls Housing Authority

MT

HUD Housing Programs Eligibility Significant Deficiency

Finding 2025-001- Public Housing Internal Control over Waiting List - Eligibility Noncompliance and Significant Deficiency Low Rent Public Housing - Subsidy ALN 14.850 Corrective Action Plan: The Great Falls Housing Authority printed out waiting lists on the date of the audit finding. We will keep n...

Finding 2025-001- Public Housing Internal Control over Waiting List - Eligibility Noncompliance and Significant Deficiency Low Rent Public Housing - Subsidy ALN 14.850 Corrective Action Plan: The Great Falls Housing Authority printed out waiting lists on the date of the audit finding. We will keep notes on the list and at periodic times when adding or deleting applicants we will maintain all lists in a binder for historical review. Person Responsible: Donna Halbleib, Program Supervisor Anticipated Completion Date: Already implemented and will be continuously kept - March 31, 2026

View Audit 370192

Finding 1154987 (2025-001)

Material Weakness 2025

Community Health Centers of Central Wyoming, Inc.

WY

Special Tests & Provisions Material Weakness Significant Deficiency

2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the sta...

2025-001 Application of Sliding Fee Discounts Corrective action planned: The CFO, Revenue Cycle Manager, Revenue Cycle Coordinator, and billing staff will begin to implement a peer review process of the sliding fee scale applications monthly. Management will develop a peer review form, train the staff on the form, and process to review each application to ensure compliance with the approved policy. The following actions will be taken: 1. Develop a formal peer review form and process for reviewing sliding fee scale applications. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 11, 2025 2. Provide training to all billing staff for peer review process and forms. Implementation of the process after training. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: August 12, 2025 and September 1, 2025 3. Monitor for effectiveness. After completion of peer review, the two managers will review and provide feedback to each employee monthly. Billing staff will be responsible for completing reviews and feedback on process and form structure. a. Responsible Party: Revenue Cycle Manager and Revenue Cycle Coordinator b. Completion Date: September 18, 2025 4. Verify effectiveness. The CFO and Revenue Cycle Manager will conduct a random audit of the peer review forms and ensure compliance with the policy for slide applications and ensure the peer review forms are completed, signed and dated. Anticipated completion date: March 1, 2026 Contact person responsible for corrective action: Evan Condelario, CFO

View Audit 367336

Finding 1153477 (2025-002)

Material Weakness 2025

The Corporation of Gonzaga University

WA

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported wit...

FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported within the federally required timeframe. Strengthening this process will support the timeliness of federal compliance. Response: There is no disagreement with this audit finding. Action taken in response to finding: Some of the corrective actions noted in our response to finding 2025-001 also apply here. For example, quality assurance reports to identify students who withdraw from all classes in a part of term and the upcoming joint training and process mapping session with Student Financial Services and the Registrar’s Office will strengthen understanding of how enrollment status updates drive downstream compliance, including R2T4 processing. These steps will also ensure exceptions are addressed consistently and that communication channels between offices are clear. To address immediate gaps specific to R2T4 compliance, the Registrar’s Office has enhanced training regarding R2T4 compliance requirements related to recording withdrawals and enrollment changes in a timely, accurate and consistent manner. Additional quality checks are being implemented to confirm that withdrawal dates and status changes are entered accurately into the student information system so that R2T4 calculations are completed within federal timeframes. Together, these interventions are designed to ensure the timeliness and accuracy of R2T4 processing and compliance with federal requirements. We expect to have these corrective actions completed by September 12, 2025. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research

View Audit 366726

Finding 1153470 (2025-001)

Material Weakness 2025

The Corporation of Gonzaga University

WA

Student Financial Aid Special Tests & Provisions Reporting

FINDING 2025‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a reconciliation between the system of record and the reporting system to ensure all student changes (enrollment status an...

FINDING 2025‐001 – Special Tests and Provisions – Enrollment Reporting Significant Deficiency in Internal Control over Compliance Recommendation: The University should implement a reconciliation between the system of record and the reporting system to ensure all student changes (enrollment status and address changes) are reported on a timely basis. Response: There is no disagreement with this audit finding. Action taken in response to finding: Gonzaga has already taken action and implemented quality assurance reports and monitoring to ensure all student changes (enrollment status and address changes) are reported timely. Additionally, to strengthen compliance going forward, Student Financial Services and the Registrar’s Office are partnering to conduct a joint annual training and process mapping session for key personnel. This session will provide an overview of enrollment reporting requirements, outline the steps needed when exceptions to normal policies occur, and evaluate processes to improve understanding of how decisions affect both upstream and downstream functions. The session will also focus on building a shared understanding of reporting processes, identifying gaps in procedures and knowledge, and establishing communication channels so that exceptions are addressed timely, consistently and appropriately. These actions are designed to enhance internal controls and ensure compliance of timely reporting between the system of record and the reporting system, and we expect to complete this training by September 12, 2025. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research

View Audit 366726

Finding 1153166 (2025-004)

Material Weakness 2025

Outpatient Medical Center, Inc.

LA

Cash Management Subrecipient Monitoring Material Weakness § 200.305

2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures...

2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures claimed for reimbursement and retains this documentation along with supporting invoices. A qualified, knowledgeable CFO will continue to ensure compliance with these requirements. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations

View Audit 366393

Finding 576119 (2025-001)

Significant Deficiency 2025

Berkshire Retirement Home INC

MA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should incr...

FINDINGS-FEDERAL AWARD PROGRAMS AUDITS United States Department of Housing and Urban Development Berkshire Retirement Home, Inc. Audit period: June 1, 2024 - May 31 , 2025 2025-001 Section 232 Mortgage Insurance for Nursing Homes -Assistance Listing No. 14.157 Recommendation: The Project should increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was increased from $1,182,615 to $1 ,282,815 effective 6/1/2025 with annual insurance renewals to be above the minimum required threshold. The new process implemented will now assess the budgeted potential organizational revenue growth prospectively in the current fiscal year and any calculation increase required will be made prior to the end of the current fiscal year before the insurance renewal for the next fiscal year to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Completion date for corrective action plan: 06/01/2025 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Edward Forfa, Executive Director at 413-445-4056 ext. 160.

View Audit 366047

Finding 575330 (2025-001)

Significant Deficiency 2025

United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health

KS

Special Tests & Provisions Subrecipient Monitoring Eligibility

Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...

Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer

View Audit 365383

Finding 573857 (2025-002)

Significant Deficiency 2025

Rannie Webster Foundation

NH

HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking

2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance cover...

2025-002 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management ensure fidelity bond insurance coverage is reviewed annually and adjusted as necessary to meet HUD requirements. Explanation of disagreement with audit finding: Management is in agreement with the finding. Prior to affiliating with Silverstone Living, the Foundation had a separate endorsement included in their Property Coverage policy that included increased crime coverage to comply with HUD requirements. After transferring coverage to Silverstone Living’s policies, the increased crime coverage did not get transferred over to keep the Foundation in compliance. Action taken in response to finding: The Foundation is actively working with its insurance provider to increase coverage to the required level. The revised policy is expected to be in place by July 31, 2025. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 31, 2025. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Janet Langlois at 603-589-4111.

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Finding 573856 (2025-001)

Significant Deficiency 2025

Rannie Webster Foundation

NH

HUD Housing Programs Procurement, Suspension & Debarment Significant Deficiency

U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 2025 The findings from the schedule of findings and questioned costs are discussed bel...

U.S. Department of Housing and Urban Development Rannie Webster Foundation respectfully submits the following corrective action plan for the period ended April 30, 2025. Audit period: September 1, 2024 – April 30, 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 and Questioned Costs – Major Federal Programs U.S. Department of Housing and Urban Development 2025-001 Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities – Assistance Listing No. 14.129 – Significant Deficiency in Internal Control over Compliance Recommendation: CLA recommends that management ensures the regulatory agreement is being followed by all parties involved, unless otherwise instructed by a HUD representative. Any communication regarding changes to the regulatory agreement should come directly from HUD. Explanation of disagreement with audit finding: Management is in agreement with the finding. They received miscommunication from Lument. Since the Foundation goes through Lument for HUD requests and approvals, management thought the communication they received from Lument was approved by HUD. As a result, management was under the impression that the residual receipts account was fully funded, and the deposit of surplus cash was not required. Action taken in response to finding: On July 18, 2025, management submitted a formal request to HUD to suspend deposits to the residual receipts fund. On July 21, 2025, HUD approved a suspension of deposits to the reserve as long as a balance of $640,856.81 is maintained. Name of the contact person responsible for corrective action: Janet Langlois, CFO Planned completion date for corrective action plan: July 21, 2025.

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