Corrective Action Plans

Finding 1160423 (2025-001)

Material Weakness 2025

TX

Questioned Costs Student Financial Aid Eligibility

Single AUdit Report for 2024-2025 Reference/Finding Number 2025-001 Management's Planned Corrective Action Management acknowledges and understands the finding associated with Eligibility. The student's Pell award has already been corrected and accepted by COD. Management is working with IT to automa...

Single AUdit Report for 2024-2025 Reference/Finding Number 2025-001 Management's Planned Corrective Action Management acknowledges and understands the finding associated with Eligibility. The student's Pell award has already been corrected and accepted by COD. Management is working with IT to automate the enrollment change report to be sent on a weekly basis to validate that all increases in hours have been appropriately updated and processed. This will also become part of our required annual reconciliation process of the Pell grant program. Responsible Official Bridget Moore Director of Student Financial Services Abilene Christian University Estimated Completion Date July 24, 2025

View Audit 370836 Questioned Costs: $1

Finding 1160404 (2025-001)

Material Weakness 2025

Greater Johnstown School District

NY

Questioned Costs School Nutrition Programs Cash Management

CORRECTIVE ACTION PLAN Finding 2025-001 – Reporting The District concurs with the finding 2025-001. Corrective Action: Moving forward, the District Treasurer will enter the monthly claims with the Food Service Director and will verify that the meal counts and the total claims are correct for both br...

CORRECTIVE ACTION PLAN Finding 2025-001 – Reporting The District concurs with the finding 2025-001. Corrective Action: Moving forward, the District Treasurer will enter the monthly claims with the Food Service Director and will verify that the meal counts and the total claims are correct for both breakfast and lunch. The anticipated completion date of the corrective action is September 29, 2025. Contact Person: Alicia D. Koster, Superintendent of Schools (518) 762-4611 akoster@johnstownschools.org

View Audit 370819 Questioned Costs: $1

Finding 1160397 (2025-001)

Material Weakness 2025

University of Mary Hardin-Baylor

TX

Student Financial Aid Special Tests & Provisions Reporting

Finding 2025-001 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster ALN: 84.268 Finding Summary: For a small group of students with very specific circumstances, our software’s enrollment report autopopulated an effective date of enrollment change tha...

Finding 2025-001 Federal Agency Name: U.S. Department of Education Program Name: Student Financial Assistance Cluster ALN: 84.268 Finding Summary: For a small group of students with very specific circumstances, our software’s enrollment report autopopulated an effective date of enrollment change that did not match the actual effective date. UMHB did not realize that these specific circumstances would require manual processes to identify and correct the enrollment report prior to submission. As a result, four students had incorrect status change effective dates reported to NSLDS. Responsible Individuals: Trent Bridges, Director Data Quality and Institutional Analytics Corrective Action Plan: UMHB plans to implement the following: 1. Review all the coding on system reports used for NSLDS reporting to assess accuracy and completeness of the data based on any changes in business practice and make updates to system reports as necessary. 2. Update internal process to document any required special handling of records based on system limitations. 3. Reassess system report and processes used for NSLDS reporting prior to the beginning of each fall and spring semester. Anticipated Completion Date: Fall 2025

View Audit 370810

Finding 1160386 (2025-001)

Material Weakness 2025

United Way of Greater Houston

TX

Allowable Costs / Cost Principles

Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #21.027, Passed through BakerRipley, Contract period: 02/01/23 – 12/31/26, Contract number: N...

Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Treasury, COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, Assistance Listing #21.027, Passed through BakerRipley, Contract period: 02/01/23 – 12/31/26, Contract number: None. Condition and context: In a sample of 35 payroll transactions, 14 transactions for three employees did not have time and effort documentation to support the allocation of salary costs charged to the major program. For these employees who work less than 100% on the program the employees track their activities on their calendars. However, salaries were allocated based on a fixed percentage that did not vary from period to period. Recommendation: Strengthen controls to require comparison of actual time and effort percentages by activity to the percentage of salaries and wages allocated to federal programs. Planned corrective action: United Way of Greater Houston has implemented a reconciliation process for billed time to ensure salary allocations reflect actual time and effort for fiscal year 2025-2026. This includes a review of calendar-based activity tracking and comparison against fixed allocation percentages. To strengthen long-term compliance, United Way plans to deploy an electronic timekeeping system that enables dynamic tracking of employee effort across government grant programs. This system will support audit readiness and improve internal control over payroll allocations. Responsible officer: Bart Ferrell, Chief Strategy and Finance Officer. Estimated completion date: September 8, 2025.

View Audit 370796

Finding 1160348 (2025-001)

Material Weakness 2025

Friendship House North Two, Inc.

IN

Questioned Costs

The Project implemented a new system in place to ensure all replacement reserve deposits are deposited within the audit period.

View Audit 370727 Questioned Costs: $1

Finding 1160347 (2025-002)

Material Weakness 2025

Kingsport Housing and Redevelopment Authority

TN

HUD Housing Programs

The Housing Authority has corrected the procedural issues and has enforced with additional training with the HCV Staff the importance of the calculation

View Audit 370719

Finding 1160346 (2025-001)

Material Weakness 2025

Kingsport Housing and Redevelopment Authority

TN

HUD Housing Programs

The Housing Authority has corrected the procedural issues and does not anticipate this being a repeated finding in the future audits. The authority has employeed a full time inspector and is in the process of hiring an additional employee to serve as back up for this position

View Audit 370719

Finding 1160343 (2025-002)

Material Weakness 2025

El Centro Del Barrio, INC

TX

Procurement, Suspension & Debarment § 200.212 § 200.318

Health Center Program Cluster – Assistance Listing No. 93.224/93.527 Recommendation: The auditor recommends management implement suspension and debarment verification process for all covered vendors, regardless of their history or reputation, to ensure compliance with federal regulations. Explanatio...

Health Center Program Cluster – Assistance Listing No. 93.224/93.527 Recommendation: The auditor recommends management implement suspension and debarment verification process for all covered vendors, regardless of their history or reputation, to ensure compliance with federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In response to the recommendation: Management agrees with the finding and acknowledges that timely suspension and debarment verification was not consistently performed across all vendors. To address this deficiency, the Agency is implementing a standardized process to ensure suspension and debarment checks are conducted prior to entering into any covered transaction, regardless of vendor history. This process will include documented verification steps, annual review protocols, and staff training to reinforce compliance with federal procurement regulations. Name(s) of the contact person(s) responsible for corrective action: Chuck Walzel, CPA, Senior Vice President & Chief Financial Officer, 210-334-3724 (office) Planned completion date for corrective action plan: August 31, 2025

View Audit 370716

Finding 1160317 (2025-002)

Material Weakness 2025

Oklahoma Christian University and Subsidiaries

OK

Student Financial Aid Internal Control / Segregation of Duties Special Tests & Provisions

Student Financial Assistance Cluster Assistance Listing Number 84.268 Federal Direct Student Loans, and 84.063 Federal Pell Grant Program U.S. Department of Education Program Year 2024-2025 Criteria or Specific Requirement – Special Tests and Provisions – Enrollment Reporting – 34 CFR Sections 690.8...

Student Financial Assistance Cluster Assistance Listing Number 84.268 Federal Direct Student Loans, and 84.063 Federal Pell Grant Program U.S. Department of Education Program Year 2024-2025 Criteria or Specific Requirement – Special Tests and Provisions – Enrollment Reporting – 34 CFR Sections 690.83(b)(2) and 685.309 Condition – Student enrollment and program information was not communicated to the National Student Loan Data System (NSLDS) timely or accurately Questioned Costs – N/A Context – A total of 7 out of 40 students tested were noted to have at least 1 error in enrollment or program information reported to NSLDS within the required 60 days. Our sample was not, and was not intended to be, statistically valid. Effect – NSLDS was not notified of student status changes or program information in accordance with compliance requirements. Cause – The University did not have effective internal control processes in place to ensure the accurate collection, review, and reporting of student status changes occurred timely or accurately. The recent turnover in personnel resulted in a lack of oversight as well. Indication as a Repeat Finding – Yes Recommendation – The University should review its internal controls surrounding the enrollment reporting process and ensure internal controls provide for the timely and accurate reporting of student status changes. Views of Responsible Officials and Planned Corrective Actions – Tina Petersen, Registrar, will oversee the two-fold corrective action plan. First, we are immediately reviewing our degree posting policy and dates to create a more effective and standardized process. This policy review will enable us to properly assess any delayed completers and ensure that students are "completed" in our systems and reported to NSLDS in a more timely and accurate manner. Additionally, we are updating our formal, step-by-step written procedure manual for all enrollment reporting processes, with a specific focus on degree conferral and the subsequent reporting to NSLDS. This updated manual will serve as a crucial resource to ensure procedural consistency, especially during personnel changes. Second, we are enhancing our training protocols and internal controls. All staff members involved in the NSLDS reporting process will be required to attend mandatory, recurring training to ensure they are up-to-date on all compliance requirements. We will also implement a more robust system of checks and balances to verify the accuracy of the data before it is submitted to NSLDS. By taking these steps, the University is dedicated to improving its internal controls and fully remediating this finding. The corrective action plan will be implemented by November 1, 2025. Office of Financial Services PO Box 11000 Oklahoma City, OK 73136 405.425.5190 financialservices@oc.edu

View Audit 370701

Finding 1160316 (2025-001)

Material Weakness 2025

Oklahoma Christian University and Subsidiaries

OK

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

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

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

View Audit 370701

Finding 1160270 (2025-001)

Material Weakness 2025

The Episcopal Theological Seminary of the Southwest

TX

Questioned Costs Student Financial Aid Eligibility

Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education...

Corrective Action Plan (CAP for Finding 2025-001) Date: 2 October 2025 Responsible official: Frederick L. Clement, Executive Vice President Management has corrected the finding by taking the following action: First, the institution entered into a professional services agreement with Higher Education Assistance Group to provide a comprehensive business process review of its financial aid operations. The objective of this review is to improve upon the functionality of processes, internal controls, and systems to ensure regulatory compliance and the effectiveness of service deliverables to students receiving financial aid. This review will include updates to policies, procedures, and internal controls for the import and export of electronic records, document tracking and file review, packaging and awarding, satisfactory academic progress, disbursement and reconciliation, withdrawal and Return to Title IV. Workflow and gap analysis will be performed to ensure intraoffice Title IV program compliance and best practices. Second, the institution has entered into a professional services agreement with Higher Education Assistance Group to provide interim staffing and third-party federal student aid processing including, but not limited to, counseling students and families on financial aid options, assisting with the management of Federal Direct Loan and Federal Graduate PLUS Loan programs to include student eligibility, file review, awarding, and origination and disbursement authorization using Populi, COD and other Department of Education software. In addition, Higher Education Assistance Group will provide additional Title IV training for personnel involved in federal student aid processing. With more than 35 years of experience, Higher Education Assistance Group and its team of seasoned consultants, all of whom have worked in federal student aid administration, whether in public/private colleges and universities or for the Department of Education itself, specializes in the compliant administration of Title IV student financial aid programs. The institution will adopt a supplemental internal control to cross-check student eligibility for Direct PLUS loans to ensure that an over-award is not originated and disbursed. Anticipated completion date: November 15, 2025

View Audit 370654 Questioned Costs: $1

Finding 1160239 (2025-002)

Material Weakness 2025

Northwest University

WA

Student Financial Aid Reporting Significant Deficiency

Auditors noted that for two of the six sampled students, funds were returned to ED more than 45 days after the date the University determined the student had withdrawn. For one selection, a Return of Title IV calculation was performed timely, but an administrative error caused the disbursement to be...

Auditors noted that for two of the six sampled students, funds were returned to ED more than 45 days after the date the University determined the student had withdrawn. For one selection, a Return of Title IV calculation was performed timely, but an administrative error caused the disbursement to be delayed eight months. For the second selection, the University was notified of withdrawal in early March 2025 and student was included in registrar’s withdrawal listing, but was missed in review by Student Financial Services until late April 2025. Contact Person(s): Vickie Rekov, VP Enrollment Services; Roger Wilson, Associate Director of Financial Aid, SFS; Ryan Porter, CFO and Bernie Rundquist, Controller Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: All employees in Student Financial Services and Accounting Office involved in the reporting, distribution, drawdown and return of federal funds have reviewed the criteria under 34 CFR 668.22 The two departments involved will be meeting in the month of September 2025 to review policies and procedures to ensure controls exist and are well documented to ensure funds are returned timely. In-charge personnel will gather training resources to educate those involved in the reporting, disbursement and return of Title IV Funds. Anticipated completion date: October 2025

View Audit 370626

Finding 1160234 (2025-001)

Material Weakness 2025

Northwest University

WA

Questioned Costs Cash Management

The University drew down $72,265 in Federal Supplemental Educational Opportunity Grants (FSEOG) funds in October 2024 and disbursed funds to students through January 2025. No amounts were disbursed to students within the required three business days from receipt of funds, and no funds were returned ...

The University drew down $72,265 in Federal Supplemental Educational Opportunity Grants (FSEOG) funds in October 2024 and disbursed funds to students through January 2025. No amounts were disbursed to students within the required three business days from receipt of funds, and no funds were returned to ED. Contact Person(s): Vickie Rekov, VP Enrollment Services; Cynthia Kennedy, Director of SFS; Ryan Porter, CFO and Bernie Rundquist, Controller Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: All employees in Student Financial Services and Accounting Office involved in the reporting, distbursement and drawdown of federal funds have reviewed the criteria under 34 CFR 668.162 under the advance payment method. The two departments involved will be meeting in the month of September 2025 to review current process and procedures and make appropriate changes to meet these requirements. Anticipated completion date: September 30, 2025

View Audit 370626 Questioned Costs: $1

Finding 1160209 (2025-003)

Material Weakness 2025

Mt. Auburn Housing, Inc.

OH

HUD Housing Programs Internal Control / Segregation of Duties

S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs they failed to maintain the property. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response Management is working with HUD to ensure all exigent h...

S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs they failed to maintain the property. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response Management is working with HUD to ensure all exigent health and safety issues are resolved by the completion date above. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar

View Audit 370591

Finding 1160208 (2025-002)

Material Weakness 2025

Mt. Auburn Housing, Inc.

OH

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response On June 17, 2025, the Corporation entere...

S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response On June 17, 2025, the Corporation entered into a purchase and sale agreement with The Christ Hospital to acquire the property for $1,485,528. Pending HUD approval. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar

View Audit 370591 Questioned Costs: $1

Finding 1160207 (2025-001)

Material Weakness 2025

Mt. Auburn Housing, Inc.

OH

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response On June 17, 2025, the Corporation entere...

S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2026 S3800-150 Response On June 17, 2025, the Corporation entered into a purchase and sale agreement with The Christ Hospital to acquire the property for $1,485,528. Pending HUD approval. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar

View Audit 370591 Questioned Costs: $1

Finding 1160184 (2025-001)

Material Weakness 2025

Saint Joseph Abbey and Seminary College

LA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2025-001: Material Weakness in Internal Control over Financial Reporting ● Condition: The Abbey did not consolidate subsidiaries in its financial statements. ● Criteria: Generally Accepted Accounting Principles (GAAP) require that all subsidiaries be consolidated into the parent Abbey's fina...

Finding 2025-001: Material Weakness in Internal Control over Financial Reporting ● Condition: The Abbey did not consolidate subsidiaries in its financial statements. ● Criteria: Generally Accepted Accounting Principles (GAAP) require that all subsidiaries be consolidated into the parent Abbey's financial statements. ● Cause: The Abbey lacked adequate internal controls to ensure all subsidiaries were identified and consolidated. ● Effect: The financial statements were materially misstated, as they did not include the financial position and results of operations of the subsidiary. Corrective Action Plan: ● Responsible Person: Right Reverend Gregory Boquet, O.S.B. ● Planned Action: We agree with the auditor’s finding that there is a material weakness in internal control over financial reporting due to the non-consolidation of subsidiaries. However, after careful consideration, management has decided not to implement the recommended procedures to consolidate the subsidiaries. ● Justification: Management believes that the current procedures are adequate, and that the non-consolidation of the subsidiaries does not materially affect the financial statements. The costs and resources required to implement the recommended procedures outweigh the benefits, given the subsidiaries’ minimal impact on the overall financial position and results of operations. We will continue to monitor the situation and reassess it if necessary. ● Anticipated Completion Date: Not applicable, as no changes will be made. Views of Responsible Officials: The Abbey disagrees with the finding. Management believes that the current procedures are adequate, and that the non-consolidation of the subsidiaries does not materially affect the financial statements. The Abbey will not implement the recommended procedures but will continue to monitor the situation and reassess if necessary.

View Audit 370554

Finding 1160151 (2025-001)

Material Weakness 2025

Burkesville Manor, Inc.

KY

Eligibility HUD Housing Programs

Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility req...

Management agrees with the finding. As of September 26, 2025, the Project has implemented a revised tenant intake checklist at the main office that includes mandatory verification of age eligibility. All tenant files are being reviewed for compliance, and staff have been retrained on eligibility requirements.

View Audit 370535

Finding 1159878 (2025-001)

Material Weakness 2025

Rose Arc Housing, Inc.

RI

HUD Housing Programs

Replacement Reserve Deposits: Comments on Finding and Recommendation - The Corporation acknowledges that sufficient deposits were not made due to the outstanding subsidies not received until the fiscal year 2026; Actions Taken or Planned - The Corporation made the deficient required reserve deposits...

Replacement Reserve Deposits: Comments on Finding and Recommendation - The Corporation acknowledges that sufficient deposits were not made due to the outstanding subsidies not received until the fiscal year 2026; Actions Taken or Planned - The Corporation made the deficient required reserve deposits once the outstanding subsidies were received in fiscal year 2026

View Audit 370421

Finding 1159866 (2025-001)

Material Weakness 2025

Village of Sebewaing

MI

Procurement, Suspension & Debarment

The Village will approve a policy to cover any and all contractors awarded contracts which federal funds or grants will be received.

View Audit 370413

Finding 1159810 (2025-001)

Material Weakness 2025

Sedalia School District #200

MO

Procurement, Suspension & Debarment § 200.320

Finding: 2025-001: Procurement Noncompliance - Child Nutrition Cluster. Contact Person: Lisa Hammerly, Director of Business Services. Recommendation: The District should continue to implement and monitor updated procurement procedures, including use of centralized tracking, pre-approval of purchases...

Finding: 2025-001: Procurement Noncompliance - Child Nutrition Cluster. Contact Person: Lisa Hammerly, Director of Business Services. Recommendation: The District should continue to implement and monitor updated procurement procedures, including use of centralized tracking, pre-approval of purchases, and adherence to formal solicitation processes. Corrective Action: The District agrees with the finding. Corrective action was initiated in April 2025, including adoption of revised procurement procedures, implementation of monitored tracking, and initiation of a formal bid process for recurring food purchases. Proposed Completion Date: Policy revision completed March 2025, staff training completed April 2025, monthly monitoring effective beginning May 2025.

View Audit 370352

Finding 1159711 (2025-001)

Material Weakness 2025

Chapman University and Affiliates

CA

Student Financial Aid Reporting

The Office of the University Registrar and the Office of the Law Registrar have reviewed current policies and procedures related to the reporting of status changes in NSLDS. The Office of the Law Registrar will report status changes to National Student Clearinghouse no later than 30 days after degre...

The Office of the University Registrar and the Office of the Law Registrar have reviewed current policies and procedures related to the reporting of status changes in NSLDS. The Office of the Law Registrar will report status changes to National Student Clearinghouse no later than 30 days after degree conferral but no later than June 30. In additional they will follow up with NSC three business days after submission to verify that the file was received and processed correctly. The Law School does not confer degrees year-round. Based on the ABA accreditation and program plan, Fowler School of Law has three conferral dates: January 31, June 10, and September 1. Most students are conferred on June 10. The Office of the University Registrar will report enrollment status changes to the National Student Clearinghouse every 30 days. Unlike the Law school, the University Registrar’s office confers degree year-round. The registrar’s office is scheduled to submit a Degree Verify file every two weeks to the clearinghouse and will review students in submited degree file for accuracy in our reporting.

View Audit 370308

Finding 1159684 (2025-001)

Material Weakness 2025

Virginia Garcia Medical Health Center

OR

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

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

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

View Audit 370272

Finding 1159647 (2025-003)

Material Weakness 2025

Les Petites Maisons Ii, Inc.

LA

HUD Housing Programs

The Project will deposit, on a monthly basis, the required amount per the CAP Regulatory Agreement. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25

View Audit 370263

Finding 1159646 (2025-002)

Material Weakness 2025

Les Petites Maisons Ii, Inc.

LA

HUD Housing Programs

The Project will strengthen controls over record keeping and maintaining tenant files with an increased emphasis on timely and appropriately documenting all compliance requirements of HUD. Contact: Adrienne Melancon, Housing Director Anticipated Completion Date: 10/15/25

View Audit 370263

Corrective Action Plans

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