Corrective Action Plans

Finding 1167027 (2025-003)

Material Weakness 2025

Rio Housing Association, Inc. /covenant Place 075-Ee045

WI

Internal Control / Segregation of Duties Subrecipient Monitoring

Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the...

Segregation of Duties Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Project should continue to evaluate its staffing in order to segregate incompatible duties whenever possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The board of directors will continue to closely monitor the financial operations of the Project. Name(s) of the contact person(s) responsible for corrective action: Mary Gilberts, Management Agent Planned completion date for corrective action plan: June 2026

View Audit 378086

Finding 1166971 (2025-001)

Material Weakness 2025

St. Luke's Health Care Clinic Dba Amador Health Center

NM

Subrecipient Monitoring Eligibility

Management’s View: During the recent audit, a finding was identified within the Sliding Fee Discount Program (SFDP) related primarily to data entry errors, incomplete documentation, and lack of proper review. Errors included incorrect or missing income calculations, misclassification of SFDP categor...

Management’s View: During the recent audit, a finding was identified within the Sliding Fee Discount Program (SFDP) related primarily to data entry errors, incomplete documentation, and lack of proper review. Errors included incorrect or missing income calculations, misclassification of SFDP categories, and inaccuracies entered into the EHR. These discrepancies were attributed to inconsistent staff performance, insufficient oversight, and gaps in training. Since the audit, the former Office Manager and two front desk employees responsible for SFDP data entry have left the organization. Proposed Corrective Action: 1. Strengthening Oversight & Accountability Office Manager Signature Required on ALL SFDP Forms signifying they have reviewed for accuracy, completeness, verified income documentation, ensure calculations are correct, and confirm appropriately and accurately entered into Athena software. 2. Updated Workflow & Process Improvement 3. Training & Competency Development - Annual Refresher Training (All Front Office Staff) The next training has already been scheduled for the week of December 8th. 4. Onboarding Process for New Front Office Employees A strengthened onboarding process will ensure new hires understand the SFDP accurately from day one. 5. Ongoing Monitoring & Quality Assurance Monthly Internal Reviews The Office Manager will audit a percentage of SFDP applications monthly, they will be documented and accuracy rates will be documented for all frontdesk staff. The Director of Administration will ensure these are maintained monthly. 6. Reinforcing the Importance of SFDP Accuracy Anticipated Completion Date: No later then December 31, 2025 Responsible Official: Diana Salcedo, Director of Administration

View Audit 378015

Finding 1166739 (2025-003)

Material Weakness 2025

Hegg Memorial Hospital D/b/a Hegg Health Center

IA

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency § 200.303

Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Center's reserve account is fully funded per the requirements of the loan resoluti...

Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Center's reserve account is fully funded per the requirements of the loan resolution security agreement. However, there is no documented secondary monitoring of the reserve balance as compared to the required minimum reserve balance. Responsible Individuals: Crystal Richter, Interim CFO Corrective Action Plan: Hired an Accountant July 2025. Management will ensure there are multiple people involved and overseeing the reserve balance and documentation will be retained review and approval over the reserve balance. Anticipated Completion Date: December 2025

View Audit 377856

Finding 1166715 (2025-004)

Material Weakness 2025

Urban Minority Alcoholism and Drug Abuse Outreach Program of Lucas County, Inc.

OH

Subrecipient Monitoring Cash Management § 200.305

2025-004 Inadequate Cash Management Procedures and Noncompliance with Period of Performance Requirements Criteria: Per 2 CFR §200.305(b), non-Federal entities must minimize the time elapsing between the transfer of funds from the U.S. Treasury and the disbursement of those funds for program purposes...

2025-004 Inadequate Cash Management Procedures and Noncompliance with Period of Performance Requirements Criteria: Per 2 CFR §200.305(b), non-Federal entities must minimize the time elapsing between the transfer of funds from the U.S. Treasury and the disbursement of those funds for program purposes under the period of performance. Furthermore, entities must have written procedures that clearly outline the timing and methods for drawing down federal funds in accordance with cash management requirements. These procedures should be documented, reviewed, approved, and periodically revised to ensure ongoing compliance. Client’s Response: The organization will revise its current draw-down procedures to reflect timing and methods for drawing down federal funds that are in compliance with cash management requirements. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444

View Audit 377793

Finding 1166714 (2025-003)

Material Weakness 2025

Urban Minority Alcoholism and Drug Abuse Outreach Program of Lucas County, Inc.

OH

Subrecipient Monitoring § 200.332 § 200.501

2025-003 Lack of Formal Subrecipient Monitoring Criteria: According to 2 CFR §200.332 (Requirements for Pass-Through Entities), a pass-through entity must monitor the activities of subrecipients as necessary to ensure that federal funds are used for authorized purposes and in compliance with applica...

2025-003 Lack of Formal Subrecipient Monitoring Criteria: According to 2 CFR §200.332 (Requirements for Pass-Through Entities), a pass-through entity must monitor the activities of subrecipients as necessary to ensure that federal funds are used for authorized purposes and in compliance with applicable statutes, regulations, and terms and conditions of the Federal award. Required monitoring includes, but is not limited to, the following: a. Reviewing financial and programmatic reports; b. Performing risk assessments of subrecipients; c. Following up on deficiencies identified through audits or reviews; and d. Ensuring subrecipients have required audits under 2 CFR §200.501. Lack of documented subrecipient monitoring constitutes noncompliance with Uniform Guidance. Client Response: While the organization was in constant contact with subrecipients regarding the progress of their programming, those meetings were not transcribed. In the future, the organization will require mid year and year-end impact reports from each grant subrecipient. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444

View Audit 377793

Finding 1166712 (2025-001)

Material Weakness 2025

Urban Minority Alcoholism and Drug Abuse Outreach Program of Lucas County, Inc.

OH

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance § 200.1 § 200.308 § 200.309 § 200.344 § 200.403

2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurr...

2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurred before the Federal award was made that were authorized by the Federal awarding agency or pass-through entity. All financial obligations incurred under the Federal award must be liquidated within the required time period. Costs incurred outside the approved period of performance are unallowable and constitute questioned costs. Client’s Response: During the grant cycle, the Organization submitted for an extension but did not receive confirmation of said extension. During the current fiscal year, the Organization has implemented additional controls to ensure that all grant funding is expended within the timeframe allotted. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444

View Audit 377793

Finding 1166685 (2025-002)

Material Weakness 2025

MacOmb Intermediate School District

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.303

Condition: The Intermediate School District (ISD) did not have internal controls in place to ensure that all the expenditures included in the quarterly claims for reimbursement were allowable. Planned Corrective Action: The ISD will review the process used by the local districts to report quarterly ...

Condition: The Intermediate School District (ISD) did not have internal controls in place to ensure that all the expenditures included in the quarterly claims for reimbursement were allowable. Planned Corrective Action: The ISD will review the process used by the local districts to report quarterly expenditures for the Administrative Outreach program. We will then create a process that ensures that the local districts provide supporting documentation that allows us to monitor the quarterly submission amounts for accuracy. Contact person responsible for corrective action: Chris Frank, Asst. Superintendent for Business Anticipated Completion Date: 1/31/2026

View Audit 377762

Finding 1166676 (2025-001)

Material Weakness 2025

Jewish Federation of Metropolitan Chicago

IL

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

Condition: Controls in place did not minimize the time elapsing between the transfer receipt of billing from the subrecipient and disbursement of federal dollars to the subrecipient in accordance with the guidance above. Planned Corrective Action: Federation typically receives vouchers from 15 subre...

Condition: Controls in place did not minimize the time elapsing between the transfer receipt of billing from the subrecipient and disbursement of federal dollars to the subrecipient in accordance with the guidance above. Planned Corrective Action: Federation typically receives vouchers from 15 subrecipient organizations approximately ten to fifteen days after the end of each month. The number of vouchers per agency depends on the number of programs they provide. Staff reviews the vouchers for allowability and accuracy and submits them to the Illinois Department of Human Services (IDHS) within 24 days of month end. During fiscal year 2025, the IDHS remitted payment to Federation anywhere from 20 to 82 days after the month end. Upon receipt of the cash, Federation typically pays subrecipient organizations within two to three business days. In the instances identified by the auditors, the IDHS remitted payment over 30 days after Federation submitted the vouchers for reimbursement. Federation’s longstanding policy has always been to reimburse each subrecipient agency after it has received payment from the IDHS. Prior to fiscal year 2024, the IDHS usually provided payment within 15 days of receipt of our voucher and therefore Federation was able to comply with the 30-day requirement. However, reimbursement delays from IDHS began to occur in fiscal year 2024 and continued throughout fiscal year 2025, resulting in the findings describe herein. IDHS made two advance payments to Federation during fiscal 2025, but the amounts provided were not adequate to fund all payments within the 30 day time period. To ensure compliance with the 30-day reimbursement requirement, Federation will again request advances from the IDHS. Kyu Kim, Director of Finance and Contract Compliance, Refugee Services will be responsible for the oversight of the reimbursement payments. Contact person responsible for corrective action: Kyu Kim Anticipated Completion Date: July 2026

View Audit 377702

Finding 1166652 (2025-002)

Material Weakness 2025

Redford Union School District #1

MI

Subrecipient Monitoring Matching / Level of Effort / Earmarking

Auditor Description of Condition and Effect: Although the District has processes in place to cover these areas, there are no formal written policies covering payments, allowability of costs, and compensation. As a result of this condition, the District did not fully comply with the Uniform Guidance ...

Auditor Description of Condition and Effect: Although the District has processes in place to cover these areas, there are no formal written policies covering payments, allowability of costs, and compensation. As a result of this condition, the District did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation: We are aware that the District is evaluating options using internal and external resources to take corrective action. We recommend that the District proceed with its selected option as soon as practical, but no later than the end of the next fiscal year. Corrective Action: As noted, the District has processes in place that cover all grant guidelines related to federal funds. However, upon bringing it to our attention that these policies should be in writing, we are making every endeavor to comply. The District is currently working on drafting policies that will meet the criteria set out in the Uniform Guidance. Responsible Person: Maria Gistinger, Interim Chief Financial Officer Anticipated Completion Date: June 30, 2026

View Audit 377623

Finding 1166611 (2025-002)

Material Weakness 2025

Poughkeepsie Housing Authority

NY

HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles

Name of Auditee: Poughkeepsie Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: March 31, 2025 CAP Prepared by: Thomas Shanley, Accountant Phone: (845) 485-8931 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Findin...

Name of Auditee: Poughkeepsie Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: March 31, 2025 CAP Prepared by: Thomas Shanley, Accountant Phone: (845) 485-8931 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2025-002 (a) Comments on the Finding and Recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action Taken - The Authority will establish internal tracking and reminder systems to ensure all required reports, including the final P&E and AMCC, are completed and submitted to HUD by the required due dates. Grant reporting responsibilities will be clearly assigned, and submission deadlines will be monitored by the Director of Finance to prevent future delays. These procedures will be implemented immediately. (c) Planned Implementation Date - The Authority plans to implement procedures during the year ending March 31, 2026 to resolve the reported finding.

View Audit 377597

Finding 1166591 (2025-001)

Material Weakness 2025

Cesar Chavez Academy

MI

Subrecipient Monitoring Cash Management School Nutrition Programs

View of the Responsible Official: We agree with the significant deficiency identified. Responsible Persons: School-based food service coordinators and Management director of food service Management Response: Training is conducted annually with school-based food service coordinators to ensure proper ...

View of the Responsible Official: We agree with the significant deficiency identified. Responsible Persons: School-based food service coordinators and Management director of food service Management Response: Training is conducted annually with school-based food service coordinators to ensure proper understanding of reporting requirements. During the 2025-2026 year standardized forms have been distributed to all school food service locations to ensure accurate counting and calculations, which will align with the monthly claim reimbursement reports submitted for reimbursement. It is the expectation that all school-based food service coordinators will properly utilize the updated forms and will receive training as necessary to ensure a thorough understanding of the importance of accurate reporting. Management’s food service director will increase oversight of the meal counts and claims reports to verify the accuracy of the reporting, and to ensure that the count records agree to the claims submitted. Anticipated Completion Date: June 30, 2026

View Audit 377582

Finding 1166504 (2025-001)

Material Weakness 2025

Nba/gpva Accessible Housing II Inc.

MO

HUD Housing Programs Subrecipient Monitoring

Statement of condition 2025-001: For the year ended June 30, 2025, the Corporation did not have a HUD approved Project Owner's/Management Agent's Certification (HUD-9839-B). Recommendation: Management should continue to request the executed Project Owner's/Management Agent's Certification (HUD-9839-...

Statement of condition 2025-001: For the year ended June 30, 2025, the Corporation did not have a HUD approved Project Owner's/Management Agent's Certification (HUD-9839-B). Recommendation: Management should continue to request the executed Project Owner's/Management Agent's Certification (HUD-9839-B) from HUD. Management should not pay any management fees until the executed Project Owner's/Management Agent's Certification (HUD-9839- B) is received. Action(s) taken or planned on the finding: Agree. Management received email correspondence from HUD on August 12, 2021 that stated the Agent is approved to take over management immediately and the Project Owner's/Management Agent's Certification (HUD-9839-B) would be retroactively effective. Management has continued to seek the executed Project Owner's/Management Agent's Certification (HUD-9839-B) from HUD.

View Audit 377520

Finding 1166501 (2025-002)

Material Weakness 2025

Springfield Housing Authority

MA

HUD Housing Programs Reporting Subrecipient Monitoring

Name of Auditee: Springfield Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: March 31, 2025 CAP Prepared by: Denise Jordan, Executive Director Phone: (413) 785-4500 (A) Current Findings on the Schedule of Findings and Questioned Costs (2) Finding 2025-002 (a...

Name of Auditee: Springfield Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: March 31, 2025 CAP Prepared by: Denise Jordan, Executive Director Phone: (413) 785-4500 (A) Current Findings on the Schedule of Findings and Questioned Costs (2) Finding 2025-002 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendations, please see below for action taken. (b) Action taken - The Authority will continue to utilize CBIZ to provide ongoing fee accounting services to incorporate the recommendations listed above on a monthly basis. A comprehensive year-end checklist will continue to be utilized to ensure all financial reports are reconciled to the underlying support. (c) Planned implementation date of corrective action - Completed by March 31, 2026.

View Audit 377514

Finding 1166465 (2025-003)

Material Weakness 2025

L'anse Area Schools

MI

Allowable Costs / Cost Principles School Nutrition Programs Internal Control / Segregation of Duties

2025-003 – UNALLOWABLE COSTS Corrective Action Plan: We have implemented a new policy that requires the Superintendent to review and sign-off on all outgoing EFT and ACH payments. We have implemented a new policy that requires the Superintendent to review and sign-off on all bank statements. Respons...

2025-003 – UNALLOWABLE COSTS Corrective Action Plan: We have implemented a new policy that requires the Superintendent to review and sign-off on all outgoing EFT and ACH payments. We have implemented a new policy that requires the Superintendent to review and sign-off on all bank statements. Responsible Party(ies): • Superintendent and Board of Education Anticipated Completion Date: June 30, 2026

View Audit 377488

Finding 1166460 (2025-006)

Material Weakness 2025

Kearney Housing Agency

NE

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

New depository agreements have been executed between the Housing Agency and the banks. Signature from HUD is pending.

View Audit 377480

Finding 1166335 (2025-002)

Material Weakness 2025

Brac Usa, Inc.

NY

Subrecipient Monitoring Reporting § 200.328

Views of Responsible Officials: In instances where Federal financial and programmatic reports were submitted after the due dates, delays were primarily driven by the time required to obtain and reconcile financial and programmatic data from subrecipients and to complete BRAC USA’s internal reviews a...

Views of Responsible Officials: In instances where Federal financial and programmatic reports were submitted after the due dates, delays were primarily driven by the time required to obtain and reconcile financial and programmatic data from subrecipients and to complete BRAC USA’s internal reviews and sampling procedures. While this resulted in late submissions, our priority was to ensure the completeness, accuracy, and integrity of reported information rather than compromising quality for timeliness. To strengthen compliance going forward, in any instance where BRAC USA anticipates a delay in submitting required Federal financial or programmatic reports, we will proactively communicate with donor or the pass-through entity in advance of the due date, explain the reasons for the delay (including any timing issues related to subrecipient data), and request written approval of a revised reporting deadline. This approach will help ensure transparency, maintain the donor’s ability to effectively monitor grant performance, and document mutual agreement on adjusted submission dates, while still allowing BRAC USA to complete the necessary review and reconciliation procedures to ensure accurate and reliable reporting. Planned Completion Date: December 31, 2025

View Audit 377413

Finding 1166334 (2025-001)

Material Weakness 2025

Brac Usa, Inc.

NY

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332

Views of Responsible Officials: In practice, BRAC USA has consistently evaluated subrecipient risk prior to issuing subawards by considering factors such as prior experience with similar awards, historical audit results, organizational capacity, and financial stability. However, we acknowledge that ...

Views of Responsible Officials: In practice, BRAC USA has consistently evaluated subrecipient risk prior to issuing subawards by considering factors such as prior experience with similar awards, historical audit results, organizational capacity, and financial stability. However, we acknowledge that these assessments were not formalized or consistently documented in a standardized format, as required by 2 CFR § 200.332(c). To address this gap, BRAC USA will develop and implement written procedures and a standardized subrecipient risk assessment tool to be completed and filed prior to issuing Federal subawards. The tool will capture required criteria, including prior audit results, prior performance under similar awards, financial stability indicators, internal control considerations, and any recent staffing or systems changes. These procedures will be incorporated into BRAC USA’s Fiscal Policies and Procedures Manual. The results of each risk assessment will be used to tailor the level and nature of ongoing subrecipient monitoring, and records will be maintained in the grant file to evidence compliance with 2 CFR § 200.332(c). Planned Completion Date: April 30, 2026

View Audit 377413

Finding 1166263 (2025-003)

Material Weakness 2025

City Colleges of Chicago

IL

Subrecipient Monitoring Reporting § 200.303

Condition For one of the four reports tested for the Higher Education Institutional Aid Program, City Colleges did not timely submit a quarterly report to the Pass-Through Entity (PTE). A quarterly performance report was due on May 1, 2025 and submitted 14 days late on May 15, 2025. Cause Submission...

Condition For one of the four reports tested for the Higher Education Institutional Aid Program, City Colleges did not timely submit a quarterly report to the Pass-Through Entity (PTE). A quarterly performance report was due on May 1, 2025 and submitted 14 days late on May 15, 2025. Cause Submission delay was the result of miscommunication between PIs and the grantor. Corrective Action Taken or Planned The Institutional Resource Development (IRD) team will review all subaward grant contracts and work with the colleges to ensure that Tasks are entered into the Salesforce system to provide automatic two-week reminders to the PIs when performance reports are due to the pass-through entity (PTE). Contact Person: Lizz Gardner, Associate Vice Chancellor, Institutional Resource Development Anticipated Completion Date: January 31, 2026

View Audit 377334

Finding 1166261 (2025-002)

Material Weakness 2025

City Colleges of Chicago

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Condition For one out of forty students tested, City Colleges properly recalculated a return of Title IV funds for a student but did not subsequently adjust the student's account to perform the return or notify the student of the adjusted award amount. Cause The lack of return of Title IV funds was ...

Condition For one out of forty students tested, City Colleges properly recalculated a return of Title IV funds for a student but did not subsequently adjust the student's account to perform the return or notify the student of the adjusted award amount. Cause The lack of return of Title IV funds was an oversight due to human error. Corrective Action Taken or Planned To strengthen internal controls, the District Office assigned an analyst to conduct a review of a random selection of files across all seven colleges scheduled for audit to help identify any discrepancies early and ensure compliance. All R2T4 specialists will receive yearly refresher trainings on R2T4 procedures and controls. Contact Person: Leticia Garcia, District Director of Student Financial Aid Anticipated Completion Date: December 13, 2025

View Audit 377334

Finding 1166256 (2025-002)

Material Weakness 2025

Fremont County School District #1

WY

Special Tests & Provisions Subrecipient Monitoring

Name of Contact Person Travis Sweeney, SFO Business Manager Corrective Action For future projects of this nature that are funded with federal dollars the District will implement a written procedure to ensure weekly certified payrolls are obtained, reviewed, and documented prior to payment approval. ...

Name of Contact Person Travis Sweeney, SFO Business Manager Corrective Action For future projects of this nature that are funded with federal dollars the District will implement a written procedure to ensure weekly certified payrolls are obtained, reviewed, and documented prior to payment approval. The District will communicate these requirements to contractors and maintain a monitoring log going forward. Proposed Completion Date Fiscal year ended June 30, 2026

View Audit 377280

Finding 1166253 (2025-001)

Material Weakness 2025

Fremont County School District #1

WY

Subrecipient Monitoring Reporting

Name of Contact Person Travis Sweeney, SFO Business Manager Corrective Action In the future all supporting documentation will be retained by Business Office personnel and kept in the audit file. Proposed Completion Date Fiscal year ended June 30, 2026

View Audit 377280

Finding 1166225 (2025-001)

Material Weakness 2025

South Central Kansas Economic Development District, Inc.

KS

Subrecipient Monitoring Cash Management Matching / Level of Effort / Earmarking

Responsible party: Bethany Johnson, Interim Executive Director and Commercial Lending Manager and Tyler Ward, Interim Finance Director and Commercial Lender Implementation date: December 31, 2025 Corrective Action Plan Both Bethany Johnson, Interim Executive Director and Commercial Lending Manager, ...

Responsible party: Bethany Johnson, Interim Executive Director and Commercial Lending Manager and Tyler Ward, Interim Finance Director and Commercial Lender Implementation date: December 31, 2025 Corrective Action Plan Both Bethany Johnson, Interim Executive Director and Commercial Lending Manager, and Tyler Ward, Interim Finance Director and Commercial Lender, will continue to monitor the budget vs actuals both on a monthly and quarterly basis. Tyler Ward will provide an initial review and Bethany Johnson will provide a secondary review of the financial statements. If any variances are more than 5% over within a category, this category and the overall variances of each line item will be monitored closely to determine if any cumulative changes would cause a 10% or more increase or decrease overall in addition to a particular category. If a budget revision is determined to be required, Tyler Ward will prepare this document and Bethany Johnson will review and sign before submitting it to SBA. A reminder will be added to both Bethany Johnson and Tyler Ward’s SCKEDD calendars along with the existing reporting reminders. This will serve as a secondary reminder to monitor the budget at 90, 60 and 30 days before the end of the grant year. This will ensure that any changes in the 4th quarter can be addressed before the budget revision cutoff date to SBA. Calendar reminders will be added on 12/15/2025, and financials statement variances towards the Microloan grant will be reviewed with more scrutiny moving forward beginning with December 31, 2025 financial statements.

View Audit 377225

Finding 1166223 (2025-001)

Material Weakness 2025

Family Health Council of Central Pennsylvania, Inc.

PA

Cash Management Subrecipient Monitoring § 200.305

Corrective Action: The organization has enhanced its payment workflow to guarantee prompt disbursement of funds to providers. Improvements include automated alerts and internal checkpoints designed to prioritize payments immediately after grant funds are received. Anticipated Completion Date: Correc...

Corrective Action: The organization has enhanced its payment workflow to guarantee prompt disbursement of funds to providers. Improvements include automated alerts and internal checkpoints designed to prioritize payments immediately after grant funds are received. Anticipated Completion Date: Corrected.

View Audit 377221

Finding 1166213 (2025-001)

Material Weakness 2025

Tongore Pines Housing Developing Fund Co., Inc.

NY

Subrecipient Monitoring Eligibility HUD Housing Programs

Finding 2025-001. The management company is required to use the Enterprise Income Verification for eligibility determination per the compliance supplement. There are numerous reports required to be created and reviewed by management on a periodic basis. (1) Recommendation: The management company sho...

Finding 2025-001. The management company is required to use the Enterprise Income Verification for eligibility determination per the compliance supplement. There are numerous reports required to be created and reviewed by management on a periodic basis. (1) Recommendation: The management company should acquire access to the HUD EIV, and begin producing and reviewing the required reports within required timeframes. The organization should further establish procedures that will ensure ongoing compliance. These procedures should include training and monitoring of responsible staff. (2) Actions Taken: Management has worked with HUD to obtain access and will begin performing this responsibility. The appropriate reports will be produced and reviewed once management has access to the HUD EIV system. Procedures are being implemented to assure that this process is taking place.

View Audit 377193

Finding 1166211 (2025-002)

Material Weakness 2025

Heartland Medical Clinic, Inc., D/b/a Heartland Community Health Center

KS

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit...

Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2025. Any findings through the audit process will be reported to the COO. At least five patient charts will be audited monthly. o In addition, the Revenue Cycle Manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper analysis and implementation of sliding fee discounts. o COO and Revenue Cycle Manager will review, implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and Revenue Cycle Manager.

View Audit 377177

Corrective Action Plans

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