Corrective Action Plans

Finding 1175824 (2025-002)

Material Weakness 2025

VA

Eligibility

We agree with this comment. Starting with fiscal year 2026, we will ensure that eligibility forms include signature or initials of the preparer, and documentation of review by the supervisor, regardless of whether or not the state form has a second line for the supervisor approval.

View Audit 389776

Finding 1175820 (2025-001)

Material Weakness 2025

First Choice Health Centers, Inc.

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

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

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

View Audit 389772

Finding 1175817 (2025-001)

Material Weakness 2025

Christ Community Health Services, Inc.

TN

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

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

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

View Audit 389757

Finding 1175815 (2025-003)

Material Weakness 2025

Isd #482 - Little Falls

MN

Subrecipient Monitoring Cash Management Reporting

Finding 2025-003 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District has already begun evaluating current procedures for accurately monitoring, recording, and re...

Finding 2025-003 School Nutrition Program Meal Claims 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The District has already begun evaluating current procedures for accurately monitoring, recording, and reporting the number and type of meals served. 3. Official Responsible Mr. Greg Johnson, Superintendent, is the official responsible for ensuring corrective action. 4. Planned Completion Date The planned completion date is June 30, 2026. 5. Plan to Monitor Completion The Board of Directors will be monitoring this Corrective Action Plan.

View Audit 389746

Finding 1175812 (2025-002)

Material Weakness 2025

Metropolitan School District of Warren County

IN

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.313

Finding 2025-002 – Education Stabilization – Equipment and Real Property Management Context: For the 3 sample items tested, the acquisitions were not reported on the capital asset listing for the School Corporation as of June 30, 2025. For 1 sample item, the School Corporation expended $5,528,730 on...

Finding 2025-002 – Education Stabilization – Equipment and Real Property Management Context: For the 3 sample items tested, the acquisitions were not reported on the capital asset listing for the School Corporation as of June 30, 2025. For 1 sample item, the School Corporation expended $5,528,730 on building renovations which was charged to the ESSER III (84.425U) grant award. The other 2 sample items were equipment purchases totaling $25,554 charged to the Homeless Children and Youth Grant (84.425W) grant award. Additionally, we noted the School Corporation’s capital asset listing did not contain all the required information, including the source of funding for the property, outlined in the criteria above. Contact Person Responsible for Corrective Action: Katy Dowling Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The township will implement a capital asset process that will identify roles and responsibilities and have appropriate internal controls to ensure accuracy. Anticipated Completion Date: June 30, 2026

View Audit 389739

Finding 1175809 (2025-001)

Material Weakness 2025

Metropolitan School District of Warren County

IN

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency § 200.303

Finding 2025-001 – Education Stabilization – Special Tests and Provisions - Wage Rate Requirements Context: For all six vendors sampled, the School Corporation did not include the necessary clauses for the Davis-Bacon federal wage rate requirements in their contracts. For the two larger vendors repr...

Finding 2025-001 – Education Stabilization – Special Tests and Provisions - Wage Rate Requirements Context: For all six vendors sampled, the School Corporation did not include the necessary clauses for the Davis-Bacon federal wage rate requirements in their contracts. For the two larger vendors representing $3,611,973, weekly payroll reports were properly collected. For the remaining four smaller vendors, the School Corporation did not obtain the weekly payroll report certifications for the work performed totaling $148,522 for the entire audit period. Contact Person Responsible for Corrective Action: Katy Dowling Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Create an internal control process that ensures roles and responsibilities as it relates to the requirements of the David Bacon Act. Anticipated Completion Date: March 15, 2026

View Audit 389739

Finding 1175808 (2025-003)

Material Weakness 2025

Albany College of Pharmacy and Health Sciences

NY

Student Financial Aid

Finding Number: 2025-003 Federal Assistance Listing Number: 84.007 Federal Supplemental Educational Opportunity Grant, 84.033 Federal Work-Study Program, 84.038 Federal Perkins Loan Program Year Ended: June 30, 2025 Responsible Individual: Steven Dwire, Director of Financial Aid Management’s Respons...

Finding Number: 2025-003 Federal Assistance Listing Number: 84.007 Federal Supplemental Educational Opportunity Grant, 84.033 Federal Work-Study Program, 84.038 Federal Perkins Loan Program Year Ended: June 30, 2025 Responsible Individual: Steven Dwire, Director of Financial Aid Management’s Response and Corrective Action Plan: Management identified the issue on October 3, 2025 and made the FISAP submission immediately and filed the signature page on October 15, 2025. The issue resulted from staff turnover during the year. Upon discovery, management promptly updated procedures, including adding calendar reminders to avoid such missed occurrences going forward. Additionally, the College has submitted a waiver request with the Department of Education to avoid the return of $441,023 in campus-based aid and to obtain eligibility to receive campus-based aid for the 2026-2027 school year. As of the date of the report, a response to the waiver request from the Department of Education has not been received.

View Audit 389734

Finding 1175805 (2025-002)

Material Weakness 2025

Albany College of Pharmacy and Health Sciences

NY

Student Financial Aid

Finding Number: 2025-002 Federal Assistance Listing Number: 84.268 Federal Direct Student Loans Year Ended: June 30, 2025 Responsible Individual: Steven Dwire Director of Financial Aid Management’s Response and Corrective Action Plan: Management identified the issue on September 23, 2025 and exit co...

Finding Number: 2025-002 Federal Assistance Listing Number: 84.268 Federal Direct Student Loans Year Ended: June 30, 2025 Responsible Individual: Steven Dwire Director of Financial Aid Management’s Response and Corrective Action Plan: Management identified the issue on September 23, 2025 and exit counseling packages were sent on October 1, 2025. The issue resulted from staff turnover during the year. Upon discovery, management promptly updated procedures, including adding calendar reminders to avoid such missed occurrences going forward.

View Audit 389734

Finding 1175804 (2025-001)

Material Weakness 2025

Albany College of Pharmacy and Health Sciences

NY

Student Financial Aid Matching / Level of Effort / Earmarking

Finding Number: 2025-001 Federal Assistance Listing Number: 84.268 Federal Direct Student Loans Year Ended: June 30, 2025 Responsible Individual: Christine Banewicz Director of Student Accounts Management’s Response and Corrective Action Plan: Management identified the issue on August 4, 2025 and ne...

Finding Number: 2025-001 Federal Assistance Listing Number: 84.268 Federal Direct Student Loans Year Ended: June 30, 2025 Responsible Individual: Christine Banewicz Director of Student Accounts Management’s Response and Corrective Action Plan: Management identified the issue on August 4, 2025 and new letters were emailed on August 8, 2025 and August 12, 2025. To mitigate potential disruptions in the electronic process, the College enhanced its controls to include manual validation of letters.

View Audit 389734

Finding 1175803 (2025-001)

Material Weakness 2025

H Councill Trenholm State Community College

AL

Student Financial Aid Subrecipient Monitoring Reporting

Corrective Action: The College will implement a revised withdrawal process that shifts outreach and financial aid counseling to occur before a student completes and submits the withdrawal form, rather than after submission. This change is designed to eliminate delays in withdrawal processing and sup...

Corrective Action: The College will implement a revised withdrawal process that shifts outreach and financial aid counseling to occur before a student completes and submits the withdrawal form, rather than after submission. This change is designed to eliminate delays in withdrawal processing and support timely institutional action. Under the current process, outreach to students occurred after the withdrawal form was submitted, which resulted in delays in routing the form to the Records Office for processing. The revised process will require that outreach and financial aid counseling occur before students complete the withdrawal form. Students who indicate they are receiving financial aid will be encouraged to consult with the Financial Aid Office prior to completing the withdrawal form. During this consultation, students will be informed of the financial implications of withdrawing and be made aware of available institutional resources and services that may assist them in remaining enrolled, when appropriate. The revised withdrawal form will allow students to complete and submit it online directly to the Records Office for immediate processing. Eliminating post-submission outreach requirements will remove prior delays and allow the Records Office to promptly process the withdrawal. Receipt of the completed withdrawal form will serve as the institution’s date of determination. Following submission, the Financial Aid Office will complete the Return to Title IV (R2T4) calculation within the required 45-day timeframe and return any required funds. Timely processing of withdrawals will ensure continued compliance with all R2T4 regulatory requirements. Anticipated Completion Date: The College will implement this revised withdrawal process immediately (March 2026). Responsible Party: Breshawn Skinner, Director of Financial Aid, in coordination with the Records Office

View Audit 389711

Finding 1175802 (2025-002)

Material Weakness 2025

Creve Coeur School District No. 76

IL

See report

View Audit 389710

Finding 1175800 (2025-001)

Material Weakness 2025

Carthage College

WI

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Credit Balance Testing Recommendation: CLA recommends that the client re-evaluate their internal controls over credit balance returns in order to establish a more timely process for the identification and disbursement of TIV credit balances. Explanation of disagreement with audit finding: There is n...

Credit Balance Testing Recommendation: CLA recommends that the client re-evaluate their internal controls over credit balance returns in order to establish a more timely process for the identification and disbursement of TIV credit balances. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Carthage College will update procedures to maintain documentation of student authorizations for credit balances held greater than 14 days. Name(s) of the contact person(s) responsible for corrective action: Vince Ceja, CFO Planned completion date for corrective action plan: June 30, 2026

View Audit 389695

Finding 1175794 (2025-003)

Material Weakness 2025

Texas Association for the Education of Young Children, Inc.

TX

Allowable Costs / Cost Principles

Management Response: Management acknowledges that funding percentages in the accounting system did not match the cost allocation plan for several transactions, resulting in a nominal overcharge to the grants. To prevent this in the future, management will institute a mandatory verification step wher...

Management Response: Management acknowledges that funding percentages in the accounting system did not match the cost allocation plan for several transactions, resulting in a nominal overcharge to the grants. To prevent this in the future, management will institute a mandatory verification step where funding percentages entered into the accounting system are cross-referenced directly against the approved cost allocation plan. We will ensure that the amounts charged to grants agree strictly with the approved percentages. Any discrepancies or rounding issues will be addressed by allocating differences to the organization's operating expense class rather than a government grant, ensuring federal awards are not overcharged. Parties Responsible and Timeline The Executive Director and Accountant will conduct a review of current system percentages against the cost allocation plan immediately. Updates to the internal review process for cost allocations will be approved by TXAEYC’s Finance Committee and Governing Board by April 30, 2026.

View Audit 389691

Finding 1175791 (2025-002)

Material Weakness 2025

Texas Association for the Education of Young Children, Inc.

TX

Allowable Costs / Cost Principles Significant Deficiency

Management Response: TXAEYC acknowledges that during testing, certain samples did not include documented approval of invoices prior to allocation to grant activities. We recognize the need for robust internal controls to reduce the risk of noncompliance. To remedy this, the organization will impleme...

Management Response: TXAEYC acknowledges that during testing, certain samples did not include documented approval of invoices prior to allocation to grant activities. We recognize the need for robust internal controls to reduce the risk of noncompliance. To remedy this, the organization will implement a strict prior approval process for all grant expenditures. We will update our standard operating procedures to ensure that every invoice is reviewed and approved by authorized personnel before being allocated to the grant. Furthermore, all support for these approvals will be documented and kept on file to ensure a clear audit trail. Parties Responsible and Timeline Updates to the expenditure approval procedures in the Accounting Manual will be drafted by the Executive Director and Accountant and submitted to the Finance Committee and Governing Board for approval by April 30, 2026. Implementation of the prior approval documentation process will begin immediately upon Board approval.

View Audit 389691

Finding 1175788 (2025-009)

Material Weakness 2025

Albright College

PA

Student Financial Aid Reporting Internal Control / Segregation of Duties

Name of Responsible Individual: Ransom Prestridge, Registrar; Jennifer Wegman, Assistant Registrar; Kai Howard, Institutional Research; Shane Himes, Director of Financial Aid Corrective Action: The College acknowledges the findings related to the timeliness and accuracy of enrollment reporting to th...

Name of Responsible Individual: Ransom Prestridge, Registrar; Jennifer Wegman, Assistant Registrar; Kai Howard, Institutional Research; Shane Himes, Director of Financial Aid Corrective Action: The College acknowledges the findings related to the timeliness and accuracy of enrollment reporting to the National Student Loan Data System (NSLDS). The identified exceptions were the result of insufficient administrative oversight and internal controls related to enrollment status reporting at both the campus and program levels. As this is a repeat finding, the College is committed to implementing enhanced and sustainable corrective measures. To address this finding, the College will strengthen internal controls and oversight of enrollment reporting by implementing the following corrective actions: • Establish a documented review and monitoring process to ensure all enrollment status changes, including graduation, withdrawal, attendance level changes, and second majors, are accurately and timely reported to NSLDS at both the campus and program levels. • Implement a standardized tracking and reconciliation process between the Registrar’s Office, the Student Information System, and NSLDS to ensure data consistency and completeness. • Develop and implement written policies and procedures that clearly define roles, responsibilities, timelines, and escalation protocols for enrollment reporting. • Enhance oversight of any third-party servicer, including periodic validation of submitted records to ensure accuracy and timeliness. • Provide comprehensive training to staff responsible for enrollment reporting on federal regulatory requirements and institutional procedures. • Conduct periodic internal quality assurance reviews and monitoring of enrollment reporting to identify and correct discrepancies in a timely manner. • Establish formal communication protocols between the Financial Aid and Registrar’s Offices to ensure timely notification of all enrollment changes. Anticipated Completion Date: May 31, 2026

View Audit 389689

Finding 1175786 (2025-008)

Material Weakness 2025

Albright College

PA

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

Name of Responsible Individual: Shane Himes, Director of Financial Aid Corrective Action: The College acknowledges the exceptions identified related to the timeliness of Return of Title IV (R2T4) calculations and the return of unearned federal funds. The errors were the result of insufficient admini...

Name of Responsible Individual: Shane Himes, Director of Financial Aid Corrective Action: The College acknowledges the exceptions identified related to the timeliness of Return of Title IV (R2T4) calculations and the return of unearned federal funds. The errors were the result of insufficient administrative oversight and internal controls over the withdrawal and R2T4 process. To address this finding, the College will strengthen internal controls and oversight to ensure compliance with federal regulations. The corrective actions include: • Implementing a documented secondary review process for all R2T4 calculations prior to finalization to ensure accuracy and compliance with regulatory requirements. • Enhancing procedures to ensure timely identification of withdrawn students and prompt initiation of the R2T4 calculation process. • Establishing standardized monitoring to ensure all required returns of Title IV funds are processed within the regulatory timeframe. • Developing and implementing a tracking system to monitor withdrawal dates, calculation completion, and return deadlines. • Providing additional training to Financial Aid staff on federal R2T4 regulations and institutional procedures. • Conducting periodic internal quality assurance reviews of R2T4 calculations and returned funds to ensure ongoing compliance. Anticipated Completion Date: May 31, 2026

View Audit 389689

Finding 1175783 (2025-007)

Material Weakness 2025

Albright College

PA

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

Name of Responsible Individual: Larry Bomback, Interim CFO / DeMornai Blackwell, Controller Corrective Action: Management acknowledges the instances in which Title IV credit balances were not refunded within the required regulatory timeframe under 34 CFR §668.164(c). Although no questioned costs wer...

Name of Responsible Individual: Larry Bomback, Interim CFO / DeMornai Blackwell, Controller Corrective Action: Management acknowledges the instances in which Title IV credit balances were not refunded within the required regulatory timeframe under 34 CFR §668.164(c). Although no questioned costs were identified, the College recognizes the need to strengthen internal controls to ensure full compliance. To address this finding, the College will: • Implement a formal Title IV credit balance monitoring procedure requiring weekly review of student accounts with credit balances • Establish an automated report identifying all Title IV–generated credit balances and tracking the 14-day refund deadline • Strengthen coordination between the Business Office, Financial Aid Office, and Registrar to ensure enrollment status and disbursement timing are properly reflected prior to refund processing • Continued documented supervisory review of credit balance aging reports These corrective measures are designed to ensure timely refunds, improve monitoring controls, and maintain compliance with federal Title IV requirements. Anticipated Completion Date: May 31, 2026

View Audit 389689

Finding 1175780 (2025-006)

Material Weakness 2025

Albright College

PA

Reporting Internal Control / Segregation of Duties § 200.510

Management acknowledges the deficiency in the preparation and oversight of the Schedule of Expenditures of Federal Awards (SEFA) for the year ended May 31, 2025. To address this finding, the College will: • Implement a formal SEFA preparation policy aligned with 2 CFR §200.510(b) • Develop and maint...

Management acknowledges the deficiency in the preparation and oversight of the Schedule of Expenditures of Federal Awards (SEFA) for the year ended May 31, 2025. To address this finding, the College will: • Implement a formal SEFA preparation policy aligned with 2 CFR §200.510(b) • Develop and maintain a centralized federal awards tracking log identifying: o Federal agency o Program name o Assistance Listing Number (ALN) o Award number o Pass-through entity (if applicable) o Expenditures by fiscal year • Establish quarterly reconciliations between the general ledger and the federal awards tracking log • Require structured cross-departmental communication between the Business Office, Financial Aid Office, Grants Administration, and program departments to ensure all federal awards received and expended are identified timely • Implement documented management review and approval of the SEFA prior to submission to auditors These corrective measures will strengthen internal controls over federal award tracking, improve the accuracy and completeness of the SEFA, and ensure compliance with Uniform Guidance requirements. Anticipated Completion Date: May 31, 2026

View Audit 389689

Finding 1175774 (2025-005)

Material Weakness 2025

Albright College

PA

Student Financial Aid Internal Control / Segregation of Duties Period of Performance

Name of Responsible Individual: Shane Himes, Director of Financial Aid Corrective Action: The College acknowledges the reporting errors identified in certain student origination records submitted to the Common Origination and Disbursement (COD) System, specifically related to cost of attendance and ...

Name of Responsible Individual: Shane Himes, Director of Financial Aid Corrective Action: The College acknowledges the reporting errors identified in certain student origination records submitted to the Common Origination and Disbursement (COD) System, specifically related to cost of attendance and academic end date data elements. To address this finding, the College will enhance internal controls and oversight over federal aid reporting by implementing the following corrective actions: • Establish a documented secondary review process for all origination records prior to submission to COD, with verification of key data elements including cost of attendance, academic start and end dates, enrollment status, and award amounts. • Implement a standardized review checklist to ensure accuracy and completeness of required data fields. • Strengthen reconciliation procedures between the student information system and COD to identify and resolve discrepancies timely. • Conduct periodic internal quality assurance reviews of origination and disbursement records. • Provide additional staff training on federal reporting requirements. Anticipated Completion Date: This process has already been implemented.

View Audit 389689

Finding 1175772 (2025-004)

Material Weakness 2025

Albright College

PA

Cash Management Student Financial Aid Internal Control / Segregation of Duties

Name of Responsible Individual: Larry Bomback, Interim CFO ; Justin Roy, VP of Enrollment ; Irene Langran, VP of Academic Affairs Corrective Action: Management acknowledges the instance in which Title IV funds were held beyond the allowable timeframe under 34 CFR §668.166. Although the amount was wi...

Name of Responsible Individual: Larry Bomback, Interim CFO ; Justin Roy, VP of Enrollment ; Irene Langran, VP of Academic Affairs Corrective Action: Management acknowledges the instance in which Title IV funds were held beyond the allowable timeframe under 34 CFR §668.166. Although the amount was within allowable tolerance thresholds and no questioned costs were identified, the College recognizes the need to strengthen internal controls over cash management compliance. To address this finding, the College will: • Implement a formal Title IV drawdown and disbursement monitoring procedure requiring review no later than the third business day following receipt of funds • Establish a standardized reconciliation process between the Business Office, Financial Aid Office, and Registrar to ensure timely identification of: o Students who have withdrawn o Enrollment status changes o Required returns of Title IV (R2T4) calculations • Develop a documented weekly reconciliation of federal drawdowns to disbursements and student account activity • Assign clear responsibility for monitoring excess cash thresholds and ensuring timely return of funds to the U.S. Department of Education when required • Provide cross-functional training to reinforce compliance requirements under federal cash management regulations These measures are intended to ensure timely disbursement of Title IV funds, proper reconciliation of enrollment changes, and full compliance with federal cash management requirements. Anticipated Completion Date: May 31, 2026

View Audit 389689

Finding 1175771 (2025-007)

Material Weakness 2025

Big Springs Medical Association D/b/a Missouri Highlands Health Care

MO

Eligibility Internal Control / Segregation of Duties

2025-007: Medication assistance was provided to a patient who was not eligible to receive assistance on the date of service due to active insurance coverage for the prescription. The Organization’s eligibility procedures were not supported by a formal policy or consistently followed as written. Addi...

2025-007: Medication assistance was provided to a patient who was not eligible to receive assistance on the date of service due to active insurance coverage for the prescription. The Organization’s eligibility procedures were not supported by a formal policy or consistently followed as written. Additionally, the Procedure for Medication Financial Assistance provides Community Health Workers and other staff significant discretion in making eligibility determinations. This flexibility and subjective process, while intended to reduce barriers to patients obtaining opioid use disorder treatments, increases the risk for inconsistent and inappropriate eligibility determinations. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: May 2026 Views of responsible officials and planned corrective actions: Issues identified during the audit were indicative of an overall lack of controls and processes by grant directors and Finance Department staff. The Organization has reviewed the processes and has developed a formalized policy for medication assistance eligibility determinations, clearly identifying grant requirements for eligibility. Additionally, the procedure associated with the policy identifies the need for secondary review of eligibility determinations and clear communication to the Finance Department along with adequate record keeping. The Organization’s CEO, a former CFO of the organization, will continue to provide oversight for the Finance Department to ensure controls and processes are implemented.

View Audit 389688

Finding 1175770 (2025-006)

Material Weakness 2025

Big Springs Medical Association D/b/a Missouri Highlands Health Care

MO

Procurement, Suspension & Debarment

2025-006: Procurement records were not maintained according to Uniform Guidance. The Organization did not comply with its procurement policy. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: May 2026 Views of responsib...

2025-006: Procurement records were not maintained according to Uniform Guidance. The Organization did not comply with its procurement policy. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: May 2026 Views of responsible officials and planned corrective actions: Issues identified during the audit were indicative of an overall lack of controls and processes due to the change in Finance Department staff and loss of knowledge. Based on the finding, a review and training for the Organization on procurement has been implemented. Additionally, with the new CFO and Finance staff, additional controls and processes to prevent this from occurring again. The Organization’s CEO, a former CFO of the organization, will continue to provide oversight for the Finance Department to ensure controls and processes are implemented.

View Audit 389688

Finding 1175769 (2025-005)

Material Weakness 2025

Big Springs Medical Association D/b/a Missouri Highlands Health Care

MO

Cash Management Internal Control / Segregation of Duties Program Income

2025-005: Funds available from program income were not disbursed before the Organization requested additional drawdowns. The Organization was not appropriately with tracking and utilizing program income. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief ...

2025-005: Funds available from program income were not disbursed before the Organization requested additional drawdowns. The Organization was not appropriately with tracking and utilizing program income. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: August 2025 Views of responsible officials and planned corrective actions: Issues identified during the audit were indicative of an overall lack of controls and processes due to the change in Finance department staff and loss of knowledge. As of August 2025, program income is no longer being generated by the grant. The new CFO and Finance staff have also implemented processes and controls to ensure proper tracking and utilization of program income related to grants. The CEO will provide ongoing oversight to ensure processes and controls are being adhered to by the Finance Department.

View Audit 389688

Finding 1175768 (2025-004)

Material Weakness 2025

Big Springs Medical Association D/b/a Missouri Highlands Health Care

MO

Cash Management

2025-004: On January 27, 2025, the Office of Management and Budget (OMB) ordered a pause to the disbursement of federal grants to take effect the following day. Due to uncertainty around how long the pause would last and the Organization’s anticipated cash flow needs, management advance drew on the ...

2025-004: On January 27, 2025, the Office of Management and Budget (OMB) ordered a pause to the disbursement of federal grants to take effect the following day. Due to uncertainty around how long the pause would last and the Organization’s anticipated cash flow needs, management advance drew on the Organization’s federal awards on January 28, 2025. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: May 2025 Views of responsible officials and planned corrective actions: This is a once in a lifetime occurrence based on uncertainty and the Organization’s cash position at the time. The Organization has reviewed the cash management policy to ensure it is compliant. Additionally, the Organization has taken steps to improve its cash position and do not view this as an ongoing issue.

View Audit 389688

Finding 1175767 (2025-003)

Material Weakness 2025

Big Springs Medical Association D/b/a Missouri Highlands Health Care

MO

Allowable Costs / Cost Principles

2025-003 Salaries and wages are charged to federal awards through separate manual tracking worksheets for each award. Additionally, although salaries and wages are allocated to grants in the Organization’s accounting system, the allocation only occurs at a summary level, moving all costs from admini...

2025-003 Salaries and wages are charged to federal awards through separate manual tracking worksheets for each award. Additionally, although salaries and wages are allocated to grants in the Organization’s accounting system, the allocation only occurs at a summary level, moving all costs from administrative rather than where they were recorded. Responsible Persons: Karen R. White, CPA, Chief Executive Officer and Matthew Derryberry, Chief Financial Officer Completion Date: January 2026 Views of responsible officials and planned corrective actions: Issues identified during the audit were indicative of an overall lack of controls and processes to ensure no double dipping occurs. The new CFO along with the newer members of the Finance Department have developed better controls and processes to ensure grant expenditures, including payroll expenses and allocations, are properly accounted for in the accounting system with adequate backup of grant draw downs. With the implementation of a new payroll system and a new accounting system in 2026, these issues should resolve themselves with oversight provided by the CFO. The Organization’s CEO, a former CFO of the organization, will continue to provide oversight for the Finance Department to ensure controls and processes are implemented.

View Audit 389688

Corrective Action Plans

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