Corrective Action Plans

Finding 1160855 (2025-003)

Material Weakness 2025

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.

View Audit 364508

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.

View Audit 364508

Finding 573134 (2025-003)

Significant Deficiency 2025

Northland Health Partners Community Health Center

ND

Significant Deficiency Internal Control / Segregation of Duties

Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS appli...

Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.

View Audit 363937

Finding 572937 (2025-002)

Significant Deficiency 2025

Csi Residential, Inc.

CT

Questioned Costs HUD Housing Programs Reporting

Deposits required by HUD were not made during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project enforce procedures that ensure deposits are made timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned i...

Deposits required by HUD were not made during fiscal year 2025 to the reserve fund. Recommendation: CLA Recommends the Project enforce procedures that ensure deposits are made timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has made the missing deposit as of March 31, 2025. Name of the contact person responsible for corrective action: Laurie Rudman, Senior Vice President, CFO Planned completion date for corrective action plan: March 31, 2025

View Audit 363778 Questioned Costs: $1

Finding 572935 (2025-001)

Significant Deficiency 2025

Csi Residential, Inc.

CT

HUD Housing Programs Reporting Significant Deficiency

The Project had not timely reviewed the bank reconciliations for July 2024. Recommendation: CLA Recommends the Project review bank reconciliations timely and formerly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to fin...

The Project had not timely reviewed the bank reconciliations for July 2024. Recommendation: CLA Recommends the Project review bank reconciliations timely and formerly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has retroactively reviewed all bank reconciliations that were not reviewed by the former management team as of March 31, 2025. Name of the contact person responsible for corrective action: Laurie Rudman, Senior Vice President, CFO Planned completion date for corrective action plan: March 31, 2025

View Audit 363778

Finding 572429 (2025-001)

Significant Deficiency 2025

Regis University

CO

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

Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non...

Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2025, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.

View Audit 363564

Finding 570852 (2025-002)

Significant Deficiency 2025

Cornish College of the Arts and Cornish Foundation

WA

Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. 84.007 Recommendation: We recommend the College implement policies to review all student award packages at the start of the academic year to ensure no overawards exist. Explanation of disagreement with audit finding: There is no disagre...

Student Financial Assistance Cluster – Assistance Listing No. 84.007 Recommendation: We recommend the College implement policies to review all student award packages at the start of the academic year to ensure no overawards exist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: I'm working closely with the academic records specialist to make sure that we align all our processes and identify why certain dates were misreported, and that we ensure our internal definitions match SU's. Name(s) of the contact person(s) responsible for corrective action: Chris Cook Planned completion date for corrective action plan: June 16th, 2025

View Audit 361771

Finding 570847 (2025-001)

Significant Deficiency 2025

Cornish College of the Arts and Cornish Foundation

WA

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the College review its reporting procedures to ensure the students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: Th...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the College review its reporting procedures to ensure the 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: The student that was incorrectly coded as FWS funds, the funds were immediately reclassified as institutional aid. Since Cornish, did not draw down all FWS funding, it did not impact the G5 drawdown and no needs needed to be returned. Going forward, a higher-level review will be conducted for students with high SAI and low need to ensure that no need-based funds, if not eligible, are in the packaging. This review, will take place after the initial counselor review, but before a student can begin working in the FWS program. This third check will ensure that these types of files are again reviewed in a timely manner and no over awards will happen in the future. Name(s) of the contact person(s) responsible for corrective action: Sara Drummond Planned completion date for corrective action plan: June 16th, 2025

View Audit 361771

Finding 1166204 (2024-001)

Material Weakness 2024

El Dorado Irrigation District

CA

Cash Management Reporting Significant Deficiency

Responsibility for grant-related financial expenditure reporting has been formally transitioned to the Finance Department. This change reduces the risk of reporting errors by leveraging Finance Staff’s specialized knowledge of the financial system and experience in researching variances, reconciling...

Responsibility for grant-related financial expenditure reporting has been formally transitioned to the Finance Department. This change reduces the risk of reporting errors by leveraging Finance Staff’s specialized knowledge of the financial system and experience in researching variances, reconciling accounts, and verifying financial data. Engineering staff will continue to serve as the program specialists and remain responsible for providing programmatic narratives, technical documentation, and compliance related information. This restricting centralizes financial reporting within Finance and allows expenditure data to be exported directly from the District’s financial system rather than relying on separate reporting tools that summarize information outside the general ledger. The District has also implemented a multi-staff financial review process to minimize errors with the creation of the Accounting Supervisor and Finance Manager positions. In addition, the District will simplify its structure of accounting records to minimize the possibility of errors to occur through the implementation of a new financial system.

View Audit 377149

Finding 1165753 (2024-004)

Material Weakness 2024

Commonwealth of Puerto Rico Department of Natural and Environmental Resources

PR

Subrecipient Monitoring Reporting Significant Deficiency

VIEWS OF RESPONSIBLE OFFICIALS We will working to establish an effective flow of communication between financial matters, including the budgetary area, and the programmatic area of infrastructure projects. This action will validate the information before submitting it to COR3. IMPLEMENTATION DATE Ma...

VIEWS OF RESPONSIBLE OFFICIALS We will working to establish an effective flow of communication between financial matters, including the budgetary area, and the programmatic area of infrastructure projects. This action will validate the information before submitting it to COR3. IMPLEMENTATION DATE March 31, 2026 RESPONSIBLE PERSON Budget Manager, Finance Director and Program Manager

View Audit 376549

Finding 1165593 (2024-230)

Material Weakness 2024

State of Idaho

ID

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.302 § 200.303

Finding 2024-230: The Department did not provide documented support to verify the accuracy of a LIHEAP performance report. Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This proc...

Finding 2024-230: The Department did not provide documented support to verify the accuracy of a LIHEAP performance report. Agency’s View: The Department Agrees with this Finding Corrective Action: A process was developed that includes obtaining and documenting approval by the Bureau Chief. This process was shared with LSO following receipt of the FY23 review findings. Supporting documents can be provided again as needed. Anticipated Corrective Action Date: Completed 03/25/2025 Responsible for Corrective Action: Kristin Matthews, Programs Bureau Chief, Self Reliance kristin.matthews@dhw.idaho.gov 208-334-5553

View Audit 376229

Finding 1165574 (2024-222)

Material Weakness 2024

State of Idaho

ID

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

Finding 2024-222: Four providers lacked documentation to support continued eligibility within the Medicaid program. Related to Prior Finding: 2023-223 Agency’s View: The Department Agrees with this finding. Corrective Action: Medicaid is currently under a Corrective Action Plan with CMS requiring al...

Finding 2024-222: Four providers lacked documentation to support continued eligibility within the Medicaid program. Related to Prior Finding: 2023-223 Agency’s View: The Department Agrees with this finding. Corrective Action: Medicaid is currently under a Corrective Action Plan with CMS requiring all Managed Care providers to enroll with Medicaid. This project is currently underway. The initial date of completion of having all providers enroll was 12/31/2025. However, there were unforeseen system enrollment issues that delayed the project. The go live date is now April 1, 2026. Once all providers are enrolled Medicaid will audit provider rosters throughout the year to ensure those providers are in fact enrolled within Medicaid's system. Anticipated Corrective Action Date: 10/31/2026 Responsible for Corrective Action: Alex Scott, Program Bureau Chief, Medicaid alex.scott@dhw.idaho.gov 208-364-1928

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Finding 1165517 (2024-206)

Material Weakness 2024

State of Idaho

ID

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

Finding 2024-206: The Department did not complete required reports for the Federal Funding Accountability and Transparency Act (FFATA) Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: Multiple RFPs were issued to obtain subject matter experts support for Grant Accounting Su...

Finding 2024-206: The Department did not complete required reports for the Federal Funding Accountability and Transparency Act (FFATA) Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: Multiple RFPs were issued to obtain subject matter experts support for Grant Accounting Support and Grant Administration Support. Internal discussions determined the need for more accounting, administration, and grant management support. Below is our status for support through public procurement. a. The Grant Accounting support was awarded October 2025. b. Procurement of Grant Administration support is in the end stages of award. 2. Updated Procedures (Implemented – April 2025) a. The Department has updated its Notice of Award procedures to explicitly include FFATA reporting as a required step once a Federal grant agreement is fully executed. This requirement is now documented in agency procedures, internal checklists, and award processing workflows. 3. Assignment of Responsibility (Implemented – April 2025) a. Responsibility for FFATA compliance has been formally assigned to the Grants and Contracts Officer with the contracted administrative grant support, with assistance provided from the contracted accounting support when necessary. Their duties now include: i. Completing required FFATA submissions following award execution, andii. The process has now been added to our internal processes and procedures and updated with staff. 4. Quarterly Monitoring and Verification (April - 2025) a. To prevent recurrence, Grants and Contracts Officer will conduct a quarterly review of all Federal Grant programs to ensure: i. All applicable awards are listed in the FFATA, ii. No required submissions have been omitted. iii. Any discrepancies are corrected promptly. iv. These quarterly reviews will be documented and retained for audit and internal monitoring purposes. 5. Training and Staff Communication (In Progress — Completion in February 2026 a. Training began in April 2025 and was expanded in October 2025 with support from our Grant Accounting Contractor. The contractor assists in finalizing accounting, reporting, and compliance with OMB guidance. They provide training, updated procedures, and staff guidance. Updated procedures and training will be completed in conjunction with our contractor’s subject matter expertise. Updated policies, training materials, and procedural guidance will be completed and fully implemented in February 2026, with training documented and provided to all Grants and Contracts Officers, contracted services, and relevant program personnel. The training includes but is not limited to: a. All Federal reporting requirements (including FFATA) b. Applicable CFR compliance obligations. Newly implemented internal controls and review procedures. Anticipated Corrective Action Date: February 2026 Responsible for Corrective Action: Ewa Szewczyk Compliance Manager Idaho Department of Commerce Email: ewa.szewczyk@commerce.idaho.gov Phone: 208-287-0784

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Finding 1165409 (2024-001)

Material Weakness 2024

Mother Lode Job Training Agency

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Late Submission of the Single Audit - (Significant Deficiency) Management's Response: Management acknowledges the finding and concurs with the auditor’s recommendation. The delay in conducting the single audit and submitting the SF-SAC Data Collection Form was due to significant timing challenges dr...

Late Submission of the Single Audit - (Significant Deficiency) Management's Response: Management acknowledges the finding and concurs with the auditor’s recommendation. The delay in conducting the single audit and submitting the SF-SAC Data Collection Form was due to significant timing challenges driven by an extraordinary hardship: the complete turnover of the agency’s fiscal team during the audit period. This resulted in the loss of seasoned staff with deep institutional knowledge of complex WIOA fund accounting requirements, including the blending and braiding of more than 25 distinct funding sources—each with separate rules, timelines, and compliance obligations. Despite hiring experienced accounting professionals and bringing in expert support from other Workforce Development Boards, it was not feasible to finalize the financial statements and complete the audit within the original deadline. The agency has since been granted an extension by the EDD Compliance Review Office. In response, the agency has begun strengthening internal controls, establishing more detailed fiscal procedures, and implementing cross-training protocols to ensure continuity of financial reporting. These improvements are designed to protect the organization from future disruptions and ensure that Single Audit reporting packages and required data collection forms will be submitted to the Federal Audit Clearinghouse within required timelines moving forward. The Agency has since taken steps to strengthen internal controls over the financial reporting and audit process. Management is committed to ensuring that future single audit reporting packages and data collection forms are submitted to the Federal Audit Clearinghouse within the required deadlines. Estimated Completion Date: March 31, 2026 Responsible Party: Dale L. Stone Controller, Mother Lode Job Training

View Audit 376076

Corrective Action Plans

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