Corrective Action Plans

Finding 567020 (2024-001)

Significant Deficiency 2024

AR

Reporting Subrecipient Monitoring

Corrective Action Plan for CDBG – Entitlement Grants Cluster: Reporting – Finding 2024-001 We are in receipt of the Findings Required to be Reported by the Uniform Guidance, specifically finding 2024-001 regarding failure to submit the required report in FSRS for the year ended December 31, 2024 for...

Corrective Action Plan for CDBG – Entitlement Grants Cluster: Reporting – Finding 2024-001 We are in receipt of the Findings Required to be Reported by the Uniform Guidance, specifically finding 2024-001 regarding failure to submit the required report in FSRS for the year ended December 31, 2024 for a first-tier subaward resulting in an obligation of $36,000. View of Responsible Officials and Planned Corrective Actions Management agrees with the finding. The City experienced turnover at the end of the fiscal year leaving less time for preparation and review of required reporting. As a result, internal controls and review processes were not in place or were not followed to ensure all required reporting was completed accurately and timely. Overall, we will increase compensating controls by introducing additional management oversight and review for the processes in this area. We will develop a process for reviewing and tracking the reporting of subaward obligations in FSRS to ensure that reporting is in compliance with Department of Housing and Urban Development, CFR, and FAR rules and regulations. Ember Strange, Chief Financial Officer, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.

View Audit 359928

Finding 567014 (2024-001)

Material Weakness 2024

City of Panama City Beach, Florida

FL

Subrecipient Monitoring Material Weakness Reporting § 200.303

City of Panama City Beach, Florida Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Finding Numbers: 2024-001 Finding 2024-001 Lack of Documented Review of Annual Project and Expenditure Report The City acknowledges the importance of maintaining strong internal con...

City of Panama City Beach, Florida Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Finding Numbers: 2024-001 Finding 2024-001 Lack of Documented Review of Annual Project and Expenditure Report The City acknowledges the importance of maintaining strong internal controls. While the report was prepared with diligence and care, we recognize that the absence of documented independent review poses a risk for potential errors and noncompliance with federal requirements. To address this issue, the City has established a formal process to ensure that future reports undergo an independent review before submission. A qualified staff member who is not involved in preparing the report will conduct the review, and both the preparer and the reviewer will sign and date the report to provide evidence of oversight. This documentation will be retained in the grant file for compliance and audit purposes. Staff involved in the reporting process have been informed of these new procedures to ensure consistency moving forward. The revised procedures have been adopted and will be applied to the next reporting cycle. Documentation of the review process will be retained and made available for future audits. The City is committed to maintaining compliance with all applicable federal regulations and improving internal controls to ensure the integrity and accuracy of all grant-related reporting. Anticipated Completion Date: June 2025 Responsible Contact Person: Debra Gibson

View Audit 359923

Finding 567004 (2024-001)

Significant Deficiency 2024

Greater Seacoast Community Health

NH

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

Finding: 2024-001 Condition: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordan...

Finding: 2024-001 Condition: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordance with their policy, the Organization will monitor the accuracy of the discounts provided to patients by a monthly random audit of 15 visits where a sliding fee discount adjustment was received. Individual(s) Responsible for Corrective Action: Kimberly Garca, Director of Patient Accounts Planned Corrective Action: 1. Complete Q1 2025: Complete internal audit/monitoring for January, February and March. 2. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 3. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences. This ensures continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign-off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Anticipated Completion Date: • Corrective Action #1 has been completed as of 4/28/2025. • Corrective Action #2 has been completed as of 5/5/2025. • Corrective Action #3 will be completed by August 2025.

View Audit 359871

Finding 566995 (2024-001)

Material Weakness 2024

Oficina Del Procurador De Las Personas De Edad Avanzada

PR

Subrecipient Monitoring

Condition: The Office of the Advocate for the Elderly requires the monitoring process of 100% of the population of the subrecipients of federal funds, at least once a year. During the year ended September 30, 2024, the OAE distributed federal funds to 118 subrecipients. However, the subrecipients s...

Condition: The Office of the Advocate for the Elderly requires the monitoring process of 100% of the population of the subrecipients of federal funds, at least once a year. During the year ended September 30, 2024, the OAE distributed federal funds to 118 subrecipients. However, the subrecipients subjected to formal monitoring were only fifty one (51) or 43%. Corrective Action Plan: The Office has changed its procedures for conducting monitoring visits. These are now based on a risk-based monitoring approach. This was implemented during 2024, and we have observed an increase in the number of monitoring visits conducted, compared to the finding from 2023, when only 11% of sub-recipients were monitored. During the audited period, this figure increased to 43% of sub-recipients who received monitoring. We expect that for the 2025 Self-Assessment, this issue will no longer be a finding, thereby meeting the required standards. Lead Person for Action Item Completion: Miguel Padilla Vázquez Budget Director Marie M Marrero Garcia Administration Director

View Audit 359862

Finding 566993 (2024-002)

Material Weakness 2024

City of Wentzville, Missouri

MO

Subrecipient Monitoring Material Weakness Reporting

Management implemented changes to the preparation and review process for grant reporting. Management will continue to evaluate it's controls regarding current federal awards and requirements to ensure accurate information captured, reported and maintained.

View Audit 359855

Finding 566992 (2024-001)

Material Weakness 2024

City of Wentzville, Missouri

MO

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Management will continue to evaluate their controls concerning current federal awards and requirements to ensure accurate information captured and reported.

View Audit 359855

Finding 566953 (2024-003)

Material Weakness 2024

North East Community Action Corporation and Subsidiaries

MO

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2024-003 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payme...

2024-003 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payment standard. Cause: Human error in the entry of payment standard which affected the assistance payment. Effect: The cost of the assistance may be disallowed. Context: A sample of grants totaling $29,234 was selected for audit from a population of $12,361,012. The test found questioned costs totaling $212. Our sample was a statistically valid sample. CORRECTIVE ACTION PLAN RESPONSE: Housing counselors have been instructed to double check that the computer system is pulling in the correct payment standard and document if they override it and why. A new transaction check list has been created with a spot where they have to note the payment standard they are using in the transaction. Anticipated completion date: 9/30/25 Responsible party: Michelle Worthington, Section 8 Housing Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.

View Audit 359820 Questioned Costs: $1

Finding 566951 (2024-001)

Material Weakness 2024

North East Community Action Corporation and Subsidiaries

MO

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2024-001 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payme...

2024-001 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payment standard. Cause: Human error in the entry of payment standard which affected the assistance payment. Effect: The cost of the assistance may be disallowed. Context: A sample of grants totaling $29,234 was selected for audit from a population of $12,361,012. The test found questioned costs totaling $212. Our sample was a statistically valid sample. CORRECTIVE ACTION PLAN RESPONSE: Housing counselors have been instructed to double check that the computer system is pulling in the correct payment standard and document if they override it and why. A new transaction check list has been created with a spot where they have to note the payment standard they are using in the transaction. Anticipated completion date: 9/30/25 Responsible party: Michelle Worthington, Section 8 Housing Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.

View Audit 359820 Questioned Costs: $1

Finding 566944 (2024-003)

Material Weakness 2024

King Philip Regional School District

MA

Reporting Subrecipient Monitoring

The District will establish policies and procedures surrounding the administration of federal grants. The District will use the template developed by the Massachusetts Association of School Business Officials with updates made that are specific to the King Philip Regional School District. Documentat...

The District will establish policies and procedures surrounding the administration of federal grants. The District will use the template developed by the Massachusetts Association of School Business Officials with updates made that are specific to the King Philip Regional School District. Documentation will include procedures to ensure identification of federal grant programs, review and documentation of annual compliance requirements of all grants received, and centralized monitoring and reporting. Grants Managers will be involved in the ongoing monitoring of each grant with the School Business Official to ensure that activity is charged appropriately. Funds will be drawn down on a reimbursement basis.

View Audit 359815

Finding 566943 (2024-003)

Significant Deficiency 2024

College of the Muscogee Nation

OK

Student Financial Aid Subrecipient Monitoring Reporting

The instances identified in this finding represent individuals who, in several cases, were processed in the same batches ( e.g., COD date 9/28/23, disbursement date on ledger 10/3/23, and COD date 11/3/23, disbursement date 11/8/23). CMN recognizes the importance of disbursing funds to student accou...

The instances identified in this finding represent individuals who, in several cases, were processed in the same batches ( e.g., COD date 9/28/23, disbursement date on ledger 10/3/23, and COD date 11/3/23, disbursement date 11/8/23). CMN recognizes the importance of disbursing funds to student accounts on the date that funds are stated to be disbursed through COD. While there have been instances of funds not being available in COD in a timely manner, the financial aid coordinator and bursar will work together to ensure these disbursements are completed on the same date in order to remain compliant with stated CMN policy.

View Audit 359811

Finding 566942 (2024-002)

Significant Deficiency 2024

College of the Muscogee Nation

OK

Student Financial Aid Special Tests & Provisions Subrecipient Monitoring

The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for all three students identified through this audit have been completed and corrected to reflect the correct return amounts, if appropriate. Studen...

The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for all three students identified through this audit have been completed and corrected to reflect the correct return amounts, if appropriate. Student 1: After changing from an attendance-taking institution to a non-attendance taking institution, this student was identified during the audit as a student who may not have completed the term due to all F/NP grades. Calculation was completed and a return was made based on the midpoint date of the spring term. Student 2: After changing from an attendance-taking institution to a non-attendance taking institution, this student was identified during the audit as a student who may not have completed the term due to all F /NP grades. Calculation was completed and a return was made based on the midpoint date of the spring term. Student 3: Student officially withdrew but withdrawal was not processed until the end of the term. Since the withdrawal was not processed in a timely manner, the enrollment status (as noted in fmding 2024-001) and subsequent R2T4 calculation was delayed. Calculation was completed and a return was made based on the date indicated in the official withdrawal documents. Due to delayed calculations on these three students, CMN will continue to work with fmancial aid staff and the registrar's office to streamline communication on withdrawals and students who complete the term with all F/NP grades, as indicated in CMN policy. CMN has already worked with Anthology (student information system)'to provide electronic triggers to the fmancial aid office when a student status changes from active to drop/withdrawal. Additionally, Enrollment Management notifies all faculty by email at the beginning of the term and again prior to fmal grades being submitted that electronic notification must be sent by the faculty to financial aid in order to alert the fmancial aid office of the date oflast academic engagement for students who earn an For NP grade. For the current audit period, the Director of Enrollment Management and the Financial Aid Coordinator work together to review a final grade report for all students and identify those who need R2T4 calculations based on that review. Both the director and coordinator sign the working documents to indicate that it has been reviewed by both parties. We will continue with this process and will refme as necessary, but we anticipate that this will resolve the issue of calculations not having been performed on students with all F /NP grades at the end of the term.

View Audit 359811

Finding 566941 (2024-001)

Significant Deficiency 2024

College of the Muscogee Nation

OK

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

The College has identified that the dates of enrollment submissions and status changes for the two students identified in the audit were out of compliance (102 days and 69 days). The statuses of both students are correct with NSLDS. Student 1: Student officially withdrew but withdrawal was not pro...

The College has identified that the dates of enrollment submissions and status changes for the two students identified in the audit were out of compliance (102 days and 69 days). The statuses of both students are correct with NSLDS. Student 1: Student officially withdrew but withdrawal was not processed until the end of the term. Since the withdrawal was not processed in a timely manner, the enollment status and subsequent R2T4 calculation (as noted in finding 2024-002) was delayed. Student 2: Student graduated, and status was updated with NSLDS at 69 days. Due to delayed communication and delayed reporting to NSLDS, CMN will revise institutional policy to clearly define the process and timeline for enrollment status changes. Financial aid staff will seek additional training in enrollment reporting through FSA and/or NSFAA. To further monitor compliance, CMN has already worked with Anthology (student information system) to provide electronic triggers to the financial aid office when a student status changes from active to drop/withdrawal. This electronic, automatic process will provide an additional layer of notification to the financial aid office when a student status change requires further attention.

View Audit 359811

Finding 566908 (2024-001)

Significant Deficiency 2024

City of Norton

OH

Subrecipient Monitoring Special Tests & Provisions Reporting § 200.208 § 200.328

Finding Number: 2024-001 Planned Corrective Action: City of Norton will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: June 2025 Responsible Contact Person: Pamela Keener, Finance Director

View Audit 359778

Finding 566892 (2024-003)

Significant Deficiency 2024

Thurston County Food Bank

WA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.318

Finding 2024-003: TCFB was negligent in two areas for one of their purchases: No record of vendor verification that they were not suspended or disbarred and no WSDA prior approval for the purchase which was over $5,000. This was in violation of both their internal procedures and WSDA requirements. T...

Finding 2024-003: TCFB was negligent in two areas for one of their purchases: No record of vendor verification that they were not suspended or disbarred and no WSDA prior approval for the purchase which was over $5,000. This was in violation of both their internal procedures and WSDA requirements. The Problem: During testing the auditors noted that one instance of purchasing using WSDA funds was made without WSDA prior approval and proper documentation of suspension and debarment or WSDA prior approval. Established Standard: Organization must verify SAM registration and conduct suspension, and debarment checks prior to entering into any sub-agency agreement, contract, purchase, or equipment repair over $5,000. It is recommended that lead agency verifies, at least annually, that sub agencies and vendors are not suspended or debarred. Information about suspension and debarment checks is to be entered onto a spreadsheet of approved vendors. When the lead agency enters into a covered transaction with another agency or vendor, lead agency must verify that the entity with whom business is transacted is registered with SAM and is not excluded or disqualified. There are two methods for verification: A. Checking SAM.GOV exclusions (this method requires saving a copy of the verification search) B. Collecting a signed certification from the vendor. Actions to be taken: • Updated training of TCFB staff on the Policy/Procedures for procurements using WSDA funding. • Create step-by-step instructions for purchases using WSDA funding. • Effective October 1, 2024 WSDA’s threshold for preapprovals changed to $10,000. We will update our purchasing policy to reflect this change. Action Assignments: • Instruction checklist will be created by lead purchaser. • Lead purchaser will ensure that any purchases follow the Policy/Procedures for procurement. • Lead purchaser will be responsible for documenting SAM registration, Suspension and Debarment check, and WSDA pre-approvals. The documentation will consist of a copy of the exclusions page on SAM.GOV, as well as a spreadsheet of approved vendors with a date of last check. Timeline: • Instruction checklist for purchases using WSDA funds will be created by July 1st, 2025. • A spreadsheet has already been created to capture the information concerning Suspension and Debarment checks. A separate folder contains copies of each entities exclusion page from SAM.GOV. Verify Implementation: • In July 2025 Lead Purchaser will submit to the Executive Director: A. A copy of step-by-step instruction checklist. B. A copy of the spreadsheet with Suspension and Debarment checks C. Copies of exclusion pages from SAM.GOV Finance Dept. will verify invoice have received WSDA prior Approvals

View Audit 359751

Finding 566887 (2024-002)

Significant Deficiency 2024

Thurston County Food Bank

WA

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332

Finding 2024-002: TCFB was negligent in monitoring sub-recipients during the grant agreement period. The Problem: During testing, the auditors noted that one of the three sub-recipients tested did not receive a site visit during the grant agreement period. Established standard Three programs requir...

Finding 2024-002: TCFB was negligent in monitoring sub-recipients during the grant agreement period. The Problem: During testing, the auditors noted that one of the three sub-recipients tested did not receive a site visit during the grant agreement period. Established standard Three programs require sub-agency monitoring visits. EFAP (3 sub-agencies) requires each sub-agency to be monitored on site once each biennium (2 year agreement period). TEFAP (40 sub-agencies) requires that a minimum of 10% of sub-agencies be monitored on site once each year. CSFP (3 sub-agencies) requires each agency to be monitored on site once every 2 years. Actions to be taken - While the EFAP requirement was used for the test above, this plan will include monitoring visits for all 3 programs. - An additional staff member will be added to the contract team who will be responsible for on-site monitoring visits once trained. - Plan out which agencies should be visited in which years. - Create a shared calendar that includes the time period visits should take place in, when to reach out to sub-agencies to schedule visits, who will conduct visits. Action assignments - The entire contract team will work together to create the calendar. - Contracts Manager and Commodities Coordinator will plan out which sub-agencies to visit, and when to visit them. - Contracts Manager and new team member will schedule and conduct the first 2 site reviews, after which the new team member will take the lead with support from the others. Timeline - The additional contract team member will be added July 1st, 2025, but will be available for planning meetings before then. - Ordered list of sub-agency visits will be completed by the end of May 2025. - Shared calendar will be fully completed by the end of June 2025. Verify implementation - The Contracts Manager will report progress of monitoring visits to CEO/ED quarterly.

View Audit 359751

Finding 566867 (2024-004)

Material Weakness 2024

Harris-Stowe State University

MO

Subrecipient Monitoring Reporting Cash Management § 200.510

Finding 2024-004 Personnel Responsible for Corrective Action: Director of Sponsored Programs - Eva Kain, Grant Accountant – Charme Benson and Comptroller – Steve Wille Anticipated Completion Date: June 30, 2025 Corrective Action Plan:. The Grant Accountant, in collaboration with the Comptroller...

Finding 2024-004 Personnel Responsible for Corrective Action: Director of Sponsored Programs - Eva Kain, Grant Accountant – Charme Benson and Comptroller – Steve Wille Anticipated Completion Date: June 30, 2025 Corrective Action Plan:. The Grant Accountant, in collaboration with the Comptroller and Director of Sponsored Programs, will compile SEFA data on a quarterly basis and reconcile it against CX reports. The Sponsored Programs Director will verify all Assistance Listing Numbers (ALNs), subrecipient amounts, and accruals. Documentation of all federal awards and drawdowns will be maintained in a centralized repository for internal and audit access.

View Audit 359750

Finding 566865 (2024-007)

Material Weakness 2024

Harris-Stowe State University

MO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.403

Finding 2024-007 Personnel Responsible for Corrective Action: Grant Principal Investigators and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: All expenses must be supported by documentation and comply with Generally Accepted Accounting Princ...

Finding 2024-007 Personnel Responsible for Corrective Action: Grant Principal Investigators and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: All expenses must be supported by documentation and comply with Generally Accepted Accounting Principles (GAAP) standards. A pre-review checklist will be required for all charges against FIPSE grants. Prepaid items must be recorded in the prepaid ledger and amortized appropriately. Documentation will be retained in alignment with the University Record Retention policy. Management will implement a formal review and approval process to ensure that all allowable costs are verified for compliance with applicable regulations and approved by designated personnel prior to reimbursement or payment.

View Audit 359750 Questioned Costs: $1

Finding 566857 (2024-006)

Significant Deficiency 2024

Harris-Stowe State University

MO

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Finding 2024-006 Personnel Responsible for Corrective Action: Director of Sponsored Programs- Eva Kain, Director of Title III – Dr. Neidra Butler and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: Payroll charges to federal programs must mat...

Finding 2024-006 Personnel Responsible for Corrective Action: Director of Sponsored Programs- Eva Kain, Director of Title III – Dr. Neidra Butler and Grant Accountant – Charme Benson Anticipated Completion Date: June 30, 2025 Corrective Action Plan: Payroll charges to federal programs must match certified time and effort documentation. The Director of Sponsored Programs, the Director of Title III, and the Grant Accountant will jointly review allocations before payrolls are processed. Monthly reports will be generated for review by the Grant Accountant, and discrepancies must be corrected within 30 days. Management will implement a formal review and approval process to ensure that all allowable costs are verified for compliance with applicable regulations and approved by designated personnel prior to reimbursement or payment.

View Audit 359750

Finding 566850 (2024-008)

Material Weakness 2024

Harris-Stowe State University

MO

Subrecipient Monitoring Special Tests & Provisions Material Weakness

Finding 2024-008 Personnel Responsible for Corrective Action: Chief Information Officer - Vacant Anticipated Completion Date: August 31, 2025 Corrective Action Plan: Harris-Stowe State University acknowledges the audit finding regarding noncompliance with the Gramm-Leach-Bliley Act (GLBA) and t...

Finding 2024-008 Personnel Responsible for Corrective Action: Chief Information Officer - Vacant Anticipated Completion Date: August 31, 2025 Corrective Action Plan: Harris-Stowe State University acknowledges the audit finding regarding noncompliance with the Gramm-Leach-Bliley Act (GLBA) and the FTC Safeguards Rule. In response, the University has collaborated with Omega Technical Solutions and ileap Group to execute a comprehensive cybersecurity compliance and modernization initiative. As of the audit period close, over 90% of related deficiencies have been remediated. Specific corrective actions taken or underway include: 1. Written Information Security Program (WISP): A formal WISP has been developed and implemented. It outlines oversight structures, risk management strategies, testing protocols, and required safeguards in alignment with 16 CFR 314.4. 2. Risk Assessment: A comprehensive risk scorecard was created. All Active Directory accounts were reviewed and flagged for deactivation or role reassignment as appropriate. 3. Access and Encryption Controls: Encryption is now deployed across all active endpoints. Logical access control and encryption policies have been adopted and published. Multi-factor authentication (MFA) is enforced for all systems handling student data. 4. Account Management and Role-Based Access: RBAC policies have been established and account provisioning is now formally documented and managed. 5. Retention, Change Management, and Training: A written data retention policy and formal change management procedures are now in place. An onboarding cybersecurity training program has been developed, with full implementation scheduled by August 31, 2025. 6. Legacy Server Risk Mitigation: One legacy Microsoft 2008 server has failed and is decommissioned. The remaining server is isolated, monitored with NIST- and Microsoft Sentinel-aligned tools, and pending full replacement as part of the upcoming infrastructure upgrade. 7. Ongoing Monitoring and Vendor Oversight: TCPM-aligned monitoring practices and vendor oversight protocols are now active and included in the WISP framework. The University’s IT Security SharePoint site houses all related documentation and is structured to support transparency, audit readiness, and continued compliance oversight.

View Audit 359750

Finding 566849 (2024-001)

Significant Deficiency 2024

Pacific Northwest Research Institute

WA

Subrecipient Monitoring Cash Management Allowable Costs / Cost Principles § 200.305

Finding Number 2024-001 Contact Person(s): Dionne Gordon dgordon@pnri.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Although the findings consisted primarily of a small number of late payments that were either ...

Finding Number 2024-001 Contact Person(s): Dionne Gordon dgordon@pnri.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Although the findings consisted primarily of a small number of late payments that were either 1 day late or late as a result of a poorly timed holiday, we fully acknowledge the accuracy of the finding and have added an additional control to account for the impact of weekends and holidays on our AP payment runs. Corrective action planned: Internal control established in AP department to keep track of sub recipients’ request reimbursement to ensure payments are disbursed within 30 calendar days after receipt of request. Anticipated completion date: March 31st 2025

View Audit 359747

Finding 566767 (2024-002)

None 2024

Battelle Memorial Institute

OH

Subrecipient Monitoring Equipment & Real Property Management § 200.508

Reference: Finding 2024-002 Access Restricted to Documentation for Various Compliance Requirements – Research & Development Cluster; Noncompliance – Period of Performance, Procurement (Micro Purchasing), Subrecipient Monitoring, and Equipment and Real Property Management Contact: Erica Classing, C...

Reference: Finding 2024-002 Access Restricted to Documentation for Various Compliance Requirements – Research & Development Cluster; Noncompliance – Period of Performance, Procurement (Micro Purchasing), Subrecipient Monitoring, and Equipment and Real Property Management Contact: Erica Classing, Controller; classinge@battelle.org; 614-424-3372 Views of Responsible Officials: Battelle acknowledges this finding is the result of access restrictions to classified contract documents imposed by federal agencies that are beyond Battelle’s control. Battelle does not have the authority to grant auditor access to classified programs without the proper security clearance and program permissions, rather this authority resides with the federal awarding agency, in accordance with applicable federal security regulations. These restrictions prohibited access to classified contracts for required audit procedures in those areas noted in Finding 2024-002. Classified contracts are a small subset (10%) of Battelle’s total reportable expenditures. Battelle provided all unclassified documentation required to support transactions selected for testing. In addition, Battelle provided all documentation necessary to audit compliance with requirements on all non-classified contracts selected. Management upholds high standards of compliance and transparency and continues to support audit processes to the fullest extent possible. Battelle agrees to explore options to satisfy audit requirements while maintaining compliance with classified contract security regulations. Corrective Action Plan: Summary of finding: During compliance testing of period of performance, procurement (micro purchasing), subrecipient monitoring, and equipment and real property management, access to classified contracts was restricted. The auditor was unable to view federal award documents to confirm the following information: • Period of performance (5 of 50 selections) - unable to confirm the authorized project period • Procurement (micro purchasing) (2 of 40 selections) - unable to review applicable requirement relating to consent to subcontract • Subrecipient monitoring (2 out of 40 selections) – unable to inspect subaward information and applicable terms • Equipment and real property management (3 out of 50 selections) – unable to obtain proof of active use and safeguard of the classified equipment and validate whether the equipment disposal was handled properly in accordance with the contractual terms and conditions. Root cause: Access to classified contracts is subject to confidentiality requirements mandated by external regulators, requiring appropriate security clearance levels and verified need-to-know status. If the classified contract is a special access program, obtaining program-specific approvals from the awarding agency in addition to possessing the appropriate security clearance and need to know is required. There is no guarantee that the federal awarding agency will ultimately grant cleared auditors access to the classified contract. Corrective action: Battelle is taking the following steps to address the finding: • Internal Review: We conducted an internal review of the areas affected by the scope limitation to validate each selection complied with the applicable contractual and regulatory requirements. This action was completed by December 19, 2024 and did not identify any instance of non-compliance with applicable rules, regulations, or contractual requirements. • We have existing monitoring mechanisms in place to ensure compliance in the areas affected by the scope limitation. • Early coordination with external auditor: We are collaborating with our external audit team to identify any classified contract audit selections earlier in the annual audit process. A proactive approach will allow Battelle extra time to engage clients for required approvals to either gain access to the classified information or obtain appropriate alternative audit evidence. In addition, any other related steps that can be completed in advance such as verifying auditor clearance types and levels will be performed early to help mitigate any delays. This corrective action requires the audit firm to provide auditors with the appropriate security clearances. • Engagement with regulatory agencies: We are in dialogue with impacted federal awarding agencies to explore options to provide necessary audit evidence. • Enhanced documentation: We are enhancing our audit support procedures to provide guidelines on how, within the bounds of regulatory restrictions, we can provide access to audit evidence for future audits. Overall Anticipated Implementation Date: December 31, 2025

View Audit 359740

Finding 566117 (2024-002)

Significant Deficiency 2024

Central Rivers Area Education Agency

IL

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency

Management will work to implement controls that will ensure subrecipient monitoring requirements are met.

View Audit 359722

Finding 566044 (2024-003)

Significant Deficiency 2024

Global Communities

MD

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Views of Responsible Officials and Planned Corrective Action: Global Communities experienced staff turnover in the positions responsible for FFATA reporting. Management will ensure those staff now responsible for maintaining compliance with FFATA reporting requirements have received adequate trainin...

Views of Responsible Officials and Planned Corrective Action: Global Communities experienced staff turnover in the positions responsible for FFATA reporting. Management will ensure those staff now responsible for maintaining compliance with FFATA reporting requirements have received adequate training and that supporting documentation of the review and approval of FFATA reports prior to submission are retained in our files.

View Audit 359700

Finding 566043 (2024-002)

Significant Deficiency 2024

Global Communities

MD

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Action: Global Communities policies and procedures did detect these instances of fraud, management of Global Communities took appropriate action ensuring that no unallowable costs were charged to Federal funds. Global Communities will continue th...

Views of Responsible Officials and Planned Corrective Action: Global Communities policies and procedures did detect these instances of fraud, management of Global Communities took appropriate action ensuring that no unallowable costs were charged to Federal funds. Global Communities will continue their due diligence with respect to any items that are considered fraudulent in nature. Any high-risk areas are carefully monitored, additional training and/or resources are provided to ensure that internal controls are functioning as designed to prevent occurrences of misappropriation of assets and procurement fraud.

View Audit 359700

Finding 566042 (2024-001)

Material Weakness 2024

Southern Nevada Regional Housing Authority

NV

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Finding 2024- 001: Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: To reinforce compliance and ensure consistent adherence to policies a specialized team including a Compliance & Training A...

Finding 2024- 001: Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: To reinforce compliance and ensure consistent adherence to policies a specialized team including a Compliance & Training Administrator, a Trainer, and two Senior Occupancy Specialists-has been established to oversee all Housing Choice Voucher (HCV) program training and compliance. This team is responsible for: ■ New hire training to ensure foundational competency. • Refresher trainings to address knowledge gaps and reinforce standards. • Policy & procedure update trainings to keep staff informed of changes. Quality Control: We conduct 100% quality control on all new hires', completed action files and 100% quality control on all contract files. Twenty-five percent (25%) of all Non-provisional employees work product is quality controlled by the compliance team. Department Structure: The entire leadership team completed Nan McKay's HOTMA training to ensure full alignment with the latest Housing Opportunity Through Modernization Act {HOTMA) requirements. This top-down approach guarantees that policy Interpretations and training materials are consistent and up to date. To ensure all required documents are properly retained and accessible, the agency has expedited the transition to a fully digital file system. This will Include standardized naming conventions, centralized storage with access controls, and a documented retention protocol to prevent future discrepancies. Additionally, any staff that falls below the 80 % success rate will be required to actively engage in all mandated trainings and utilize the compliance team as a resource for clarification. Furthermore, staff requiring further reinforcement will be promptly addressed through one-on one coaching or additional training sessions with their immediate supervisor. Anticipated Completion Date: The current staff is attending monthly trainings on the Administrative Plan, best practices and HOTMA policy changes. We anticipate completion of the plan by 12/31/2025. Person Responsible: Ms. Rhonda Jackson, Housing Program Manager II, Ms. Malandria Watson, Housing Program Manager I, -and Ebony Bell, Compliance and Training Administrator will be responsible for reviewing the Quality Control Report and error ratios monthly.

View Audit 359697 Questioned Costs: $1

Corrective Action Plans

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