Corrective Action Plans

Finding 1176450 (2025-004)

Material Weakness 2025

Board of Child Care of the United Methodist Church, Inc.

MD

Subrecipient Monitoring § 200.332

Views of Responsible Officials: Management acknowledges the audit finding related to the Federal Funding Accountability and Transparency Act of 2006 (FFATA) Reporting and appreciates the opportunity to address this matter. Everstand does have an established procedure for consistent reporting of subr...

Views of Responsible Officials: Management acknowledges the audit finding related to the Federal Funding Accountability and Transparency Act of 2006 (FFATA) Reporting and appreciates the opportunity to address this matter. Everstand does have an established procedure for consistent reporting of subrecipient activities as required under FFATA regulations. However, the lack of a clearly defined responsibility for this task resulted in non-compliance. Management recognizes this gap and is committed to implementing corrective measures to ensure full compliance moving forward.

View Audit 390264

Finding 1176449 (2025-003)

Material Weakness 2025

Board of Child Care of the United Methodist Church, Inc.

MD

Subrecipient Monitoring § 200.332

Views of Responsible Officials: Management acknowledges the audit finding related to Subrecipient Monitoring and appreciates the opportunity to address this matter. We recognize the importance of robust monitoring procedures to ensure compliance with Federal requirements and mitigate risk. Although ...

Views of Responsible Officials: Management acknowledges the audit finding related to Subrecipient Monitoring and appreciates the opportunity to address this matter. We recognize the importance of robust monitoring procedures to ensure compliance with Federal requirements and mitigate risk. Although procedures exist for verifying SAM.gov registration (suspension/debarment status) and obtaining audited financial statements from subgrantees, these procedures were not documented or codified in the Caminos Nacional Policy Manual. Pre-award risk assessments have been conducted informally without a formal determination of risk, and protocols surrounding risk assessment were inadequately documented, resulting in inconsistent implementation.

View Audit 390264

Finding 1176448 (2025-002)

Material Weakness 2025

Board of Child Care of the United Methodist Church, Inc.

MD

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.430

Views of Responsible Officials: Management acknowledges the findings related to Payroll Allocation, and Training & Compliance, as outlined in the recent audit report. We appreciate the recommendations provided and are committed to implementing corrective actions to strengthen compliance, improve pay...

Views of Responsible Officials: Management acknowledges the findings related to Payroll Allocation, and Training & Compliance, as outlined in the recent audit report. We appreciate the recommendations provided and are committed to implementing corrective actions to strengthen compliance, improve payroll allocation accuracy, and enhance staff knowledge of grant management requirements.

View Audit 390264

Finding 1176380 (2025-008)

Material Weakness 2025

Madison Commuity Unit School District #12

IL

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the ...

Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the expenditure reports against the budget items before submitting. Management Response: The District will add a verification process to reconcile the general ledger to the budget and expenditure reports before submitting. The District will consider implementing a detailed grant tracking sheet to ensure the general ledger expenditures agree to the expenses reported to ISBE by grant. Anticipated Date of Completion: June 30, 2026

View Audit 390196

Finding 1176377 (2025-007)

Material Weakness 2025

Madison Commuity Unit School District #12

IL

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the ...

Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the expenditure reports against the budget items before submitting. Management Response: The District will add a verification process to reconcile the general ledger to the budget and expenditure reports before submitting. The District will consider implementing a detailed grant tracking sheet to ensure the general ledger expenditures agree to the expenses reported to ISBE by grant. Anticipated Date of Completion: June 30, 2026

View Audit 390196

Finding 1176364 (2025-002)

Material Weakness 2025

Volunteers of America Colorado Branch

CO

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Condition: The Organization lacked adequate controls to ensure reviews were performed by a different individual than the one responsible for preparing monthly financial reporting, calculations of per-unit activity, and requests for reimbursement. Planned Corrective Action: 1. Standardization of Fina...

Condition: The Organization lacked adequate controls to ensure reviews were performed by a different individual than the one responsible for preparing monthly financial reporting, calculations of per-unit activity, and requests for reimbursement. Planned Corrective Action: 1. Standardization of Financial Reporting Workflow: A formal segregation of duties for all federal and pass-through reimbursement requests and financial reports has been implemented. Effective immediately, the individual responsible for accumulating cost data and calculating per-unit activity (preparer) is prohibited from being the reviewer. 2. Implementation of Approval Process: All reports must now be submitted by the preparer to the designated reviewer for approval via email prior to submission. An approval response from the reviewer is required prior to submission to the awarding agency. 3. Staff Training: All grants management and accounting personnel have been briefed on the requirements of 2 CFR 200.303, specifically regarding the necessity of documented internal controls to provide reasonable assurance of compliance. Contact person responsible for corrective action: Erin Nordmann (Controller) Chiyoko Yokota (Chief Financial Officer) Anticipated Completion Date: Fully Corrected

View Audit 390182

Finding 1176360 (2025-001)

Material Weakness 2025

Volunteers of America Colorado Branch

CO

Reporting Subrecipient Monitoring § 200.303

Condition: The Organization lacked adequate controls to ensure the SEFA was complete and accurate. Planned Corrective Action: 1. Federal Award Classification Review: Federal versus non-federal classification will be reviewed by the program manager, Director of Internal Control, and CFO based on the ...

Condition: The Organization lacked adequate controls to ensure the SEFA was complete and accurate. Planned Corrective Action: 1. Federal Award Classification Review: Federal versus non-federal classification will be reviewed by the program manager, Director of Internal Control, and CFO based on the executed agreement. Any reclassification will require documented CFO approval. 2. Annual Cross-System Reconciliation: An annual reconciliation between the contract management system and the general ledger will be performed to ensure all federal awards are captured for SEFA reporting. 3. SEFA Format Standardization: The SEFA preparation schedule will be reverted to a prior-year rollover format that retains carryforward data and enables year-over-year comparison to improve completeness review and anomaly detection. 4. General Ledger Tagging Controls: General ledger dimensional tagging has been enhanced so federally funded activity is automatically identified and included in the preliminary SEFA. 5. Independent SEFA Review: The SEFA will undergo documented independent review and approval by the CFO prior to auditor submission, consistent with 2 CFR 200.303. Contact person responsible for corrective action: Ian Kile (Director of Internal Controls and Analysis) Chiyoko Yokota (Chief Financial Officer) Anticipated Completion Date: Fully Corrected

View Audit 390182

Finding 1176359 (2025-001)

Material Weakness 2025

City of Sterling Heights, Michigan

MI

Subrecipient Monitoring Questioned Costs Allowable Costs / Cost Principles

2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report fir...

2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Direct recipients must report key data elements by registering through the FSRS and reporting subaward data through that system. Direct recipients that are awarded a federal grant are required to file a FFATA sub-award report by the end of the month following the month in which the prime awardee awards any sub-grant equal to or greater than $30,000. The City did not submit the required key data elements through the FSRS reporting system as required by the Uniform Guidance and as a result has not completed the appropriate sub-award reporting that is required for direct recipients. Auditor Recommendation: We recommend that the City review its procedures for FFATA reporting through FSRS and ensure that all key data elements are reported timely moving forward. Corrective Action: Upon discovery of the issue in November 2025, City staff corrected the noncompliance by submitting the required report to the appropriate reporting system/entity. To prevent recurrence, management has strengthened internal controls over FFATA reporting and Single Audit preparation by (1) adding review and verification steps, (2) communicating expectations with key personnel, and (3) explicitly assigning submission responsibility to a designated submitter who is independent of the individual(s) responsible for monitoring compliance. These control enhancements are expected to identify and prevent similar deficiencies and, based on implementation to date, appear to be operating effectively. Responsible Person: Jason Denton, Controller Anticipated Completion Date: June 30, 2026

View Audit 390179

Finding 1176358 (2025-001)

Material Weakness 2025

Jamestown Community College

NY

Student Financial Aid Subrecipient Monitoring Equipment & Real Property Management

The College agrees with the finding. While many GLBA-required safeguards are operationally in place, documentation and a formal enterprise risk assessment have not been fully completed. The College will engage a qualified third party to perform a comprehensive GLBA-aligned risk assessment using a re...

The College agrees with the finding. While many GLBA-required safeguards are operationally in place, documentation and a formal enterprise risk assessment have not been fully completed. The College will engage a qualified third party to perform a comprehensive GLBA-aligned risk assessment using a recognized framework such as NIST. Based on the results, the College will document identified risks, existing safeguards, and remediation plans. Additionally, the College will formalize and update its Written Information Security Program, including policies addressing vendor management, user access controls, data transmission and destruction, change management, and data inventory. Policies will be reviewed and approved through the College’s governance process. Responsible Party: Kyle Brown, Executive Director of Technology, Jamestown Community College, kylebrown@sunyjcc.edu, 716.338.1118 Anticipated Completion Date: August 31, 2026

View Audit 390178

Finding 1176354 (2025-001)

Material Weakness 2025

Lowndes County Board of Education

GA

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.303 § 200.403 § 200.430

FA 2025-001 Strengthen Controls over Employee Compensation Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Allowable Costs/Cost Principles Significant Defici...

FA 2025-001 Strengthen Controls over Employee Compensation Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Allowable Costs/Cost Principles Significant Deficiency Nonmaterial Noncompliance U.S. Department of Education Georgia Department of Education 84.027 - Special Education Cluster Grant to States 84.173 - Special Education Cluster Preschool Grants H027A230073 (Year: 2024), H027A240073 (Year: 2025), H173A240081 (Year: 2025) $1,283 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the employee compensation process as it relates to the Special Education Cluster. Corrective Action Plans: The District concurs with the finding and is committed to strengthening internal controls. While the identified discrepancies were isolated, we recognize the need for enhanced reconciliation during personnel transitions. The Human Resources and Finance departments will enhance our review process. This pre-payroll validation step will ensure that all salary adjustments and position changes align with Board authorized pay documentation prior to disbursement. Estimated Completion Date: 3/31/2026 Contact Person: Julie Wiley, Chief Financial Officer Telephone: 229-316-1878 Email: juliewiley@lowndes.k12.ga.us

View Audit 390177

Finding 1176329 (2025-003)

Material Weakness 2025

Hall County Housing Authority

NE

Subrecipient Monitoring HUD Housing Programs Material Weakness § 200.302

Finding 2025-003 See response to finding 2025-001.

View Audit 390146

Finding 1176328 (2025-002)

Material Weakness 2025

Dallas/fort Worth International Airport Board

TX

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

Condition: The controls in place to review the final grant packet, including the grant draw-down template and the drawdown invoice detail, prior to final processing of the drawdown were not operating as designed. Planned Corrective Action: Treasury will work with PMM and DCC departments to out-line ...

Condition: The controls in place to review the final grant packet, including the grant draw-down template and the drawdown invoice detail, prior to final processing of the drawdown were not operating as designed. Planned Corrective Action: Treasury will work with PMM and DCC departments to out-line a process to ensure accurate reporting of eligible expenses when invoices are re-viewed for compliance with grant program requirements. The process will be documented and adhered to once agreed by all departments. A review process for the final drawdown submission will also be adopted to ensure costs that are identified as ineligible are appro-priately excluded from the final submission. Contact person responsible for corrective action: Sr. Grants Manager Anticipated Completion Date: 06/30/2026

View Audit 390144

Finding 1176309 (2025-005)

Material Weakness 2025

Oregon Food Bank, Inc.

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Questioned Costs § 200.317 § 200.327

Since the prior audit period, management has taken steps to review and revise OFB’s procurement policy and procedures, in alignment with federal procurement standards. Finance will continue implementing the corrective actions and establishing the internal controls to ensure adherence to the policy, ...

Since the prior audit period, management has taken steps to review and revise OFB’s procurement policy and procedures, in alignment with federal procurement standards. Finance will continue implementing the corrective actions and establishing the internal controls to ensure adherence to the policy, retaining documentation of the procurement process to demonstrate compliance. These recent and planned improvements will enhance transparency, strengthen accountability, and reduce compliance risk, ensuring a more efficient and well-documented procurement process that supports the organization’s long-term financial integrity and operational effectiveness. The anticipated completion date remains June 30, 2026.

View Audit 390140

Finding 1176301 (2025-004)

Material Weakness 2025

Oregon Food Bank, Inc.

OR

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.414

Since the prior audit period, management has taken steps to establish procedures and internal controls to ensure consistent application, billing, and reporting of indirect cost rates across all federal awards. Such steps include defining and documenting roles and responsibilities for applicable staf...

Since the prior audit period, management has taken steps to establish procedures and internal controls to ensure consistent application, billing, and reporting of indirect cost rates across all federal awards. Such steps include defining and documenting roles and responsibilities for applicable staff members during each phase of the grants management lifecycle, as well as implementing procedures and tools to ensure compliance with subrecipient monitoring requirements. These steps involve multiple levels of review for accurate and consistent application of indirect cost rates. Finance will continue implementing the corrective actions necessary to achieve effective controls over compliance with indirect cost rate requirements. Policy and procedures on allowable and allocable costs will be drafted to clearly document how direct and indirect costs will be billed to federal awards. Training will be provided to relevant staff members to ensure accurate implementation and ongoing compliance. These actions will improve our ability to manage indirect costs effectively and ensure compliance with federal requirements. The anticipated completion date remains June 30, 2026.

View Audit 390140

Finding 1176293 (2025-003)

Material Weakness 2025

Oregon Food Bank, Inc.

OR

Allowable Costs / Cost Principles Questioned Costs Procurement, Suspension & Debarment § 200.430

Since the prior audit period, management has taken steps to develop and implement a time and effort reporting system that meets federal documentation standards, such as activating the electronic timekeeping system to track actual work performed and testing adoption of reporting procedures across dep...

Since the prior audit period, management has taken steps to develop and implement a time and effort reporting system that meets federal documentation standards, such as activating the electronic timekeeping system to track actual work performed and testing adoption of reporting procedures across departments and teams. Finance will continue implementing the corrective actions necessary to establish an effective and compliant time and effort reporting system, including providing training for employees and regularly monitoring for effective system utilization. These actions will strengthen internal controls and ensure personnel costs are accurately recorded and appropriately allocated. The anticipated completion date remains June 30, 2027.

View Audit 390140

Finding 1176192 (2025-001)

Material Weakness 2025

City of North Richland Hills, Texas

TX

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.328

Corrective Action Plan for Finding 2025-001 We are in receipt of the Finding Required to be reported by the Uniform Guidance regarding the Reporting Compliance Requirement. Management agrees with the finding. The discrepancy in current-year reporting resulted from a computational oversight caused by...

Corrective Action Plan for Finding 2025-001 We are in receipt of the Finding Required to be reported by the Uniform Guidance regarding the Reporting Compliance Requirement. Management agrees with the finding. The discrepancy in current-year reporting resulted from a computational oversight caused by a formula error within the reporting templates. Where possible, we will add automated check figures to the reporting spreadsheets to validate data accuracy and strengthen internal review procedures. Jamie Moore, Accounting Manager, will be responsible for ensuring this is accomplished. The correction action plan will be implemented by September 30, 2026.

View Audit 390015

Finding 1175956 (2025-004)

Material Weakness 2025

Naf Senior Housing, Inc.

NE

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

Finding 2025-004: Reporting – Owner – Certified Submission Management Response Management agrees with the finding. REAC submission was late because year – end accounting records were not done in time. Corrective Action Plan 1. Establish a Closing Calendar and Compliance Calendar • Year-end data dead...

Finding 2025-004: Reporting – Owner – Certified Submission Management Response Management agrees with the finding. REAC submission was late because year – end accounting records were not done in time. Corrective Action Plan 1. Establish a Closing Calendar and Compliance Calendar • Year-end data deadlines • Dates for draft and final financials • REAC submission due date 2. Coordination with Fee Accountant • Schedule year-end preparation work earlier • Fee Accountant set a deadline for LHA to provide supporting documents IMPLEMENTATION TIMELINE: PRIOR TO NEXT FISCAL YEAR-END.

View Audit 389924

Finding 1175927 (2025-002)

Material Weakness 2025

BOYS AND GIRLS CLUBS OF KING COUNTY

WA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Contact Person(s): Sandy Fabre, CFO Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement Corrective action planned: Management will complete a two-step review process to ensure expenses are being validated...

Contact Person(s): Sandy Fabre, CFO Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement Corrective action planned: Management will complete a two-step review process to ensure expenses are being validated correctly. Additionally, a selective self-audit program will be developed to verify that recordkeeping is complete and effective. Anticipated completion date: 05/01/2026

View Audit 389897

Finding 1175895 (2025-001)

Material Weakness 2025

Worksystems, INC

OR

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

02/09/2026 Worksystems, Inc respectfully submits the following corrective action plan for the year ending June 30, 2025. Audit: July 01, 2024 – June 30, 2025 The findings from the schedule of findings and questioned cost are discussed below. The findings are numbered with the number assigned in the ...

02/09/2026 Worksystems, Inc respectfully submits the following corrective action plan for the year ending June 30, 2025. Audit: July 01, 2024 – June 30, 2025 The findings from the schedule of findings and questioned cost are discussed below. The findings are numbered with the number assigned in the schedule. FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department Labor (pass through from the Oregon Higher Education Coordinating Commission) 2025-001 WIOA Cluster – Assistance Listing #17.258, 17.259, 17.278 Recommendation: The Organization should establish written policies and procedures regarding monitoring of the maximum earmark percentage allowed. Explanation of disagreement with audit findings: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal management promptly developed a report to monitor WIOA administrative expenditures to ensure compliance with applicable earmarking requirements. It was recently used to confirm compliance during the quarterly FSR reporting cycle. Fiscal management has also incorporated the review of this report into the monthly close process. Action Plan: Fiscal management is currently reviewing and updating existing process documentation, calculation templates, and journal entry import procedures related to cost pool allocations to WIOA funds. These procedures will be revised as necessary and will incorporate the validation report and related control activities. Upon completion, fiscal staff will be retrained on the updated procedures to ensure consistent application and understanding. In addition, fiscal management will perform a review of current program year allocations to WIOA funds to confirm continued compliance with administrative cost limitations. Name(s) of the contact people responsible for correction action: Andrew L Fitch, CFO afitch@worksystems.org 503-478-7357. Plan completion date for corrective action plan: 03/31/2026

View Audit 389877

Finding 1175877 (2025-001)

Material Weakness 2025

City of Independence, Missouri

MO

Procurement, Suspension & Debarment Subrecipient Monitoring

During our fiscal year 2025 – the City began requiring vendors to complete and submit a certification form regarding debarment and suspension if funding for the contract or purchase order involved Federal funds. This certification form requires the vendor to certify that they are not debarred, suspe...

During our fiscal year 2025 – the City began requiring vendors to complete and submit a certification form regarding debarment and suspension if funding for the contract or purchase order involved Federal funds. This certification form requires the vendor to certify that they are not debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. The certification form is to be submitted prior to the City issuing contracts and purchase orders. We will review and adjust our internal review processes to ensure the form is submitted and not missed as part of our contract and purchase order issuing process. We will also review open purchase orders that were issued prior to fiscal year 2025 to obtain the debarment and suspension certification from the vendors.

View Audit 389848

Finding 1175863 (2025-001)

Material Weakness 2025

United Way of New York City

NY

Subrecipient Monitoring § 200.332

Finding No. 2025-001 – Subrecipient Monitoring – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: UWNYC will implement a formal annual subrecipient audit verification procedure to ensure compliance with 2 CFR 200.332(g). Staff will annually determine and document whet...

Finding No. 2025-001 – Subrecipient Monitoring – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: UWNYC will implement a formal annual subrecipient audit verification procedure to ensure compliance with 2 CFR 200.332(g). Staff will annually determine and document whether each subrecipient is subject to Single Audit requirements under 2 CFR Part 200, Subpart F. For subrecipients subject to these requirements, staff will obtain and review the final Single Audit report, document the review, and consider any identified audit findings as part of the subrecipient risk assessment to inform the level and nature of ongoing monitoring. These procedures will be documented and incorporated into UWNYC’s subrecipient monitoring internal controls. Anticipated Completion Date: Initial review by September 30, 2026 Person(s) Responsible for Corrective Action: Eichakeem McClary, Chief Legal Officer (212.251.4093) Tanisha McKnight, Chief Operations Officer (212.251.4010)

View Audit 389836

Finding 1175829 (2025-003)

Material Weakness 2025

North Central Education Cooperative

ND

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.430

Contact Person Tonya Hunskor Planned Corrective Action The Cooperative will ensure proper subrecipient monitoring is implemented. Planned Completion Date June 30, 2026.

View Audit 389783

Finding 1175828 (2025-003)

Material Weakness 2025

City of Staunton, Virginia

VA

Subrecipient Monitoring

We agree with the finding. In the future, the appropriate language will be included in subaward documentation.

View Audit 389776

Finding 1175820 (2025-001)

Material Weakness 2025

First Choice Health Centers, Inc.

NY

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Repeat Finding No Action Taken Management has implemented enhanced internal controls to ensure sliding fee discounts are accuratel...

The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Repeat Finding No Action Taken Management has implemented enhanced internal controls to ensure sliding fee discounts are accurately calculated and fully supported. The Center standardized income verification procedures, reinforced documentation requirements for family size and income, and updated its sliding fee eligibility checklist to ensure consistency. Supervisory review protocols were established to verify proper calculation and supporting documentation prior to approval. Additionally, staff received refresher training on sliding fee policy requirements to promote ongoing compliance. Management will conduct periodic internal audits to monitor adherence and ensure continued effectiveness of these controls. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sean Murphy, CFO at 860-610-6387.

View Audit 389772

Finding 1175817 (2025-001)

Material Weakness 2025

Christ Community Health Services, Inc.

TN

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

Finding: 2025-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Frackson Salak, CFO Planned Corrective Action: Christ Community Health Services will perform...

Finding: 2025-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Frackson Salak, CFO Planned Corrective Action: Christ Community Health Services will perform monthly audits on patients who receive a sliding fee discount. The monthly audits will include verifying the correct fee was applied based on documents received during the patients sliding fee enrollment. If any errors are found they will be immediately corrected. Anticipated Completion Date: 06/30/2026

View Audit 389757

Corrective Action Plans

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