Corrective Action Plans

Finding 1218293 (2025-005)

Material Weakness 2025

Resilience: Advocates for Ending Violence

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and...

Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should expand its financial reporting review procedures to require the documented review and approval of all performance reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: During the fiscal year, the Organization properly implemented procedures that require the documented review of the monthly financial reports, including the corresponding indirect cost calculations. The Organization will expand these policies and procedures to require the documented review and approval of all performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.

View Audit 404531

Finding 1218292 (2025-004)

Material Weakness 2025

Resilience: Advocates for Ending Violence

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00...

Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should establish and maintain written internal control procedures that cover the required five components of internal control for each area of compliance for each of its federal programs. The Organization should educate all employees working with federal programs of the Organization’s procedures and monitor compliance with them. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.

View Audit 404531

Finding 1218262 (2025-002)

Material Weakness 2025

Five-Town Health Alliance, Inc. D/b/a Mountain Health Center

VT

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

Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a disco...

Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a discount but did not have an active sliding fee application for the service date the sliding fee discount was applied. Individual(s) Responsible for Corrective Action: Lori Slicer, Revenue Cycle Manager (organization-wide sliding fee discount monitoring procedure across the medical and dental service lines). Crystal Kinsman, Dental Practice Manager (dental-specific monitoring, with increased sampling of the Dental system given its higher level of manual processing). Heidi Melbostad, Chief Executive Officer and Compliance Officer (sliding fee discount schedule redesign and oversight). Planned Corrective Action: Management is addressing this finding through both an immediate interim action and a comprehensive redesign, together with an ongoing monitoring control. Interim action (completed): the Board approved revised nominal fee levels on 2026-04-27, effective 2026-04-28, establishing Category A as the most favorable discount category, consistent with Section 330(k)(3)(G) of the Public Health Service Act. Full corrective action: management will complete a comprehensive redesign of the Sliding Fee Discount Program, including separate schedules for the medical and dental service lines, data-driven evaluation of tier thresholds and fee levels, and replacement of the percentage-based payment option with a clearer flat-fee structure, for Board review and approval. Ongoing monitoring control: management will establish a documented monitoring procedure over sliding fee discount application across both the medical and dental service lines, including a defined monthly sample drawn from each service line with increased sampling of the Dental system given its higher level of manual processing, verification that an active sliding fee application is on file for each service date, documented review results, timely correction of identified errors, and supervisory sign-off, with error rates reviewed at least quarterly. Anticipated Completion Date: Interim nominal fee revision effective 2026-04-28 (completed). Comprehensive Sliding Fee Discount Program redesign and ongoing monitoring procedure to be Board-approved and operational by 2026-08-24.

View Audit 404523

Finding 1218250 (2025-002)

Material Weakness 2025

SOUTH FEATHER WATER AND POWER AGENCY

CA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.320

Finding 2025-002 – Significant Deficiency Award No.: 21.027 Federal Grantor: U.S. Department of Treasury, Passed-through the County of Butte, Pass-through Grantor’s Number X25534. Compliance Requirement: Procurement, Suspension and Debarment. Condition: The Agency’s procurement policy does not adequ...

Finding 2025-002 – Significant Deficiency Award No.: 21.027 Federal Grantor: U.S. Department of Treasury, Passed-through the County of Butte, Pass-through Grantor’s Number X25534. Compliance Requirement: Procurement, Suspension and Debarment. Condition: The Agency’s procurement policy does not adequately document procurement requirements under the Uniform Guidance or contract provisions under Appendix II to Part 200 of the Uniform Guidance. Criteria: Uniform Guidance, Section 200.318(a) indicates “the recipient or subrecipient must maintain and use documenting procedures for procurement transactions under a Federal award or subaward, including for acquisition of property or services. These documented procurement procedures must be consistent with State, local, and tribal laws and regulations and the standards identified in §§ 200.317 through 200.327”. Required contracting provisions are documented in Appendix II to Part 200 – Contract Provisions for Non-federal Entity Contracts Under Federal Awards. Cause: The Agency’s procurement policy needs to be updated to document the requirements of the Uniform Guidance. Effect: The Agency’s procurement policy does not comply with the requirements of the Uniform Guidance, which could result in procurements that do not comply with the Uniform Guidance and the awarding agency disallowing the federal award and requesting the return of the award. Context: The Agency’s procurement policy complies with many requirements of the Uniform Guidance, but the policy does not comply with certain required provisions, including the thresholds for micro purchases, simplified acquisition threshold and full public procurements and the requirements for sole sourcing procurements under section 200.320. The procurements tested were found to comply with procurement requirements under Uniform Guidance even though the policy did not include all of the required provisions. Recommendation: The Agency should update its procurement policy to reference Uniform Guidance §§ 200.317 through 200.327 and should reference contracting provisions under Appendix II to Part 200 to be in compliance with Uniform Guidance prior to procurements being made under future federal awards. Views of Responsible Officials and Planned Corrective Actions: The procurement policy will be updated to include procurement guidance under Uniform Guidance §§ 200.317 through 200.327 and contracting provisions under Appendix II to Part 200 – Contract Provisions for Non-federal Entity Contracts Under Federal Awards. Title of Responsible Party: Finance Manager Implementation Date: By September 22, 2026

View Audit 404498

Finding 1218247 (2025-002)

Material Weakness 2025

Valorus

CA

Subrecipient Monitoring § 200.332 § 200.510

Finding 2025-002 – Incomplete Subrecipient Agreements and Inaccurate Subrecipient SEFA Reporting Subrecipient agreements were executed based on California’s State Administrator of federal funds (CalOES) requirements applicable to second-tier subawards. Based on guidance provided during Federal Grant...

Finding 2025-002 – Incomplete Subrecipient Agreements and Inaccurate Subrecipient SEFA Reporting Subrecipient agreements were executed based on California’s State Administrator of federal funds (CalOES) requirements applicable to second-tier subawards. Based on guidance provided during Federal Grants Advanced Training and the 2025 CalOES Subrecipient Handbook (page 65), entities receiving pass-through funding from the state are required to follow CalOES second-tier subaward requirements. Accordingly, VALOR’s agreements include the elements required for second-tier subawards. Elements of a Second-Tier Subaward (From the 2025 CalOES Subrecipient Handbook) The following elements must be included in a Second-Tier Subaward: • Name of the Subrecipient Organization and the participating agency/organization, • The titles and contact information for the individuals that will serve as the primary contacts,• The timeframe of the agreement (this must cover the Grant Subaward performance period), • The roles and responsibilities (as they relate to the specific Grant Subaward) of the Subrecipient Organization and the participating agency/organization, • Specific information concerning all non-fiscal resources shared between the Subrecipient Organization and the participating agency/organization, • Reporting requirements necessary for the Subrecipient Organization to meet Cal OES reporting requirements, • Signatures of the chief executive or designee of the Subrecipient Organization and the participating agency/organization, including the dates of those signatures, and • Specific information concerning the transfer of any Grant Subaward funds from the Subrecipient Organization to the participating agency/organization. At a minimum, this information must include the total amount of Grant Subaward funds that will be transferred, the process for transferring the Grant Subaward funds (e.g., monthly invoices, payment based on deliverables), what the Grant Subaward funds will be used for, and any match contribution provided by the participating agency/organization. Any funds included in the Second-Tier Subaward must be clearly designated (not itemized) in the Grant Subaward Budget Pages (Cal OES Form 2-106a or b). Additionally, second tier subrecipients are prohibited from charging indirect costs; therefore, indirect cost provisions were not included in the agreements. Based on the above, management believes the subrecipient agreements substantially complied with applicable CalOES requirements. Any omissions identified were administrative in nature and did not impact program performance, allowability of costs, or oversight of subrecipient activities. To strengthen internal controls and ensure full compliance with all applicable grant requirements, beginning January 1, 2027, VALOR’s Director of Operations, Rosemary Gonzales, will include all required elements identified in the finding in future subrecipient agreements. In addition, VALOR will review subrecipient Single Audit reports to verify that applicable grant funding is properly reported on the SEFA. VALOR will also notify subrecipients of the requirement to include these amounts in their future SEFA reporting. Contracts for the current year, 2026, have already been signed.

View Audit 404493

Finding 1218244 (2025-001)

Material Weakness 2025

Partnership for the Umpqua Rivers

OR

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2025-001: Material Weaknesses in Internal Control Management’s response: Concur Responsible individual: Finance Manager, Executive Director, Board of Directors Anticipated completion date: March 31, 2026 Management agrees with this finding and will implement the following: • Develop and impl...

Finding 2025-001: Material Weaknesses in Internal Control Management’s response: Concur Responsible individual: Finance Manager, Executive Director, Board of Directors Anticipated completion date: March 31, 2026 Management agrees with this finding and will implement the following: • Develop and implement a formal document retention and destruction policy • Develop and implement a formal periodic close and invoicing policy • Develop and implement a formal conflict of interest policy • Develop and implement a formal internal control policy • Develop and implement a formal whistleblower policy • Develop and implement a formal Board code of ethics policy • Develop and implement a formal reporting schedule • Actively recruit Directors with financial experience to participate in Board oversight

View Audit 404490

Finding 1218216 (2025-002)

Material Weakness 2025

Town of Castle Rock, Colorado

CO

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.328 § 200.329

Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient t...

Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient to Douglas County who is the recipient of the funds. Eide Bailly LLP identified that the Town did not have documented or consistently applied internal controls to ensure compliance with the County’s subrecipient guidance requiring the submission of formal special reports for ALN 21.027. Responsible Individuals: Mark Henderson, Assistant Director of Castle Rock Water Corrective Action Plan: Staff will complete quarterly reports including project progress and estimated project infrastructure costs. The reports will be reviewed by management prior to submission to the recipient of the Federal Funds (Douglas County). Anticipated Completion Date: Ongoing during the period that the Town is a subrecipient of these funds for the project.

View Audit 404489

Finding 1218213 (2025-002)

Material Weakness 2025

New Phoenix Park I LLC

CA

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Finding 2025-002: Eligibility – Untimely Recertifications Type: Significant Deficiency Condition: During testing of tenant files, the auditor identified fourteen instances in which 2025 annual recertifications were not completed in a timely manner. Recertifications were performed in the subsequent y...

Finding 2025-002: Eligibility – Untimely Recertifications Type: Significant Deficiency Condition: During testing of tenant files, the auditor identified fourteen instances in which 2025 annual recertifications were not completed in a timely manner. Recertifications were performed in the subsequent year, and effective dates were backdated to reflect the current year. Management agrees with the finding and acknowledges the need to strengthen internal controls over tenant file compliance. To address this issue, management will implement a formalized tracking system for annual recertifications to ensure they are completed timely with accurate effective dates. Additionally, supervisory review and approval procedures will be enhanced prior to finalizing tenant rent changes. A. The Compliance Manager will oversee the compliance department and ensure staff complete recertifications prior to required effective dates. B. The Property Manager will conduct weekly meetings with staff to review upcoming recertifications and monitor progress to ensure timeliness. C. Management is in the process of hiring additional staff dedicated to processing recertifications to improve timeliness and compliance. Contact for Corrective Action: Cornelia Reith anticipated Completion date:12/31/26

View Audit 404487

Finding 1218191 (2025-003)

Material Weakness 2025

La Familia Medical Center

NM

Internal Control / Segregation of Duties Subrecipient Monitoring

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommend the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee r...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommend the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that all documentation supporting the sliding discount provided is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: These errors are due to incorrect slide percentage amounts being put into eCW. There is also a known issue within eCW where the eCW changes the slide amount to either 100% or a different slide than was entered. The Organization has found a work around so that the Organization can fix this issue before claims are adjusted. Billing will start reviewing slide documents prior to applying slide to make sure that the percentage entered into eCW is correct for income/family size. These will also be reviewed by the front desk manager and lead patient service representative.

View Audit 404425

Finding 1218185 (2025-003)

Material Weakness 2025

Child Care & Nutrition INC

MN

Internal Control / Segregation of Duties Subrecipient Monitoring

Child Care and Nutrition, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2025. Audit period: October 1, 2024-September 30, 2025 The findings from the September 30, 2025 schedule of findings and questioned costs are discussed below. The findings are nu...

Child Care and Nutrition, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2025. Audit period: October 1, 2024-September 30, 2025 The findings from the September 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT MATERIAL WEAKNESS 2025-001 Internal Accounting Controls Recommendation: We recommend management be aware to the lack of segregation of duties within the accounting functions and provide oversight to ensure the internal control policies and procedures are being implemented by organization staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will continue to review the accounting functions of all affected departments so segregate them as it is cost beneficial. Name of the contact person responsible for corrective action: Sherri Looft, Executive Director Planned completion date for corrective action plan: September 30, 2026. MATERIAL WEAKNESS 2025-002 Annual Financial Reporting Under Generally Accepted Accounting Principles Recommendation: Management should continue to evaluate their internal staff capacity to determine if an internal control policy over the annual financial reporting is beneficial. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization understands this is required communications for the preparation of the financial statements and will continue to work at this area to achieve the overall goal. Name of the contact person responsible for corrective action: Sherri Looft, Executive Director Planned completion date for corrective action plan: September 30, 2026. FINDINGS – FEDERAL AWARD PROGRAMS 2025-003 Internal Accounting Controls Federal Agency: U.S. Department of Agriculture Federal Program: Child and Adult Care Food Program CFDA Number: 10.558 Pass Through Agency: Minnesota Department of Education, Child Nutrition Section Pass Through Number: 1000003400 Award Periods: Year ended September 30, 2025 Recommendation: We recommend management be aware to the lack of segregation of duties within the accounting functions and provide oversight to ensure the internal control policies and procedures are being implemented by organization staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will continue to review the accounting functions of all affected departments so segregate them as it is cost beneficial. Name of the contact person responsible for corrective action: Sherri Looft, Executive Director Planned completion date for corrective action plan: September 30, 2026.

View Audit 404424

Finding 1218151 (2025-002)

Material Weakness 2025

West Elk Unified School District No. 282

KS

Internal Control / Segregation of Duties Subrecipient Monitoring

Management recognized the importance of timely bank reconciliations and accurate financial reporting. The District has implemented procedures requiring all bank reconciliations to be completed and reviewed within 30 days of month-end. A reconciliation checklist has been established to ensure all bal...

Management recognized the importance of timely bank reconciliations and accurate financial reporting. The District has implemented procedures requiring all bank reconciliations to be completed and reviewed within 30 days of month-end. A reconciliation checklist has been established to ensure all balance sheet accounts are reviewed and reconciled monthly. Management will also perform periodic reviews of the general ledger throughout the year to identify and correct discrepancies before year-end. In addition, the District will provide additional training to accounting personnel regarding month-end closing procedures and financial reporting requirements.

View Audit 404340

Finding 1218150 (2025-001)

Material Weakness 2025

West Elk Unified School District No. 282

KS

Internal Control / Segregation of Duties Subrecipient Monitoring

Management recognized the importance of timely bank reconciliations and accurate financial reporting. The District has implemented procedures requiring all bank reconciliations to be completed and reviewed within 30 days of month-end. A reconciliation checklist has been established to ensure all bal...

Management recognized the importance of timely bank reconciliations and accurate financial reporting. The District has implemented procedures requiring all bank reconciliations to be completed and reviewed within 30 days of month-end. A reconciliation checklist has been established to ensure all balance sheet accounts are reviewed and reconciled monthly. Management will also perform periodic reviews of the general ledger throughout the year to identify and correct discrepancies before year-end. In addition, the District will provide additional training to accounting personnel regarding month-end closing procedures and financial reporting requirements.

View Audit 404340

Finding 1218098 (2025-002)

Material Weakness 2025

City of Wentzville, Missouri

MO

Subrecipient Monitoring Material Weakness Reporting

Management has implemented changes to the preparation and review process for grant reporting. Management will continue to evaluate its controls regarding current federal awards and requirements to ensure that accurate information is captured, reported, and maintained. Anticipated completion date: Al...

Management has implemented changes to the preparation and review process for grant reporting. Management will continue to evaluate its controls regarding current federal awards and requirements to ensure that accurate information is captured, reported, and maintained. Anticipated completion date: Already implemented and all final grant expenditures included in final annual report for reporting period ending March 31, 2026.

View Audit 404277

Finding 1218097 (2025-001)

Material Weakness 2025

City of Wentzville, Missouri

MO

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Management will continue to evaluate its controls concerning current federal awards and requirements to ensure that accurate information is captured and reported. Anticipated completion date: Already implemented and all final grant expenditures included in final annual report for reporting period en...

Management will continue to evaluate its controls concerning current federal awards and requirements to ensure that accurate information is captured and reported. Anticipated completion date: Already implemented and all final grant expenditures included in final annual report for reporting period ending March 31, 2026.

View Audit 404277

Finding 1218096 (2025-004)

Material Weakness 2025

Union-North United School Corporation

IN

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.328

The Director of Grants will continue to prepare the reports and then the Superintendent and Corporation Treasurer will review and sign off on the reports to ensure they agree to the underlying details. The Director of Grants will make sure this is done in a timely manner to comply with the reporting...

The Director of Grants will continue to prepare the reports and then the Superintendent and Corporation Treasurer will review and sign off on the reports to ensure they agree to the underlying details. The Director of Grants will make sure this is done in a timely manner to comply with the reporting deadlines for each fiscal year.

View Audit 404274

Finding 1218065 (2025-001)

Material Weakness 2025

City of Norton

OH

Subrecipient Monitoring Reporting Significant Deficiency § 200.208 § 200.328

Finding Number: 2025-001 Planned Corrective Action: City of Norton will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: June 2026 Responsible Contact Person: Pamela Keener, Finance Director

View Audit 404227

Finding 1217948 (2025-006)

Material Weakness 2025

Opportunities Industrialization Center, INC

NC

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302 § 200.303

Classification Material Weakness Responsible Official Chief Financial Officer and Chief Health Operations Officer Anticipated Completion Date March 31, 2027 Management Response Management concurs with the finding. OIC will strengthen revenue cycle controls to improve patient service revenue recognit...

Classification Material Weakness Responsible Official Chief Financial Officer and Chief Health Operations Officer Anticipated Completion Date March 31, 2027 Management Response Management concurs with the finding. OIC will strengthen revenue cycle controls to improve patient service revenue recognition, accounts receivable valuation, write-off governance, and billing system reconciliations. Corrective Action Plan 1. Transition from a flat encounter-based revenue estimate to a net realizable value methodology that incorporates contractual allowances, sliding fee discounts, implicit price concessions, and allowance for doubtful accounts. 2. Perform monthly documented reconciliations between EPIC, eClinicalWorks, Sage MIP, patient receivables, gross charges, adjustments, collections, write-offs, and general ledger balances. 3. Require documented management review and approval of accounts receivable aging, collectability analyses, write-offs impacting the general ledger, and revenue cycle dashboard reporting.

View Audit 404115

Finding 1217928 (2025-003)

Material Weakness 2025

Town of Terry

MT

Subrecipient Monitoring

FINDING 2025-003: Audit report deadline Response: Clerk’s office will strive to develop a timeline that works for both the clerk and firm to complete the audit report on time.

View Audit 404066

Finding 1217927 (2025-001)

Material Weakness 2025

Agency for Substance Abuse Prevention, Inc.

AL

Internal Control / Segregation of Duties Subrecipient Monitoring

Management of The Agency for Substance Abuse Prevention, Inc. hereby submits the following corrective action plan in response to the single audit findings for the fiscal year ending September 30, 2025: Finding 2025-001 – Segregation of Duties: Description of Finding: The auditor found that duties we...

Management of The Agency for Substance Abuse Prevention, Inc. hereby submits the following corrective action plan in response to the single audit findings for the fiscal year ending September 30, 2025: Finding 2025-001 – Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.

View Audit 404065

Finding 1217923 (2025-001)

Material Weakness 2025

Fisk University

TN

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

2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recogni...

2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recognizes that consistent execution and documentation of these controls were not fully adhered to in all instances. Management will formally re-communicate federal disbursement approval requirements to all relevant personnel, i ncluding principal investigators, department heads, and finance staff. This will include mandatory training sessions on federal compliance and approval protocols and distribution of updated written procedures outlining required approval l evels and documentation standards. To reduce reliance on manual processes, the University will configure the financial system/workilow to require multiple l evels of electronic approval prior to payment processing and restrict disbursement processing until all required a pprovals are completed and documented within the system. Management will implement ongoing monitoring procedures to ensure compliance, including monthly reviews of a sample of federal disbursements by the Controller's Office or Grants Accounting, quarterly compliance reporting to the CFO and senior leadership, and documentation of review results and corrective follow-up actions. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026

View Audit 404057

Finding 1217920 (2025-002)

Material Weakness 2025

Fisk University

TN

Allowable Costs / Cost Principles Subrecipient Monitoring

2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes th...

2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes the importance of maintaining complete and readily accessible documentation to support all federal expenditures in accordance with institutional policy and federal compliance requirements. The University will reinforce documentation and record retention requirements with all relevant personnel, including finance staff, grant administrators, and principal investigators. Additionally, management will implement enhanced controls to ensure that all required supporting documentation is properly maintained and centrally accessible. This will include transitioning toward a more standardized and, where feasible, electronic document management process to reduce the risk of missing records. Furthermore, periodic monitoring procedures will be established, including routine reviews of disbursement files to confirm the presence of required supporting documentation. Any identified deficiencies will be promptly addressed, and corrective actions will be taken to prevent recurrence. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026

View Audit 404057

Finding 1217919 (2025-003)

Material Weakness 2025

Fisk University

TN

Cash Management Period of Performance Subrecipient Monitoring

2025-003: Period of Performance Compliance Action Taken/Planned: Management acknowledges the instances identified in which disbursements were processed after the award's period of performance. While no questioned costs were noted, the University recognizes that timely processing of expenditures and ...

2025-003: Period of Performance Compliance Action Taken/Planned: Management acknowledges the instances identified in which disbursements were processed after the award's period of performance. While no questioned costs were noted, the University recognizes that timely processing of expenditures and drawdowns is critical to ensuring compliance with federal requirements governing grant periods. To Strengthening Grant Closeout Procedures management will establish a formal grant closeout timeline to begin 90 days prior to the award end date, require principal investigators (PIs) and grant administrators to review all outstanding obligations and ensure timely submission of final expenses and implement a standardized closeout checklist to confirm all costs are recorded within the allowable period To Enhanced Monitoring of Grant Periods management will develop and maintain a centralized tracking system for all federal awards, including start and end dates, generate monthly reports identifying grants nearing expiration (within 90, 60, and 30 days) and distribute reports to Pis, Grants Accounting, and Finance leadership for proactive management. For timely processing and drawdown controls management will require all invoices and expenditures to be submitted within a defined timeframe (e.g., within 30 days of service or project completion), establish internal deadlines for processing disbursements and drawdowns prior to the grant end date and implement a review step within Grants Accounting to verify that expenses fall within the period of performance before payment is released. The grants department will conduct mandatory training for PIs, grant managers, and finance staff on period of performance requirements and federal compliance expectations and reinforce accountability for timely submission and processing of expenditures Management will also put in place for any costs identified outside the period of performance will require, documented justification, review and approval by the Director of Grants Accounting and CFO, and verification of allowability under award terms or sponsor approval, if applicable. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026

View Audit 404057

Finding 1217916 (2025-003)

Material Weakness 2025

Lewis Cass Schools

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.214 § 200.303 § 200.317 § 200.318

FINDING 2025-003 Mr. Tim Johnson - President Elected 1/2/2025-12/31/2028 Mrs. Becky Comoglio - V. President Elected 1/2/2025-12/31/2028 Mr. Ryan Zeck - Secretary Elected 1/2/2023-12/31/2026 Mrs. Kristi Hull - Member Elected 1/2/2023-12/31/2026 Mr. Rick Lee - Member Elected l/2/2025-12/31/2028 Findin...

FINDING 2025-003 Mr. Tim Johnson - President Elected 1/2/2025-12/31/2028 Mrs. Becky Comoglio - V. President Elected 1/2/2025-12/31/2028 Mr. Ryan Zeck - Secretary Elected 1/2/2023-12/31/2026 Mrs. Kristi Hull - Member Elected 1/2/2023-12/31/2026 Mr. Rick Lee - Member Elected l/2/2025-12/31/2028 Finding Subject: Special Education Cluster - Procurement, Suspension, and Debarment Contact Person Responsible for Corrective Action: Jackquan Gray, Business Manager Contact Phone Number and Email Address: 574-626-2525 grayj@lewiscass.net Views of Responsible Officials: We Concur with the Finding. Description of Corrective Action Plan: o Create a clear procedure for all small purchases as it relates to procurement. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. o Implement a policy requiring verification of all vendors/contractors for "covered transactions" prior to entering into the contract or issuing payment. A "covered transaction" includes contracts for goods and services expected to equal or exceed $25,000. o The standard procedure should be to check the System for Award Management (SAM} exclusions (www.sam.gov) for all vendors involved in covered transactions funded with federal awards. o Establish proper segregation of duties within the procurement and payment processes to ensure no single person controls an entire transaction. Implement a review process to check for compliance with the new procedures before a purchase order is issued or a payment is made. Anticipated Completion Date: This new policy will take place immediately and the process will be followed when there is a need to check vendors in such circumstances.

View Audit 404046

Finding 1217903 (2025-001)

Material Weakness 2025

Marion County Housing Authority

OR

Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs

1. Implementation of Formal Written Policy MCHA implemented a comprehensive Tenant File Review Policy and Procedure in November 2025. The policy: • Establishes mandatory monthly file review requirements • Defines standardized file selection methodology • Requires consistent documentation of all revi...

1. Implementation of Formal Written Policy MCHA implemented a comprehensive Tenant File Review Policy and Procedure in November 2025. The policy: • Establishes mandatory monthly file review requirements • Defines standardized file selection methodology • Requires consistent documentation of all reviews • Assigns clear roles and responsibilities for oversight and implementation • Requires reviews to be completed monthly without exception, regardless of workload or competing priorities 2. Review Frequency and File Selection • A minimum of 14 tenant files per month are reviewed: o 7 files from the prior month (retrospective review) o 7 files from the upcoming/proactive review group • Files are selected through a randomized process within Compliance Manager, ensuring: o Representation across annual reexaminations, interim reexaminations, and new admissions o A consistent and unbiased sampling of program activity 3. Standardized Review Procedures All file reviews are conducted using a uniform, HOTMA-compliant audit checklist, requiring verification of: • Income and asset calculations • Third-party verification documentation • Required HUD forms and signatures • Accuracy of subsidy determinations (TTP, HAP, utility allowance) • Proper application of payment standards and program requirements 4. Documentation and Internal Control Measures MCHA established a centralized internal tracking system (Excel-based) to document and monitor all file reviews and corrections. • The tracking log: o Is accessible to Case Managers for visibility o Has restricted editing access limited to the Compliance Manager and HCV Program Manager • The log includes: o File selected and review date o Identified deficiencies o Date file is submitted for audit o Date file is returned for correction o Date corrections are completed and formally signed off This process ensures: • A complete audit trail of all reviews and corrections • Separation of duties • Data integrity and accountability 5. Correction and Verification Process • All identified deficiencies must be corrected within established timeframes • Corrections may include: o File documentation updates o Participant or owner follow-up • No file is closed until: o Corrections are verified o Compliance is confirmed by management o Final sign-off is documented 6. Oversight and Accountability • The Program Manager is responsible for: o Overall oversight of the policy and procedures o Ensuring monthly compliance with review requirements o Confirming all deficiencies are resolved prior to closure • The Compliance Manager is responsible for: o Execution and implementation of the review process o Conducting detailed file audits o Maintaining and controlling the tracking log o Monitoring and documenting all correction activity This structure ensures clear segregation of duties, accountability, and consistent oversight. 7. Staff Training and Acknowledgment • All Case Managers received formal training in November 2025 • Each staff member signed a written acknowledgment confirming: o Receipt of the policy o Understanding of requirements • Documentation has been: o Provided to the auditors o Retained for compliance verification Status of Corrective Action Corrective actions were fully implemented in November 2025 and are currently in effect. Planned Completion Date Completed – November 2025 Responsible Officials • HCV Program Manager – Oversight and compliance monitoring • Compliance Manager – Implementation and audit execution Conclusion MCHA believes the corrective actions implemented fully address the identified deficiency. The Authority has established formal written policies, strengthened internal controls, and implemented a structured and sustainable monitoring process. These measures ensure: • Consistent and timely tenant file reviews • Documented tracking and accountability of corrections • Ongoing compliance with HUD program requirements MCHA is confident that these controls prevent recurrence of the issues identified in this finding.

View Audit 404023

Finding 1217823 (2025-003)

Material Weakness 2025

Virginia Foundation for Community College Education

VA

Subrecipient Monitoring § 200.339

View of Responsible Officials The Foundation did indicate to the subrecipients that the subawards were federal funds and outlined terms and uses associated with the subawards. The Foundation also monitored and reviewed subrecipient reimbursement submissions and corresponding support to ensure reques...

View of Responsible Officials The Foundation did indicate to the subrecipients that the subawards were federal funds and outlined terms and uses associated with the subawards. The Foundation also monitored and reviewed subrecipient reimbursement submissions and corresponding support to ensure requests complied with the terms and conditions of the subaward. Action planned: • Develop and implement written policies and procedures that: o Establish a formal process for identifying all subrecipients receiving federal awards and determining which ones meet the single audit threshold. o Define procedures to ensure subrecipients complete the required audits under 2 CFR 200 Subpart F. o Outline steps for reviewing subrecipient audit reports, identifying findings related to the Foundation's subawards, and ensuring the subrecipient develops a corrective action plan for those findings. o Formalize the process for the Foundation to issue a management decision on relevant findings within the required six-month timeframe. o Include procedures for considering sanctions if a subrecipient does not comply with audit requirements. • Perform a lookback review: o Review existing subrecipient agreements to identify any instances of non-compliance with past monitoring requirements and ensure the necessary follow-up actions (e.g., obtaining audit reports, issuing management decisions) are completed for those periods. • Establish a monitoring system: o Implement a tracking system (e.g., a spreadsheet or software) to monitor the status of subrecipient audits, deadlines for management decisions, and follow-up on corrective actions. o Designate a responsible individual/department to oversee the subrecipient monitoring process and ensure all requirements are met consistently. Responsibility: The Chief Operating Officer and Finance Manager will work to draft the policy and will bring it to the Audit Committee for review and approval. The Finance Manager will be responsible for overseeing the implementation and ongoing compliance of the new subrecipient monitoring procedures. Timeline: • February 2026: Policy approved and implemented, and lookback review of prior periods completed. • Ongoing: Continuously monitor subrecipients and ensure timely action is taken on all future audit findings.

View Audit 403931

Corrective Action Plans

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