Corrective Action Plans

Finding 1162876 (2025-002)

Material Weakness 2025

MI

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.318 § 200.331 § 200.430

2025-002 – Lack of Written Policies and Procedures. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have been de...

2025-002 – Lack of Written Policies and Procedures. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have been developed, these policies have not yet been formally approved and adopted by the Village. As a result of this condition, the Village did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation. We recommend that the Village review and approve the draft policies as soon as practical, but no later than the end of fiscal year 2026. Corrective Action. The Village has prepared a policies and procedures manual for the federal grant programs, which will be approved by the Village Council before the end of fiscal year 2026. Responsible Person. Vicki Burrell, Village Clerk. Anticipated Completion Date: February 2026.

View Audit 372529

Finding 1162805 (2025-001)

Material Weakness 2025

Indiana Agriculture Education, Inc.

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214

In response to the findings of the Annual Audit for Indiana Agriculture Education, Inc. dba Indiana Agriculture & Technology School, our business process includes a review on SAMS.GOV to ensure that payments from any federal grant are not made to any person or business entity that is listed as suspe...

In response to the findings of the Annual Audit for Indiana Agriculture Education, Inc. dba Indiana Agriculture & Technology School, our business process includes a review on SAMS.GOV to ensure that payments from any federal grant are not made to any person or business entity that is listed as suspended, excluded or disbarred. The review of each payment is made prior to issuing an order for goods or services, by our corporate treasurer, currently Kendell Sanders, and is confirmed as approved for payment to our Executive Director prior to issuance of a voucher for payment and subsequent reimbursement with federal funds. This has been included in our internal financial procedures policy documents effective October 15th, 2015, by action of the Board of Directors. The policy shall be reviewed annually. Allan R. Sutherlin Board President Indiana Agriculture Education, Inc

View Audit 372446

Finding 1162408 (2025-001)

Material Weakness 2025

Trustees of Boston College

MA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214

2025-001 - Suspension and Debarment Cluster: Research and Development Grantor: Social Security Administration, National Science Foundation Award Name: Center for Retirement Research at Boston College and Affiliated Institutions: Retirement and Disability Research Consortium, Building a Youth-Led Lea...

2025-001 - Suspension and Debarment Cluster: Research and Development Grantor: Social Security Administration, National Science Foundation Award Name: Center for Retirement Research at Boston College and Affiliated Institutions: Retirement and Disability Research Consortium, Building a Youth-Led Learning Community through Automating Hydroponic Systems, Empowering Youth in STEM and Technological Careers through Al-Enhanced Sustainable and Community-Focused Urban Gardening Award Number: 6 RDR23000010, 2048994, 2241766 Award Year: FY2025 Assistance Listing Numbers: 96.007, 47.076, 47.076 Assistance Listing Titles: Social Security Research and Demonstration; STEM Education (formerly Education and Human Resources) Pass-Through Entities: None - Direct Management's View and Corrective Action Plan The University concurs with this finding. On June 25, 2024, the University encountered multiple job failures due to the expiration of a Java Security Certificate. As a result, the file which was to be submitted to the University's third-party servicer for new vendor suspension and debarment screening was not transmitted. The University's Data Center has procedures in place which should have ensured that the vendor file was resubmitted to the third-party servicer once the University's server-related issues were resolved. Unfortunately, due to incorrect documentation in the production operations system (a.k.a. runbook) the vendor file was not resubmitted. Upon further review it was determined that over the course of the fiscal year this was the only incident where the file failed to be transmitted to the servicer. The 25 vendors not screened as a result of the job failure represented less than 1 % of the 3,860 new vendors successfully transmitted and screened by the third-party servicer during the 2025 fiscal year. To ensure that any system issues affecting the daily transmission of the vendor files to the third-party servicer are promptly resolved and new vendors are checked for suspension and debarment, the Information Technology team will enhance the procedure documentation (runbook) and team members will receive cross training. Both the update to the runbook and cross training of team members will be completed by the end of November 2025. University Contact Lyndsay King Associate Vice President, Finance and University Controller Office of the Controller 617-552-3363

View Audit 372190

Finding 1162313 (2025-002)

Material Weakness 2025

Arizona Association of Community Health Centers, INC

AZ

Subrecipient Monitoring Material Weakness § 200.332

Item: 2025-002 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2021 th...

Item: 2025-002 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2021 through August 26, 2024; August 27, 2024 through August 26, 2029 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR 200.332 (e), (g) and (h) - pass-through entities must monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Condition: While AACHC performed several of the required subrecipient monitoring tasks, AACHC’s system of internal controls did not include a process to monitor the subrecipients’ financial and performance reports by verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Name of Contact Person: Brenda Hanserd, CFO Phone Number: 602-288-7559 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Action Plan: AACHC will update their subrecipient monitoring policies and procedures to specifically include a process to monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. AACHC will also regularly attend trainings on the Uniform Guidance to ensure they are knowledge of the required compliance procedures.

View Audit 372128

Finding 1162312 (2025-001)

Material Weakness 2025

Arizona Association of Community Health Centers, INC

AZ

Subrecipient Monitoring Material Weakness § 200.332

Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: Maricopa County Pass-Through Grantor Identifying Number: None Award Year: November 1, 2021 through September 3...

Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: Maricopa County Pass-Through Grantor Identifying Number: None Award Year: November 1, 2021 through September 30, 2026 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR 200.332 (e), (g) and (h) - pass-through entities must monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Condition: While AACHC performed several of the required subrecipient monitoring tasks, AACHC’s system of internal controls did not include a process to monitor the subrecipients’ financial and performance reports by verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Name of Contact Person: Brenda Hanserd, CFO Phone Number: 602-288-7559 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Action Plan: AACHC will update their subrecipient monitoring policies and procedures to specifically include a process to monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. AACHC will also regularly attend trainings on the Uniform Guidance to ensure they are knowledge of the required compliance procedures.

View Audit 372128

Finding 1162004 (2025-001)

Material Weakness 2025

All Faiths

NM

Subrecipient Monitoring Material Weakness Reporting

Finding 2025-001: Reporting Planned Corrective Action: To prevent continued issues with late grant invoice submissions, we are implementing the following items: 1. Alignment of position responsibilities and cross-training within the Finance department – roles and updated job descriptions are being f...

Finding 2025-001: Reporting Planned Corrective Action: To prevent continued issues with late grant invoice submissions, we are implementing the following items: 1. Alignment of position responsibilities and cross-training within the Finance department – roles and updated job descriptions are being finalized to identify clear responsibilities with primary and backup employees responsible for these submissions, including always having three individuals in the department trained on the process. 2. Monitoring and review of grant submissions – we are now utilizing two monthly checklists, one for month-end processes and one for grant invoicing process, that are closely monitored by the CFO and the Accountant to ensure tasks are completed timely. Additionally, and prior to submitting, the grant invoice will be reviewed by an additional departmental sta􀆯, who is trained on the grant process. 3. Documentation – as part of the alignment of position responsibilities, the Finance department is working to fully update the standard operating procedure (SOP) for the grant invoicing process to ensure accurate steps and instructions are available to support the user(s) completing the tasks. Anticipated Completion Date: November 30, 2025. Responsible Contact Person: Phillip London, Chief Financial O􀆯icer

View Audit 371865

Finding 1161733 (2025-003)

Material Weakness 2025

Citadel Gardens, Inc. Dba the Woodlands at Citadel

MO

Allowable Costs / Cost Principles HUD Housing Programs Special Tests & Provisions

Finding 2025-003 Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles, E – Eligibility, and N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comments on Finding Auditee has not had time to evaluate Auditor’s finding. Corrective Act...

Finding 2025-003 Compliance Requirements A/B – Activities Allowed or Unallowed and Allowable Costs / Cost Principles, E – Eligibility, and N – Special Tests and Provisions Finding Type Federal Awards Auditee’s Comments on Finding Auditee has not had time to evaluate Auditor’s finding. Corrective Action We will keep all required documentation in tenant files and establish processes and procedures to ensure compliance with the provisions in HUD Handbook 4350.3, HUD Handbook 4381.5, and the Regulatory Agreement. Anticipated Completion Date December 31, 2025

View Audit 371688

Finding 1161732 (2025-002)

Material Weakness 2025

Citadel Gardens, Inc. Dba the Woodlands at Citadel

MO

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs

Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action On July 24, 2025 we filed HUD Form 9839-B requesting retroactive approval to March 1, 202...

Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action On July 24, 2025 we filed HUD Form 9839-B requesting retroactive approval to March 1, 2025. Anticipated Completion Date July 24, 2025

View Audit 371688

Finding 1161731 (2025-001)

Material Weakness 2025

Citadel Gardens, Inc. Dba the Woodlands at Citadel

MO

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to p...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended March 31, 2025. Responsible Party Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Supportive Housing for the Elderly (Section 202) Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comments on Finding We agree with the auditors’ finding. Corrective Action We will follow our policies and procedures to ensure that our accounting records are kept accurate and complete, and a responsible official will review and sign off on the monthly financial statements. Anticipated Completion Date December 31, 2025

View Audit 371688

Finding 1161679 (2025-003)

Material Weakness 2025

Village of Farwell

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.327 § 200.331

2025-003 – Lack of Written Findings and Questioned Costs. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have b...

2025-003 – Lack of Written Findings and Questioned Costs. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have been developed, these policies have not yet been formally approved and adopted by the Village. As a result of this condition, the Village did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation. We recommend that the Village review and approve the draft policies as soon as practical, but no later than the end of fiscal year 2026. Corrective Action. The Village has prepared a policies and procedures manual for the federal grant programs, which will be approved by the Village Council before the end of fiscal year 2026. Responsible Person. Ross Wilson, Village Clerk/Treasurer. Anticipated Completion Date: February 2026.

View Audit 371608

Finding 1161678 (2025-004)

Material Weakness 2025

Village of Farwell

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.214

2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were per...

2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were performed for vendors. As a result, there is no evidence that the Village verified whether these parties were suspended or debarred prior to entering covered transactions. Auditor Recommendation. We recommend that the Village retain evidence that SAM.gov exclusion checks are being completed for vendors to document that vendors are not suspended or debarred prior to entering covered transactions. Corrective Action. The Village will begin retaining documentation for its SAM.gov exclusion checks that it completes for vendors to verify whether these parties were suspended or debarred prior to entering covered transactions. Responsible Person. Ross Wilson, Village Clerk/Treasurer. Anticipated Completion Date: February 2026.

View Audit 371608

Finding 1161383 (2025-001)

Material Weakness 2025

Uncompahgre Combined Clinics Dba Uncompahgre Medical Center

CO

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended 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...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended 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 the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has recognized the deficiency of internal controls regarding this determination, recording, and monitoring of the sliding fee process from application through making the adjustment. The Organization has implemented a comprehensive input and verification process that applies to both the initial application and the subsequent adjustment phases. This includes enhanced checks to ensure accuracy in data entry and calculation, as well as verification of application information. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Tricia Lippert, Comptroller at 970-327-0537.

View Audit 371259

Finding 1161269 (2025-001)

Material Weakness 2025

MacAlester College

MN

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.303

Student Financial Assistance Cluster – CFDA No. 84.063, 84.268 Recommendation: We recommend the College review its procedures to ensure controls are in place to ensure to catch any inconsistencies that occur during the year. Explanation of disagreement with audit finding: No disagreement with the au...

Student Financial Assistance Cluster – CFDA No. 84.063, 84.268 Recommendation: We recommend the College review its procedures to ensure controls are in place to ensure to catch any inconsistencies that occur during the year. Explanation of disagreement with audit finding: No disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office will maintain documentation of monthly communication between the External Programs Manager, the Financial Aid Director and the Director of Accounting, related to the monthly reconciliation of Federal Direct Loans, Federal Pell Grant. Federal SEOG and Federal Work Study programs. Name of the contact person responsible for corrective action: Jenae Schmidt, Director of Financial Aid Planned completion date for corrective action plan: September 30, 2025

View Audit 371195

Finding 1161133 (2025-001)

Material Weakness 2025

Boys & Girls Club of Weber-Davis

UT

Procurement, Suspension & Debarment Subrecipient Monitoring Cash Management

BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by th...

BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by the grant facilitator to provide member income data. However, to ensure compliance with federal reporting requirements, we will begin requesting income information from our members. In addition, we will reach out to our partner schools to determine whether they can confirm which of our members participate in the free or reduced lunch program.

View Audit 371150

Finding 1160856 (2025-004)

Material Weakness 2025

Texas Christian University

TX

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.430

To safeguard from future errors and ensure data accuracy, Human Resources partnered with Enterprise Application Services department to develop an automated process that populates earnings codes and project account codes based on employee, job record and earnings code. This enhancement streamlines da...

To safeguard from future errors and ensure data accuracy, Human Resources partnered with Enterprise Application Services department to develop an automated process that populates earnings codes and project account codes based on employee, job record and earnings code. This enhancement streamlines data entry by consolidating it into a single interface, reducing the risk of manual entry errors. Additionally, the HR Technology Manager has implemented a new monitoring report to track employees with multiple salary distribution accounts as a part of payroll process. The biweekly report will be automatically generated and sent via email to HR’s HRIS Consultants for review. The HRIS Consultants will analyze the report, resolve any discrepancies and escalate any issues to the HR Technology Manager or Lead Application Consultant as necessary. These processes will be routinely reviewed, with adjustments made as needed.

View Audit 370942 Questioned Costs: $1

Finding 1160657 (2025-001)

Material Weakness 2025

Sen Citizens Hsg Dev Fund CORP of Steuben County Two,inc

FL

Subrecipient Monitoring Reporting

Oversight Agency for Audit, Senior Citizens Housing Development Fund Corporation of Steuben County Two, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N Universit...

Oversight Agency for Audit, Senior Citizens Housing Development Fund Corporation of Steuben County Two, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201 Coral Springs, Florida 33067 Audit period: April 1, 2024 through March 31, 2025 The findings from the March 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2025-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should make sufficient deposits to the escrow account in a timely manner and correctly allocate policy premiums. The excess workers’ compensation policy premium should be returned to the Project. Also, the Project should replenish the funds that were transferred from the escrow account to the operating account and improve monitoring of the escrow account balance to ensure it is properly funded. Action Taken: The project will fund the shortfall and replenish funds that were incorrectly transferred from the escrow account. Escrow balances will be reviewed on a regular basis to ensure adequate funding.

View Audit 370923

Finding 1160316 (2025-001)

Material Weakness 2025

Oklahoma Christian University and Subsidiaries

OK

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

Student Financial Assistance Cluster Assistance Listing Number 84.268 Federal Direct Student Loans, and 84.063 Federal Pell Grant Program U.S. Department of Education Program Year 2024-2025 Criteria or Specific Requirement – Disbursements to or on behalf of students, 34 CFR Section 668.164(h)(2) Con...

Student Financial Assistance Cluster Assistance Listing Number 84.268 Federal Direct Student Loans, and 84.063 Federal Pell Grant Program U.S. Department of Education Program Year 2024-2025 Criteria or Specific Requirement – Disbursements to or on behalf of students, 34 CFR Section 668.164(h)(2) Condition – Students did not receive refunds within the required timeframe Questioned Costs – N/A Context – 7 out of 25 students tested received their credit balance refund more than 14 days after the credit balance was generated. All but 1 of these students received their refund within 16 days of the generation of the credit balance. Our sample was not, and was not intended to be, statistically valid. Effect – Noncompliance with federal regulations requiring timely disbursement of credit balance refunds Cause – Due to the high volume of credit balance refunds being processed, the University encountered operational constraints that prevented all refunds from being generated within the designated 14-day timeframe. Indication as a Repeat Finding – N/A Recommendation – To ensure timely refund of student credit balances, implement a control that flags any refund not processed before the end of the 14-day timeframe for immediate review and escalation. Additionally, establish a monitoring report to track refund timeliness weekly and reinforce accountability for processing within the required timeframe. Views of Responsible Officials and Planned Corrective Actions – Amy Schlup, Director of Student Financial Services, and Carrie Hamilton, Assistant Director of Financial Aid, will oversee the corrective action plan. As part of this process, they will review the daily Student Refund Report to identify and assist the personal financial counselor in expediting student refunds. The Student Financial Services team will also review and retrain on the proper procedures for processing refunds within the required timeframe. The corrective action plan is already in progress and will be fully implemented by October 1, 2025. Office of Financial Services PO Box 11000 Oklahoma City, OK 73136 405.425.5190 financialservices@oc.edu

View Audit 370701

Finding 1159684 (2025-001)

Material Weakness 2025

Virginia Garcia Medical Health Center

OR

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

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration...

Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration, Electronic Health Records (EHR) not operating as expected for one line of the SFDS and error not caught and corrected, and a significant process change from percentage to fixed fee SFDS causing inconsistent application during transition and training period. Planned corrective action: System Configuration:  Leaders for all service lines and Billing Department will work with EHR Support Team and vendor to review and test all possible SFDS options to verify rules are functioning as expected and as outlined in the SFDS policy.  Annual review and testing of EHR rules governing SFDS to validate ongoing compliance. Contact person: Jennifer Velez, Revenue Cycle Director Completion date for action: 10/31/2025 Staff Training and Documentation:  All staff responsible for registration and income verification in all service lines, programs, and sites will receive a review of income eligibility assessment, documentation, and application.  Registration Program Manager and EHR Trainers will work with Learning and Development Department to develop competency standard for income eligibility assessment, documentation, and application for all staff responsible for registration and income verification in all service lines, programs, and sites. All identified staff will be required to demonstrate competence annually using the Learning Management System (LMS).  The Center will audit 5 patient records for FPL (Federal Poverty Level) documentation per site or program two times annually during C-Qual (the Center’s internal audit process). This will result in 180 charts each year.  Site Managers or Department Administrators will review front office dashboard in monthly management meetings and develop site specific action plans if exceptions are identified. This was added to the standing agenda for the Primary Care Clinic Managers (PCCM) meeting in September 2025. Contact person: Angela Hurley, Director of Operations Completion date for action: 12/31/2025 Implementation Controls:  Update SFDS policy to include review and verification of EHR alignment with fee schedule following any update or change approved by the Board of Directors.  Develop checklist for roll-out of changes in SFDS that prompts change management and training team to review readiness and validation procedures before going live with changes. Contact person: Angela Hurley, Director of Operations Completion date for action: 9/30/2025

View Audit 370272

Finding 1159582 (2025-002)

Material Weakness 2025

Wpc Housing Corp. Danford Hall Apartments

MO

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025

View Audit 370221

Finding 1159581 (2025-001)

Material Weakness 2025

Wpc Housing Corp. Danford Hall Apartments

MO

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended February 28, 2025. Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Rental and Cooperative Housing (Section 221(d)(4)) Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will ensure that the accounts reconcile to source documents as part of our month-end closing process. Anticipated Completion Date August 31, 2025

View Audit 370221

Finding 1159580 (2025-007)

Material Weakness 2025

Full Harvest Housing, Inc.

IA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. ...

Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. Anticipated Completion Date July 31, 2025

View Audit 370220 Questioned Costs: $1

Finding 1159578 (2025-005)

Material Weakness 2025

Full Harvest Housing, Inc.

IA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completio...

Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completion Date July 1, 2025

View Audit 370220 Questioned Costs: $1

Finding 1159576 (2025-003)

Material Weakness 2025

Full Harvest Housing, Inc.

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2025-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will contact HUD to discuss resolution of this matter within 30 days. Anticipated Completion Date September 30, 2025

View Audit 370220 Questioned Costs: $1

Finding 1159575 (2025-002)

Material Weakness 2025

Full Harvest Housing, Inc.

IA

Questioned Costs HUD Housing Programs Special Tests & Provisions

Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will deposit $732 into the residual receipts account within 30-days. Anticipated Completion Date July 31, 2025

View Audit 370220 Questioned Costs: $1

Finding 1159574 (2025-001)

Material Weakness 2025

Full Harvest Housing, Inc.

IA

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs

Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and com...

Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and complete. Anticipated Completion Date September 30, 2025

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