Corrective Action Plans

Finding 1238109 (2025-005)

Material Weakness 2025

Renville County

MN

Subrecipient Monitoring Eligibility Material Weakness § 200.303

CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The County will reinforce procedures requiring eligibility workers to maintain adequate documentation supporting all income so...

CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: The County will reinforce procedures requiring eligibility workers to maintain adequate documentation supporting all income sources used in Medical Assistance eligibility determinations. Supervisory reviews will be performed periodically to ensure case files contain the necessary supporting documentation and that eligibility calculations agree to information maintained in the case record. 3. Official Responsible for Ensuring CAP: Lisa Herges, County Administrator, is the official responsible for ensuring corrective action of the compliance finding. 4. Planned Completion Date for CAP: December 31, 2026 5. Plan to Monitor Completion of CAP: The County Board will be monitoring this corrective action plan. Sincerely, Lisa Herges County Administrator

View Audit 412976

Finding 1238106 (2025-003)

Material Weakness 2025

Town of Zionsville

IN

Internal Control / Segregation of Duties Reporting § 200.1 § 200.303

FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Cindy Poore, Director of Finance and Records Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsibl...

FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Cindy Poore, Director of Finance and Records Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with this finding. Explanation and Reasons for Disagreement: The field in question was not completed, however the total amount obligated was accurate. This is also how we completed the report in prior years and it was not questioned. We will make sure that the field is completed going forward. Anticipated Completion Date: 8/19/26

View Audit 412966

Finding 1238105 (2025-002)

Material Weakness 2025

Town of Zionsville

IN

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.214 § 200.303

FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Cindy Poore, Director of Finance and Records Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov View...

FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Cindy Poore, Director of Finance and Records Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We disagree with the finding. Description of Corrective Action Plan: We received a comment on this during our last audit for 2024. That audit was completed the end of August 2025. The 1 vendor found during this current audit that didn’t have the suspension and debarment verification had been paid prior to the last audit being completed, so there was no way of fixing the issue when it was brought to our attention. This was more of an overlap or timing issue rather than a recurring issue. We have already put a couple of things in place to be compliant with this “finding”. All contracts have a section regarding suspension and debarment added to the verbiage. Vendors that do not have a contract are given to the Deputy Director to look up and print the verification to be kept for audit purposes. Anticipated Completion Date: 8/19/26

View Audit 412966

Finding 1238100 (2025-001)

Material Weakness 2025

Stearns County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2025-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Michael Pooler, Economic Supports Division Director Corrective Action Planned: The County will continue to implement TANF quality cont...

Finding Number: 2025-001 Finding Title: Eligibility Program: 93.558 Temporary Assistance for Needy Families Name of Contact Person Responsible for Corrective Action: Michael Pooler, Economic Supports Division Director Corrective Action Planned: The County will continue to implement TANF quality control review measures and hold weekly unit meetings to address case-specific questions and policy clarifications with program experts. These practices support ongoing learning, reduce knowledge gaps, and reinforce the importance of consistent documentation and attention to detail across the unit. Anticipated Completion Date: March 31, 2027

View Audit 412954

Finding 1238083 (2025-003)

Material Weakness 2025

COUNTY OF BLACKFORD

IN

Internal Control / Segregation of Duties § 200.1 § 200.303

FINDING 2025-003 Finding Subject: Reporting Contact Person Responsible for Corrective Action: Lisa Simmons, Auditor Contact Phone Number and Email Address: (765) 348-1620 lsimmons@blackfordcounty.in.gov Views of Responsible Officials: The County agrees with the finding regarding internal controls ov...

FINDING 2025-003 Finding Subject: Reporting Contact Person Responsible for Corrective Action: Lisa Simmons, Auditor Contact Phone Number and Email Address: (765) 348-1620 lsimmons@blackfordcounty.in.gov Views of Responsible Officials: The County agrees with the finding regarding internal controls over the reporting requirements associated with the Coronavirus State and Local Fiscal Recovery Funds (SLFRF) program. Description of Corrective Action Plan: The County recognizes that, although the required Project and Expenditure (P&E) report was prepared and submitted to the U.S. Department of the Treasury, the County did not have an adequate documented oversight and review process in place prior to submission. To strengthen internal controls, the County will establish a formal process for the preparation, review, and submission of all required SLFRF reports. The County Auditor or designated employee will prepare the P&E report using the County's financial records and supporting documentation. Prior to submission, a separate individual with appropriate knowledge and oversight responsibilities will independently review the report for completeness and accuracy. The review will include verification of reported expenditures to the County's accounting records, review of projects and activities reported, and verification of applicable contracts and other required information. The reviewer will document completion of the review and any discrepancies identified will be resolved prior to submission. The County will also maintain a reporting calendar identifying applicable reporting periods and submission deadlines. The calendar will be monitored to ensure reports are prepared, reviewed, and submitted timely. Supporting documentation for the preparation and review of each report will be retained with the County's financial records. Employees responsible for federal grant reporting will receive additional training regarding the applicable Treasury reporting requirements and the County's established procedures. These procedures will provide an additional level of oversight and segregation of duties and are intended to ensure that future SLFRF reports are complete, accurate, properly reviewed, and submitted by the applicable deadlines. Anticipated Completion Date: December 31, 2026

View Audit 412917

Finding 1238082 (2025-004)

Material Weakness 2025

Kandiyohi County

MN

Eligibility Reporting Significant Deficiency § 200.303

ELIGIBILITY Recommendation: It is recommended that the County start reviewing casefiles. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will start printing a coversheet for the Fiscal Supervisor to sign...

ELIGIBILITY Recommendation: It is recommended that the County start reviewing casefiles. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will start printing a coversheet for the Fiscal Supervisor to sign and retain physical evidence of the review being done. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2026

View Audit 412906

Finding 1238078 (2025-001)

Material Weakness 2025

Employment Connection

MO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Finding 2025-001: Significant Deficiency over Internal Controls related to Allowable Costs Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Or...

Finding 2025-001: Significant Deficiency over Internal Controls related to Allowable Costs Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed monthly review process. This will include verifying payroll charges against supporting documentation such as payroll registers, time records, and allocation spreadsheets. Management will also explore the development of a standardized reconciliation checklist and introduce a secondary review step to ensure accuracy and completeness. These measures, combined with continued monthly oversight by the CFO, are intended to reduce the risk of billing errors due to human oversight and reinforce the reliability of payroll cost allocations. Name of Responsible Person: Nora Davis, Chief Financial Officer Anticipated Completion Date: October 1, 2026

View Audit 412896

Finding 1238052 (2025-002)

Material Weakness 2025

NORTHEAST NEBRASKA PUBLIC POWER DISTRICT

NE

Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.317 § 200.318 § 200.327

Federal Agency Name: Department of Energy Pass-Through Entity: Nebraska Department of Environment and Energy Assistance Listing Number: 81.254 Program Name: Grid Infrastructure Deployment and Resilience Finding Summary: Testing of the federal program identified opportunities to strengthen the Distri...

Federal Agency Name: Department of Energy Pass-Through Entity: Nebraska Department of Environment and Energy Assistance Listing Number: 81.254 Program Name: Grid Infrastructure Deployment and Resilience Finding Summary: Testing of the federal program identified opportunities to strengthen the District’s procurement and vendor compliance documentation practices. Specifically: • The District has not formalized and adopted a written procurement policy. • In two instances involving covered transactions exceeding $25,000, documentation was not retained to demonstrate that a verification was performed to confirm the vendor was not suspended or debarred from participation in federally funded programs. • In two instances, supporting documentation was not maintained to demonstrate the procurement method utilized and the basis for the vendor selection. Corrective Action Plan: The District will develop and formally adopt a written procurement policy addressing procurement activities involving federal awards and the applicable requirements of the Uniform Guidance. The District will establish procedures to document the procurement method utilized and the basis for vendor selection, verify and retain documentation that vendors subject to federal suspension and debarment requirements are not suspended or debarred from participation in federal programs, and ensure that federally funded contracts include applicable federal contract provisions required by 2 CFR Part 200. Responsible Individuals: Mandy Backer, Chief Financial Officer, and Josh Strafelda, Engineer Anticipated Completion Date: March 2027

View Audit 412863

Finding 1238011 (2025-003)

Material Weakness 2025

Lawrence County

IN

Internal Control / Segregation of Duties § 200.1 § 200.303

FINDING 2025-003 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Audit Findings: Material Weakness, Non-Compliance Contact Person Responsible for Corrective Action: Martha L. Arnold-Turner Contact Phone Number and Email Address: 812-275-3111, mturner@lawrencecounty....

FINDING 2025-003 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Reporting Audit Findings: Material Weakness, Non-Compliance Contact Person Responsible for Corrective Action: Martha L. Arnold-Turner Contact Phone Number and Email Address: 812-275-3111, mturner@lawrencecounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The county corrective action plan will be designed to implement a proper system of internal controls that will ensure compliance with the Reporting requirements of the grant and has already started with the report that was due in 2026. - The County will continue to implement internal controls that will prevent or correct noncompliance. For all Federal grants that require reports, after one person who understands the program and its requirements prepares the report, another person will continue to review the report for accuracy and completeness prior to it being submitted. Anticipated Completion Date: 12/31/2026

View Audit 412831

Finding 1237984 (2025-002)

Material Weakness 2025

Miami County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2025-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Fund – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Annette Phillippo Contact Phone Number and Email Address: 765-472-3901, ext. 1240 and aphillippo@miamicountyin.go...

FINDING 2025-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Fund – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Annette Phillippo Contact Phone Number and Email Address: 765-472-3901, ext. 1240 and aphillippo@miamicountyin.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Policies and procedures will be put in place to search on sam.gov to determine if a vendor has been suspended or disbarred. Anticipated Completion Date: September 2026 INDIANA STATE

View Audit 412772

Finding 1237948 (2025-003)

Material Weakness 2025

Grant County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2025-003 Finding Subject: 21.027 State and Local Fiscal Recovery Fund - Suspension and Debarment Contact Person Responsible for Corrective Action: Angela Jarvis, County Auditor Contact Phone Number and Email Address: 765-668-6552 ajarvis@grantcounty.in.gov Views of Responsible Officials: We ...

FINDING 2025-003 Finding Subject: 21.027 State and Local Fiscal Recovery Fund - Suspension and Debarment Contact Person Responsible for Corrective Action: Angela Jarvis, County Auditor Contact Phone Number and Email Address: 765-668-6552 ajarvis@grantcounty.in.gov Views of Responsible Officials: We Concur with the finding. Description of Corrective Action Plan: We recognize the importance of ensuring that federal funds are not provided to individuals or entities that are suspended or debarred. To correct this issue on future agreements, the appropriate suspension and debarment provisions will be incorporated into the agreement at the time of drafting and prior to execution. Anticipated Completion Date: September 8, 2026

View Audit 412738

Finding 1237946 (2025-006)

Material Weakness 2025

City of Vincennes

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2025-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-677-3959 clane@vincennes.in.gov Views of Responsible Officials: We concur with th...

FINDING 2025-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-677-3959 clane@vincennes.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All reports will be prepared by the clerk’s office and will be reviewed for errors and omissions by someone who is knowledgeable about the reporting requirements prior to submission. Anticipated Completion Date: The corrective action plan will be implemented by December 31, 2026.

View Audit 412721

Finding 1237945 (2025-005)

Material Weakness 2025

City of Vincennes

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2025-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-677-3959 clane@vincennes.in.gov Views of Responsible Officials: We...

FINDING 2025-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-677-3959 clane@vincennes.in.gov Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: The clerk’s office will verify that vendors are not excluded or disqualified by checking the SAM’s website, addressing the vendor or adding a clause or condition to the contract to be signed by the vendor. Any documentation will be retained in the city’s grant files. Anticipated Completion Date: The corrective action plan will be implemented by December 31, 2026.

View Audit 412721

Finding 1237944 (2025-004)

Material Weakness 2025

City of Vincennes

IN

Allowable Costs / Cost Principles § 200.300 § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2025-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Allowable Costs/Cost Principles and Period of Performance Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-677-3959 clane@vincennes.in.gov V...

FINDING 2025-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Allowable Costs/Cost Principles and Period of Performance Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-677-3959 clane@vincennes.in.gov Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: The clerk’s office will work with the grant administrators and departments to assist in identifying non-compliant activities to ensure that funds are being used appropriately and according to the federal guidelines for the grant. We will consult with the relevant personnel to ensure understanding of allowable and disallowed costs as well as period of performance and help departments who may need additional training. Anticipated Completion Date: The corrective action plan will be implemented by December 31, 2026.

View Audit 412721

Finding 1237943 (2025-003)

Material Weakness 2025

City of Vincennes

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Activities Allowed or Unallowed Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Offici...

FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Activities Allowed or Unallowed Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: The Clerk-Treasurer’s office will prepare APV for all claims, including those related to payroll benefits. The APVs will be included on the claims docket which will be presented to the City Council for their review and approval. Additionally, the Clerk-Treasurer will certify each claim prior to payment. Anticipated Completion Date: The corrective action plan will be implemented by December 31, 2026.

View Audit 412721

Finding 1237940 (2025-009)

Material Weakness 2025

Cincinnati Health Network, Inc.

OH

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.334 § 200.430

There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that employee compensation approvals were not consistently performed in accordance with documented procedures. To strengthen segregation of...

There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that employee compensation approvals were not consistently performed in accordance with documented procedures. To strengthen segregation of duties and oversight, responsibility for review and approval of employee compensation changes will be reassigned to appropriate executive leadership personnel independent of payroll processing responsibilities, consistent with the requirement under the Uniform Guidance (2 CFR 200.303) that the Organization establish and maintain effective internal control over federal awards. All pay raises will be initiated upon the recommendation of the respective department directors and must be approved by the Chief Executive Officer (CEO) or Chief Financial Officer (CFO) prior to processing. All compensation changes will be made in accordance with the Organization's Board-approved written compensation policies and will be reasonable and consistent with compensation paid for similar work, as required by the compensation standards for personal services under the Uniform Guidance (2 CFR 200.430). Human Resources will be responsible for ensuring that all pay raise documentation, including department director recommendations and CEO/CFO approvals, is properly completed and filed in the employee’s personnel record. Documentation of all compensation approvals will be maintained in accordance with the record retention requirements of the Uniform Guidance (2 CFR 200.334) and periodically reviewed to ensure compliance with established policies and procedures. Name(s) of the contact person(s) responsible for corrective action: Edward Murphy, Asante Muyungga, Charity Gutierrez, Anthony Parker, Bennett Baber, Jannell Robinson. Planned completion date for corrective action plan: June 30, 2027

View Audit 412715

Finding 1237938 (2025-008)

Material Weakness 2025

Cincinnati Health Network, Inc.

OH

Allowable Costs / Cost Principles § 200.303 § 200.334 § 200.403

There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that evidence of review and approval was not consistently retained and that documentation supporting reimbursement requests was not maintai...

There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that evidence of review and approval was not consistently retained and that documentation supporting reimbursement requests was not maintained at a level sufficient to demonstrate compliance with federal requirements. To address this deficiency, management is implementing formal documentation standards requiring each reimbursement request to be supported by a reconciliation of amounts requested to actual allowable expenditures recorded in the general ledger, together with documented evidence of reviewer approval. Each reconciliation will be prepared by grant and budget category and will compare cumulative expenditures recorded in the general ledger to cumulative amounts previously drawn through the Payment Management System, with any differences investigated and resolved before the request is submitted. The Chief Financial Officer (CFO) or the Chief Executive Officer (CEO) will then review and approve each Request for Reimbursement form and related reconciliation before submission, consistent with the approval process described in the responses to Findings 2025-003 and 2025-006. Evidence of this review will include the approver’s handwritten or electronic signature and the approval date on both the Request for Reimbursement form and the supporting reconciliation. In addition, all expenditures will require documented preapproval by the respective department director or other designated personnel before costs are incurred. Original receipts, invoices, and other supporting documentation will be submitted to the Accounting Department, which will review each expenditure to verify that it is properly authorized, adequately supported, accurately coded, and incurred for a legitimate business purpose of the Organization. Prior to the submission of any reimbursement request, expenditures charged to federal awards will be reviewed for allowability, allocability, reasonableness, and adequate documentation in accordance with the cost principles of the Uniform Guidance (2 CFR Part 200, Subpart E). All reconciliations, approvals, and supporting documentation will be retained in accordance with federal record retention requirements and made readily available for review. Supporting documentation will be maintained in a centralized location, organized by grant and reimbursement period, and retained in accordance with the Uniform Guidance record retention requirements (2 CFR 200.334). The Organization will incorporate these review and approval procedures into its written financial policies and procedures, and finance staff involved in preparing reimbursement requests will receive training on them. In addition, management will periodically perform a secondary review of a sample of completed reimbursement requests to verify that reconciliations, approvals, and supporting documentation are complete, and any exceptions identified will be promptly corrected and documented. Name(s) of the contact person(s) responsible for corrective action: Edward Murphy, Asante Muyungga, Charity Gutierrez, Anthony Parker, Bennett Baber, Jannell Robinson. Planned completion date for corrective action plan: June 30th, 2027

View Audit 412715

Finding 1237934 (2025-005)

Material Weakness 2025

Cincinnati Health Network, Inc.

OH

Subrecipient Monitoring Eligibility Significant Deficiency § 200.303

There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that controls intended to ensure annual renewal of sliding fee discount applications were not consistently operating as intended. Managemen...

There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that controls intended to ensure annual renewal of sliding fee discount applications were not consistently operating as intended. Management is strengthening monitoring procedures by implementing tracking mechanisms to identify expiring applications and requiring verification of eligibility documentation prior to continued application of discounts, consistent with the requirement under Section 330(k)(3)(G) of the Public Health Service Act (42 U.S.C. 254b(k)(3)(G)) that health centers establish systems for sliding fee eligibility determination. In addition, management will provide additional training to all billing and front-desk staff on the sliding fee discount program, including eligibility determination, income and household-size documentation requirements, application renewal procedures, and the proper application of discounts in the practice management system. Periodic supervisory reviews will be performed to ensure compliance with the Board-approved sliding fee discount policy, consistent with the internal control requirements of the Uniform Guidance (2 CFR 200.303). Management will also review the sliding fee discount schedule on a regular basis, no less than annually, and will update it in a timely manner whenever necessary, including upon publication of the annual Federal Poverty Guidelines, so that discounts continue to be adjusted on the basis of each patient’s ability to pay as required by 42 CFR 51c.303(f), with all updates presented to the Board of Directors for approval and communicated promptly to billing staff. Documentation of staff training, schedule reviews, and Board approvals will be retained to demonstrate compliance with HRSA Health Center Program requirements, including Chapter 9 (Sliding Fee Discount Program) of the HRSA Health Center Program Compliance Manual. Name(s) of the contact person(s) responsible for corrective action: Edward Murphy, Asante Muyungga, Charity Gutierrez, Anthony Parker, Bennett Baber, Jannell Robinson. Planned completion date for corrective action plan: December 31st, 2026

View Audit 412715

Finding 1237930 (2025-002)

Material Weakness 2025

Cincinnati Health Network, Inc.

OH

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

There is no disagreement with the audit finding. Action planned in response to finding: Management concurs with the finding. The Organization recognizes that documentation and reconciliation procedures supporting the Uniform Data System (UDS) submission were not sufficient to demonstrate the accurac...

There is no disagreement with the audit finding. Action planned in response to finding: Management concurs with the finding. The Organization recognizes that documentation and reconciliation procedures supporting the Uniform Data System (UDS) submission were not sufficient to demonstrate the accuracy and completeness of all reported data elements. During 2026, management will implement formal procedures requiring each UDS reporting element to be supported by documented source data, reconciled to underlying records, and independently reviewed prior to submission. These procedures will include a pre-submission review checklist and internal timeline so that all reconciliations and supporting documentation are completed and reviewed in advance of the UDS reporting deadline. Responsibility for preparation, review, and approval of UDS reporting will be formally assigned and documented. To strengthen this review, management plans to hire additional senior management personnel, including an Accounting Manager, to support the Accounting Department and oversee reconciliation of the UDS financial tables (Tables 8A, 9D, and 9E) to the general ledger and audited financial statements. In addition, management plans to hire a Director of Risk and Compliance, who will be responsible for overseeing the Organization's compliance with HRSA Health Center Program requirements, including the UDS reporting process. The Director of Risk and Compliance will perform an independent review of the completed UDS submission prior to certification, verifying that each reported data element is supported by documented source data and reconciliations, and will periodically monitor adherence to the procedures described in this response, with results reported to the Chief Executive Officer (CEO) and the Board of Directors. Any discrepancies identified before or after submission will be documented, investigated, and corrected in a timely manner, including through the HRSA UDS review and revision process where applicable. Management will also provide additional training to all staff involved in collecting, preparing, and reviewing UDS data, covering HRSA UDS reporting requirements, data definitions, and documentation standards. In addition, management will establish document retention procedures to ensure all supporting schedules, reconciliations, and reports are maintained in a centralized location and readily available for future review. New policies requiring timely account reconciliations and the retention of supporting records will be monitored and reviewed regularly by the Chief Financial Officer (CFO) to ensure they are consistently followed. Name(s) of the contact person(s) responsible for corrective action: Edward Murphy, Asante Muyungga, Charity Gutierrez, Anthony Parker, Bennett Baber, Jannell Robinson. Planned completion date for corrective action plan: June 30th, 2027

View Audit 412715

Finding 1237927 (2025-158)

Material Weakness 2025

The Geneva Foundation

WA

Procurement, Suspension & Debarment § 200.303

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and ...

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and U.S. Department of Health and Human Services (HHS) – Various R&D Assistance Listings Questioned Costs: None Condition: The Foundation did not follow internal control procedures designed to ensure compliance with suspension and debarment requirements for covered contracts. During our testing of procurement transactions subject to suspension and debarment requirements, we noted that the Foundation did not retain documentation demonstrating that it had reviewed the System for Award Management (SAM.gov) exclusion records prior to entering into contractual agreements. Specifically, there was no evidence that a SAM.gov printout was reviewed or approved to verify that vendors were not suspended or debarred at the time of contract execution. In conjunction with the audit, we reviewed the SAM Exclusions for all transactions in our sample and we noted that no transactions were with entities that were suspended or debarred. 2. Corrective Action: The Foundation will review and update its procurement and vendor eligibility procedures to ensure compliance with federal suspension and debarment requirements under 2 CFR Part 180 and applicable Uniform Guidance requirements. The revised procedures will: a. Define when SAM.gov exclusion verification is required. b. Identify personnel responsible for performing and documenting the verification. c. Require retention of date-stamped evidence of the SAM.gov review within the procurement file prior to contract execution. d. Establish supervisory review procedures to confirm required documentation is present before procurement approval is granted. e. Incorporate suspension and debarment verification requirements into procurement checklists, vendor onboarding procedures, and procurement approval workflows. f. Require that covered procurement actions cannot proceed to contract execution without documented evidence of suspension and debarment verification. g. Incorporate periodic compliance monitoring to assess adherence to the revised procedures and identify any exceptions requiring corrective action. These actions are designed to strengthen the Foundation's internal control environment, enhance documentation practices, and ensure consistent compliance with federal suspension and debarment requirements. Management believes these corrective actions adequately address the root cause of the finding and will reduce the risk of recurrence in future audit periods. 3. Responsible Party: The Director and Financial Controller will jointly oversee the policy review, procedural updates, and ongoing monitoring to ensure compliance with federal requirements. Day-to-day implementation and monitoring will be coordinated by the Procurement Manager, with oversight and periodic compliance review performed by the Financial Controller. 4. Anticipated Completion Date: December 31, 2026. Key milestones include: a. Revised procedures drafted and approved by October 31, 2026 b. Procurement workflow and checklist updates completed by November 15, 2026 c. Staff training completed by November 30, 2026 d. Updated controls and workflow requirements implemented by November 30, 2026 e. Compliance review completed by December 31, 2026 5. Implementation Details: To implement the updated procedures, the Foundation will incorporate SAM.gov suspension and debarment verification requirements into its procurement workflow, vendor onboarding process, and procurement file review procedures. Prior to execution of any covered contract subject to federal requirements, designated personnel will perform a SAM.gov exclusion search and retain date-stamped evidence of the search within the procurement file. Procurement approvals will not be finalized until the required documentation has been obtained and reviewed. In addition, Finance personnel processing covered transactions will verify that required suspension and debarment documentation is maintained within the procurement file before payments are processed. Transactions lacking required suspension and debarment documentation will be returned to Procurement for correction and completion prior to contract execution or payment processing, as applicable. The Procurement Manager will conduct periodic reviews of procurement files to verify compliance with documentation requirements. Any exceptions identified will be documented and reported to the Director and Financial Controller for resolution and corrective action. Additionally, procurement personnel and other employees involved in vendor onboarding, contracting, and accounts payable activities will receive training regarding federal suspension and debarment requirements, documentation standards, and revised approval procedures. During FY27, management will conduct and document quarterly reviews of a sample of covered procurement transactions to verify compliance with the revised controls. Any deficiencies identified will be evaluated and corrective actions implemented as necessary. Sincerely, Matt Rueckert Chief Operating Officer (COO)

View Audit 412698

Finding 1237926 (2025-157)

Material Weakness 2025

The Geneva Foundation

WA

Procurement, Suspension & Debarment § 200.303

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and ...

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and U.S. Department of Health and Human Services (HHS) – Various R&D Assistance Listings Questioned Costs: None Condition: The Foundation did not follow internal control procedures designed to ensure compliance with suspension and debarment requirements for covered contracts. During our testing of procurement transactions subject to suspension and debarment requirements, we noted that the Foundation did not retain documentation demonstrating that it had reviewed the System for Award Management (SAM.gov) exclusion records prior to entering into contractual agreements. Specifically, there was no evidence that a SAM.gov printout was reviewed or approved to verify that vendors were not suspended or debarred at the time of contract execution. In conjunction with the audit, we reviewed the SAM Exclusions for all transactions in our sample and we noted that no transactions were with entities that were suspended or debarred. 2. Corrective Action: The Foundation will review and update its procurement and vendor eligibility procedures to ensure compliance with federal suspension and debarment requirements under 2 CFR Part 180 and applicable Uniform Guidance requirements. The revised procedures will: a. Define when SAM.gov exclusion verification is required. b. Identify personnel responsible for performing and documenting the verification. c. Require retention of date-stamped evidence of the SAM.gov review within the procurement file prior to contract execution. d. Establish supervisory review procedures to confirm required documentation is present before procurement approval is granted. e. Incorporate suspension and debarment verification requirements into procurement checklists, vendor onboarding procedures, and procurement approval workflows. f. Require that covered procurement actions cannot proceed to contract execution without documented evidence of suspension and debarment verification. g. Incorporate periodic compliance monitoring to assess adherence to the revised procedures and identify any exceptions requiring corrective action. These actions are designed to strengthen the Foundation's internal control environment, enhance documentation practices, and ensure consistent compliance with federal suspension and debarment requirements. Management believes these corrective actions adequately address the root cause of the finding and will reduce the risk of recurrence in future audit periods. 3. Responsible Party: The Director and Financial Controller will jointly oversee the policy review, procedural updates, and ongoing monitoring to ensure compliance with federal requirements. Day-to-day implementation and monitoring will be coordinated by the Procurement Manager, with oversight and periodic compliance review performed by the Financial Controller. 4. Anticipated Completion Date: December 31, 2026. Key milestones include: a. Revised procedures drafted and approved by October 31, 2026 b. Procurement workflow and checklist updates completed by November 15, 2026 c. Staff training completed by November 30, 2026 d. Updated controls and workflow requirements implemented by November 30, 2026 e. Compliance review completed by December 31, 2026 5. Implementation Details: To implement the updated procedures, the Foundation will incorporate SAM.gov suspension and debarment verification requirements into its procurement workflow, vendor onboarding process, and procurement file review procedures. Prior to execution of any covered contract subject to federal requirements, designated personnel will perform a SAM.gov exclusion search and retain date-stamped evidence of the search within the procurement file. Procurement approvals will not be finalized until the required documentation has been obtained and reviewed. In addition, Finance personnel processing covered transactions will verify that required suspension and debarment documentation is maintained within the procurement file before payments are processed. Transactions lacking required suspension and debarment documentation will be returned to Procurement for correction and completion prior to contract execution or payment processing, as applicable. The Procurement Manager will conduct periodic reviews of procurement files to verify compliance with documentation requirements. Any exceptions identified will be documented and reported to the Director and Financial Controller for resolution and corrective action. Additionally, procurement personnel and other employees involved in vendor onboarding, contracting, and accounts payable activities will receive training regarding federal suspension and debarment requirements, documentation standards, and revised approval procedures. During FY27, management will conduct and document quarterly reviews of a sample of covered procurement transactions to verify compliance with the revised controls. Any deficiencies identified will be evaluated and corrective actions implemented as necessary. Sincerely, Matt Rueckert Chief Operating Officer (COO)

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Finding 1237925 (2025-156)

Material Weakness 2025

The Geneva Foundation

WA

Procurement, Suspension & Debarment § 200.303

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and ...

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and U.S. Department of Health and Human Services (HHS) – Various R&D Assistance Listings Questioned Costs: None Condition: The Foundation did not follow internal control procedures designed to ensure compliance with suspension and debarment requirements for covered contracts. During our testing of procurement transactions subject to suspension and debarment requirements, we noted that the Foundation did not retain documentation demonstrating that it had reviewed the System for Award Management (SAM.gov) exclusion records prior to entering into contractual agreements. Specifically, there was no evidence that a SAM.gov printout was reviewed or approved to verify that vendors were not suspended or debarred at the time of contract execution. In conjunction with the audit, we reviewed the SAM Exclusions for all transactions in our sample and we noted that no transactions were with entities that were suspended or debarred. 2. Corrective Action: The Foundation will review and update its procurement and vendor eligibility procedures to ensure compliance with federal suspension and debarment requirements under 2 CFR Part 180 and applicable Uniform Guidance requirements. The revised procedures will: a. Define when SAM.gov exclusion verification is required. b. Identify personnel responsible for performing and documenting the verification. c. Require retention of date-stamped evidence of the SAM.gov review within the procurement file prior to contract execution. d. Establish supervisory review procedures to confirm required documentation is present before procurement approval is granted. e. Incorporate suspension and debarment verification requirements into procurement checklists, vendor onboarding procedures, and procurement approval workflows. f. Require that covered procurement actions cannot proceed to contract execution without documented evidence of suspension and debarment verification. g. Incorporate periodic compliance monitoring to assess adherence to the revised procedures and identify any exceptions requiring corrective action. These actions are designed to strengthen the Foundation's internal control environment, enhance documentation practices, and ensure consistent compliance with federal suspension and debarment requirements. Management believes these corrective actions adequately address the root cause of the finding and will reduce the risk of recurrence in future audit periods. 3. Responsible Party: The Director and Financial Controller will jointly oversee the policy review, procedural updates, and ongoing monitoring to ensure compliance with federal requirements. Day-to-day implementation and monitoring will be coordinated by the Procurement Manager, with oversight and periodic compliance review performed by the Financial Controller. 4. Anticipated Completion Date: December 31, 2026. Key milestones include: a. Revised procedures drafted and approved by October 31, 2026 b. Procurement workflow and checklist updates completed by November 15, 2026 c. Staff training completed by November 30, 2026 d. Updated controls and workflow requirements implemented by November 30, 2026 e. Compliance review completed by December 31, 2026 5. Implementation Details: To implement the updated procedures, the Foundation will incorporate SAM.gov suspension and debarment verification requirements into its procurement workflow, vendor onboarding process, and procurement file review procedures. Prior to execution of any covered contract subject to federal requirements, designated personnel will perform a SAM.gov exclusion search and retain date-stamped evidence of the search within the procurement file. Procurement approvals will not be finalized until the required documentation has been obtained and reviewed. In addition, Finance personnel processing covered transactions will verify that required suspension and debarment documentation is maintained within the procurement file before payments are processed. Transactions lacking required suspension and debarment documentation will be returned to Procurement for correction and completion prior to contract execution or payment processing, as applicable. The Procurement Manager will conduct periodic reviews of procurement files to verify compliance with documentation requirements. Any exceptions identified will be documented and reported to the Director and Financial Controller for resolution and corrective action. Additionally, procurement personnel and other employees involved in vendor onboarding, contracting, and accounts payable activities will receive training regarding federal suspension and debarment requirements, documentation standards, and revised approval procedures. During FY27, management will conduct and document quarterly reviews of a sample of covered procurement transactions to verify compliance with the revised controls. Any deficiencies identified will be evaluated and corrective actions implemented as necessary. Sincerely, Matt Rueckert Chief Operating Officer (COO)

View Audit 412698

Finding 1237924 (2025-155)

Material Weakness 2025

The Geneva Foundation

WA

Procurement, Suspension & Debarment § 200.303

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and ...

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and U.S. Department of Health and Human Services (HHS) – Various R&D Assistance Listings Questioned Costs: None Condition: The Foundation did not follow internal control procedures designed to ensure compliance with suspension and debarment requirements for covered contracts. During our testing of procurement transactions subject to suspension and debarment requirements, we noted that the Foundation did not retain documentation demonstrating that it had reviewed the System for Award Management (SAM.gov) exclusion records prior to entering into contractual agreements. Specifically, there was no evidence that a SAM.gov printout was reviewed or approved to verify that vendors were not suspended or debarred at the time of contract execution. In conjunction with the audit, we reviewed the SAM Exclusions for all transactions in our sample and we noted that no transactions were with entities that were suspended or debarred. 2. Corrective Action: The Foundation will review and update its procurement and vendor eligibility procedures to ensure compliance with federal suspension and debarment requirements under 2 CFR Part 180 and applicable Uniform Guidance requirements. The revised procedures will: a. Define when SAM.gov exclusion verification is required. b. Identify personnel responsible for performing and documenting the verification. c. Require retention of date-stamped evidence of the SAM.gov review within the procurement file prior to contract execution. d. Establish supervisory review procedures to confirm required documentation is present before procurement approval is granted. e. Incorporate suspension and debarment verification requirements into procurement checklists, vendor onboarding procedures, and procurement approval workflows. f. Require that covered procurement actions cannot proceed to contract execution without documented evidence of suspension and debarment verification. g. Incorporate periodic compliance monitoring to assess adherence to the revised procedures and identify any exceptions requiring corrective action. These actions are designed to strengthen the Foundation's internal control environment, enhance documentation practices, and ensure consistent compliance with federal suspension and debarment requirements. Management believes these corrective actions adequately address the root cause of the finding and will reduce the risk of recurrence in future audit periods. 3. Responsible Party: The Director and Financial Controller will jointly oversee the policy review, procedural updates, and ongoing monitoring to ensure compliance with federal requirements. Day-to-day implementation and monitoring will be coordinated by the Procurement Manager, with oversight and periodic compliance review performed by the Financial Controller. 4. Anticipated Completion Date: December 31, 2026. Key milestones include: a. Revised procedures drafted and approved by October 31, 2026 b. Procurement workflow and checklist updates completed by November 15, 2026 c. Staff training completed by November 30, 2026 d. Updated controls and workflow requirements implemented by November 30, 2026 e. Compliance review completed by December 31, 2026 5. Implementation Details: To implement the updated procedures, the Foundation will incorporate SAM.gov suspension and debarment verification requirements into its procurement workflow, vendor onboarding process, and procurement file review procedures. Prior to execution of any covered contract subject to federal requirements, designated personnel will perform a SAM.gov exclusion search and retain date-stamped evidence of the search within the procurement file. Procurement approvals will not be finalized until the required documentation has been obtained and reviewed. In addition, Finance personnel processing covered transactions will verify that required suspension and debarment documentation is maintained within the procurement file before payments are processed. Transactions lacking required suspension and debarment documentation will be returned to Procurement for correction and completion prior to contract execution or payment processing, as applicable. The Procurement Manager will conduct periodic reviews of procurement files to verify compliance with documentation requirements. Any exceptions identified will be documented and reported to the Director and Financial Controller for resolution and corrective action. Additionally, procurement personnel and other employees involved in vendor onboarding, contracting, and accounts payable activities will receive training regarding federal suspension and debarment requirements, documentation standards, and revised approval procedures. During FY27, management will conduct and document quarterly reviews of a sample of covered procurement transactions to verify compliance with the revised controls. Any deficiencies identified will be evaluated and corrective actions implemented as necessary. Sincerely, Matt Rueckert Chief Operating Officer (COO)

View Audit 412698

Finding 1237923 (2025-154)

Material Weakness 2025

The Geneva Foundation

WA

Procurement, Suspension & Debarment § 200.303

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and ...

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and U.S. Department of Health and Human Services (HHS) – Various R&D Assistance Listings Questioned Costs: None Condition: The Foundation did not follow internal control procedures designed to ensure compliance with suspension and debarment requirements for covered contracts. During our testing of procurement transactions subject to suspension and debarment requirements, we noted that the Foundation did not retain documentation demonstrating that it had reviewed the System for Award Management (SAM.gov) exclusion records prior to entering into contractual agreements. Specifically, there was no evidence that a SAM.gov printout was reviewed or approved to verify that vendors were not suspended or debarred at the time of contract execution. In conjunction with the audit, we reviewed the SAM Exclusions for all transactions in our sample and we noted that no transactions were with entities that were suspended or debarred. 2. Corrective Action: The Foundation will review and update its procurement and vendor eligibility procedures to ensure compliance with federal suspension and debarment requirements under 2 CFR Part 180 and applicable Uniform Guidance requirements. The revised procedures will: a. Define when SAM.gov exclusion verification is required. b. Identify personnel responsible for performing and documenting the verification. c. Require retention of date-stamped evidence of the SAM.gov review within the procurement file prior to contract execution. d. Establish supervisory review procedures to confirm required documentation is present before procurement approval is granted. e. Incorporate suspension and debarment verification requirements into procurement checklists, vendor onboarding procedures, and procurement approval workflows. f. Require that covered procurement actions cannot proceed to contract execution without documented evidence of suspension and debarment verification. g. Incorporate periodic compliance monitoring to assess adherence to the revised procedures and identify any exceptions requiring corrective action. These actions are designed to strengthen the Foundation's internal control environment, enhance documentation practices, and ensure consistent compliance with federal suspension and debarment requirements. Management believes these corrective actions adequately address the root cause of the finding and will reduce the risk of recurrence in future audit periods. 3. Responsible Party: The Director and Financial Controller will jointly oversee the policy review, procedural updates, and ongoing monitoring to ensure compliance with federal requirements. Day-to-day implementation and monitoring will be coordinated by the Procurement Manager, with oversight and periodic compliance review performed by the Financial Controller. 4. Anticipated Completion Date: December 31, 2026. Key milestones include: a. Revised procedures drafted and approved by October 31, 2026 b. Procurement workflow and checklist updates completed by November 15, 2026 c. Staff training completed by November 30, 2026 d. Updated controls and workflow requirements implemented by November 30, 2026 e. Compliance review completed by December 31, 2026 5. Implementation Details: To implement the updated procedures, the Foundation will incorporate SAM.gov suspension and debarment verification requirements into its procurement workflow, vendor onboarding process, and procurement file review procedures. Prior to execution of any covered contract subject to federal requirements, designated personnel will perform a SAM.gov exclusion search and retain date-stamped evidence of the search within the procurement file. Procurement approvals will not be finalized until the required documentation has been obtained and reviewed. In addition, Finance personnel processing covered transactions will verify that required suspension and debarment documentation is maintained within the procurement file before payments are processed. Transactions lacking required suspension and debarment documentation will be returned to Procurement for correction and completion prior to contract execution or payment processing, as applicable. The Procurement Manager will conduct periodic reviews of procurement files to verify compliance with documentation requirements. Any exceptions identified will be documented and reported to the Director and Financial Controller for resolution and corrective action. Additionally, procurement personnel and other employees involved in vendor onboarding, contracting, and accounts payable activities will receive training regarding federal suspension and debarment requirements, documentation standards, and revised approval procedures. During FY27, management will conduct and document quarterly reviews of a sample of covered procurement transactions to verify compliance with the revised controls. Any deficiencies identified will be evaluated and corrective actions implemented as necessary. Sincerely, Matt Rueckert Chief Operating Officer (COO)

View Audit 412698

Finding 1237922 (2025-153)

Material Weakness 2025

The Geneva Foundation

WA

Procurement, Suspension & Debarment § 200.303

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and ...

The Geneva Foundation (Foundation) submits the following corrective action plan in response to the finding identified during the audit for the year ending December 31, 2025. 1. Finding 2025-001: Research and Development Cluster - Suspension and Debarment; U.S Department of Defense/War (DoD/DoW) and U.S. Department of Health and Human Services (HHS) – Various R&D Assistance Listings Questioned Costs: None Condition: The Foundation did not follow internal control procedures designed to ensure compliance with suspension and debarment requirements for covered contracts. During our testing of procurement transactions subject to suspension and debarment requirements, we noted that the Foundation did not retain documentation demonstrating that it had reviewed the System for Award Management (SAM.gov) exclusion records prior to entering into contractual agreements. Specifically, there was no evidence that a SAM.gov printout was reviewed or approved to verify that vendors were not suspended or debarred at the time of contract execution. In conjunction with the audit, we reviewed the SAM Exclusions for all transactions in our sample and we noted that no transactions were with entities that were suspended or debarred. 2. Corrective Action: The Foundation will review and update its procurement and vendor eligibility procedures to ensure compliance with federal suspension and debarment requirements under 2 CFR Part 180 and applicable Uniform Guidance requirements. The revised procedures will: a. Define when SAM.gov exclusion verification is required. b. Identify personnel responsible for performing and documenting the verification. c. Require retention of date-stamped evidence of the SAM.gov review within the procurement file prior to contract execution. d. Establish supervisory review procedures to confirm required documentation is present before procurement approval is granted. e. Incorporate suspension and debarment verification requirements into procurement checklists, vendor onboarding procedures, and procurement approval workflows. f. Require that covered procurement actions cannot proceed to contract execution without documented evidence of suspension and debarment verification. g. Incorporate periodic compliance monitoring to assess adherence to the revised procedures and identify any exceptions requiring corrective action. These actions are designed to strengthen the Foundation's internal control environment, enhance documentation practices, and ensure consistent compliance with federal suspension and debarment requirements. Management believes these corrective actions adequately address the root cause of the finding and will reduce the risk of recurrence in future audit periods. 3. Responsible Party: The Director and Financial Controller will jointly oversee the policy review, procedural updates, and ongoing monitoring to ensure compliance with federal requirements. Day-to-day implementation and monitoring will be coordinated by the Procurement Manager, with oversight and periodic compliance review performed by the Financial Controller. 4. Anticipated Completion Date: December 31, 2026. Key milestones include: a. Revised procedures drafted and approved by October 31, 2026 b. Procurement workflow and checklist updates completed by November 15, 2026 c. Staff training completed by November 30, 2026 d. Updated controls and workflow requirements implemented by November 30, 2026 e. Compliance review completed by December 31, 2026 5. Implementation Details: To implement the updated procedures, the Foundation will incorporate SAM.gov suspension and debarment verification requirements into its procurement workflow, vendor onboarding process, and procurement file review procedures. Prior to execution of any covered contract subject to federal requirements, designated personnel will perform a SAM.gov exclusion search and retain date-stamped evidence of the search within the procurement file. Procurement approvals will not be finalized until the required documentation has been obtained and reviewed. In addition, Finance personnel processing covered transactions will verify that required suspension and debarment documentation is maintained within the procurement file before payments are processed. Transactions lacking required suspension and debarment documentation will be returned to Procurement for correction and completion prior to contract execution or payment processing, as applicable. The Procurement Manager will conduct periodic reviews of procurement files to verify compliance with documentation requirements. Any exceptions identified will be documented and reported to the Director and Financial Controller for resolution and corrective action. Additionally, procurement personnel and other employees involved in vendor onboarding, contracting, and accounts payable activities will receive training regarding federal suspension and debarment requirements, documentation standards, and revised approval procedures. During FY27, management will conduct and document quarterly reviews of a sample of covered procurement transactions to verify compliance with the revised controls. Any deficiencies identified will be evaluated and corrective actions implemented as necessary. Sincerely, Matt Rueckert Chief Operating Officer (COO)

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