Corrective Action Plans

Finding 1159455 (2025-001)

Material Weakness 2025

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 Questioned Costs Special Tests & Provisions

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 Questioned Costs Subrecipient Monitoring § 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

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

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

Questioned Costs 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 Questioned Costs Special Tests & Provisions

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

Questioned Costs 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

Questioned Costs Student Financial Aid Reporting

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 1241763 (2024-004)

Material Weakness 2024

Bristol Township

PA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

U.S. Department of Treasury COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that management review their policies and procedures to ensure that all monthly and quarterly reports are submitted timely, and the supporting docu...

U.S. Department of Treasury COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that management review their policies and procedures to ensure that all monthly and quarterly reports are submitted timely, and the supporting documentation used to prepare the reports retained for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review and update existing policies and procedures for the SLFRF program to establish formal requirements for preparing, reviewing, approving, and submitting all applicable monthly and quarterly reports by their respective deadlines. Management will develop a reporting calendar identifying all required reports and submission deadlines. Management will Conduct periodic monitoring to verify that reports are submitted timely, supporting documentation is retained, and any identified reporting deficiencies are corrected promptly. Name(s) of the contact person(s) responsible for corrective action: Township Manager and Finance Officer Planned completion date for corrective action plan: Initial procedures and checklists will be developed within 60 days. The revised controls will be fully applied during the next year-end close, subject to the applicable fiscal year-end schedule.

View Audit 415766

Finding 1241474 (2024-003)

Material Weakness 2024

Elder Care Services, Inc.

FL

Eligibility Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Eligibility – Foster Grandparent/Senior Companion Programs ECS is strengthening its existing review procedures by implementing a more structured and documented secondary review process. Income eligibility determinations will be reviewed for completeness and mathematical accuracy, including proper an...

Eligibility – Foster Grandparent/Senior Companion Programs ECS is strengthening its existing review procedures by implementing a more structured and documented secondary review process. Income eligibility determinations will be reviewed for completeness and mathematical accuracy, including proper annualization of income and inclusion of applicable income sources. Program staff responsible for preparing and reviewing eligibility determinations will receive training regarding calculation procedures, required supporting documentation, document retention, and evidence of review and approval. The SVP Director will serve as the second level of review for all completed income eligibility forms. A Director’s signature line has been added to the income eligibility form to provide documented evidence that the secondary review was completed. Periodic file reviews will be performed to verify that eligibility calculations are accurate, required supporting documentation is maintained, and Director review is appropriately documented. A formal annual completion timeline will be incorporated into departmental procedures to establish deadlines for completion, secondary review, approval, and retention of annual income eligibility documentation.

View Audit 415564

Finding 1241237 (2024-004)

Material Weakness 2024

Black Womens Health Imperative

DC

Subrecipient Monitoring Internal Control / Segregation of Duties Procurement, Suspension & Debarment

Audit Finding Number 2024-004 Audit Finding Title Reporting Planned Corrective Action Effective October 2026, the 2023, 2024, 2025 FFATA reporting requirements have been completed. Going forward, once the NOA is confirmed and the subgrantees have submitted workplans and signed agreements, the FFATA ...

Audit Finding Number 2024-004 Audit Finding Title Reporting Planned Corrective Action Effective October 2026, the 2023, 2024, 2025 FFATA reporting requirements have been completed. Going forward, once the NOA is confirmed and the subgrantees have submitted workplans and signed agreements, the FFATA will be completed in the Federal Subaward Reporting System. This item is still pending for 2026 because those agreements have not been signed. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting

View Audit 415344

Finding 1241236 (2024-003)

Material Weakness 2024

Black Womens Health Imperative

DC

Cash Management Internal Control / Segregation of Duties Significant Deficiency § 200.303 § 200.305

Audit Finding Number 2024-003 Audit Finding Title Cash Management Planned Corrective Action Effective September 2026, each drawdown will be prepared by Kim Cockerham, Sr. Director of Finance and Accounting and then reviewed by a separate employee before submission. Preparation and review are time st...

Audit Finding Number 2024-003 Audit Finding Title Cash Management Planned Corrective Action Effective September 2026, each drawdown will be prepared by Kim Cockerham, Sr. Director of Finance and Accounting and then reviewed by a separate employee before submission. Preparation and review are time stamped and documented in the CDC payment system. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting

View Audit 415344

Finding 1240850 (2024-003)

Material Weakness 2024

State of Kosrae

FM

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

We partially agree with this Finding which cited certain teachers who had only official transcripts on file and no diplomas. Before the JEMCO resolution came out, we were not required to file diplomas in our personnel files, so most of our teachers do not have diplomas on file. We had sought concurr...

We partially agree with this Finding which cited certain teachers who had only official transcripts on file and no diplomas. Before the JEMCO resolution came out, we were not required to file diplomas in our personnel files, so most of our teachers do not have diplomas on file. We had sought concurrence from our grant manager on whether we could use official transcripts in lieu of proof of degrees for existing teachers without degrees and for new hires to get them on board sooner. Our pool of personnel to select teachers from is limited, and it is challenging to get quality teachers with degrees. He concurred that we use transcripts as long as they are the official ones from the institutions and clearly state that the students have been awarded the required degrees and that the students’ names are written clearly on them. In the meantime, each student/teacher will continue to provide a copy of the required degree so we can have it on file. I think this is the process we are still using and if it is not correct, please let us know.

View Audit 415177

Finding 1240849 (2024-002)

Material Weakness 2024

State of Kosrae

FM

Special Tests & Provisions Eligibility Significant Deficiency

We agree with this Finding. We have updated our Sliding fee scale using the US Federal poverty guideline for year 2026, it has been approved by our board of directors as of 04/10/26. This new sliding fee scale is applied in the new ECW Electronic Health Records system that we are currently in the pr...

We agree with this Finding. We have updated our Sliding fee scale using the US Federal poverty guideline for year 2026, it has been approved by our board of directors as of 04/10/26. This new sliding fee scale is applied in the new ECW Electronic Health Records system that we are currently in the process of completing and instituting into our health centers. This new system is presumed to go live in September 2026 and will be able to accommodate our need to capture accurate demographic data that is needed to determine whether a patient is eligible for the discount or not, it will be able to automatically place each individual patient under the different sliding fee scale categories that they fall under based on their income once they register to see a doctor. So to correct our finding for 2023 and 2024, this is what we have been working on to improve our health center and build a system in place that will be able to capture the data we need, we will also be updating our sliding fee scale in the system every year based on the yearly US federal poverty guideline.

View Audit 415177

Finding 1240753 (2024-001)

Material Weakness 2024

Public Buildings Authority

PR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

IMPLEMENT SEFA RECONCILIATION CONTROL MATRIX DOCUMENTATION, MONITORING AND TRAINNING

View Audit 415138

Finding 1240615 (2024-005)

Material Weakness 2024

City of Dickinson

ND

Reporting Significant Deficiency

Contact Person – Katie Greenwood, Deputy Finance Director Corrective Action Plan – The City experienced turnover of accounting personnel in 2023, leaving the Finance Supervisor position vacant during 2024. This resulted in a delay of financial audit completions for 2023 and 2024. The 2025 audit has ...

Contact Person – Katie Greenwood, Deputy Finance Director Corrective Action Plan – The City experienced turnover of accounting personnel in 2023, leaving the Finance Supervisor position vacant during 2024. This resulted in a delay of financial audit completions for 2023 and 2024. The 2025 audit has been scheduled. The City understands the importance of timely audits and plans to complete them annually going forward. Completion Date – December 31, 2026

View Audit 415008

Finding 1240522 (2024-009)

Material Weakness 2024

Kitsap Community Resources

WA

Reporting Significant Deficiency § 200.328

2024-009 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is working on updating all internal controls, as we have new members throughout the organization, by providing cross training to identify who is responsible for specific functions. To addr...

2024-009 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is working on updating all internal controls, as we have new members throughout the organization, by providing cross training to identify who is responsible for specific functions. To address the specific finding, KCR will require that anytime a change is made on an employee a new PAF is required from the program director, the current PAF form will be updated. Completion date 11/30/2026. Staff responsible: Head Start Program Manager Nathan Griffin ngriffin@kcr.org, Division Director Jill Brenner j.brenner@kcr.org, CFO Irmgard Davis irmgardd@kcr.org, Executive Director Anthony Ives aives@kcr.org

View Audit 414976

Finding 1240521 (2024-008)

Material Weakness 2024

Kitsap Community Resources

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.430

2024-008 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is working on updating all internal controls, as we have new members throughout the organization, by providing cross training to identify who is responsible for specific functions, to addr...

2024-008 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is working on updating all internal controls, as we have new members throughout the organization, by providing cross training to identify who is responsible for specific functions, to address the specific finding, to prevent further incidents KCR is requiring that anytime a change is made on an employee a new PAF is required from the program, the current PAF form will updated and completion date 11/30/2026. Staff responsible: CFO Irmgard Davis irmgardd@kcr.org.

View Audit 414976

Corrective Action Plans

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