Corrective Action Plans

Finding 1175727 (2025-001)

Material Weakness 2025

MN

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

Saint Mary's University of Minnesota Corrective Action Plan For the Year Ended May 31, 2025 Finding 2025-001 Criteria: Title IV regulations (34 CFR 668.22) require the University to return the unearned portion of grants or loans to the Title IV program within 45 days after a student withdraws. Addit...

Saint Mary's University of Minnesota Corrective Action Plan For the Year Ended May 31, 2025 Finding 2025-001 Criteria: Title IV regulations (34 CFR 668.22) require the University to return the unearned portion of grants or loans to the Title IV program within 45 days after a student withdraws. Additionally, The U.S. Department of Education (ED) requires that an institution must ensure that its administrative procedures for the FSA programs include an adequate system of internal controls or checks and balances to ensure compliance with FSA laws and regulations including the return of Title IV funds. Condition/Context: The federal aid refunds for 1 out of 8 of the students tested was not calculated correctly and subsequently, not returned within 45 days from the withdrawal date. The sample was not statistically valid. Also, the auditor noted that the University did not have evidence or documentation available to support the control/review process for return of Title IV calculations. Cause: The University's review procedures for the return of Title IV funds were not followed and the system was not programmed to ensure the correct withdrawal date was used in the calculation of the return of Title IV funds. Effect: The University was in possession of funds belonging to the federal government longer than allowed and could have incorrect return of Title IV calculations and return incorrect amounts to students and/or the ED. Questioned Costs: Not applicable. Recommendation: The University should adhere to its procedures for refunding awards and implement a more formal documented review process/control to ensure refunds are calculated correctly and timely and any returns are made within the required timeframe. Management Response: The University agrees with this finding. The JFA R2T4 calculation incorrectly populated the wrong date used to perform the calculation, thus causing the error. The error was corrected and the director performs the R2T4 and is working to have a back-up employee trained. Staffing levels will have to be brought up to allow for new financial aid staff to complete this task. Corrective Action Plan Corrective Action Planned: To ensure accuracy, the withdrawal date generated in the JFA calculation will be cross-referenced against the J1 SIS record. Once verified, this date will be documented alongside the R2T4 calculation. This process guarantees that the student's period of attendance is calculated using the correct data. Name(s) of Contact Person(s) Responsible for Corrective Action: Holly Weberg, Director of Financial Aid and new hire designee. Anticipated Completion Date: The director is still fulfilling the R2T4 duties until a new hire candidate is hired and trained.

View Audit 389644

Finding 1175721 (2025-002)

Material Weakness 2025

Saint Mary's University of Minnesota

MN

Student Financial Aid

Saint Mary's University of Minnesota Corrective Action Plan For the Year Ended May 31, 2025 Finding 2025-002 Criteria: Title IV regulations (34 CFR 685.309(b)) require that upon receipt of an enrollment report from the Secretary, institutions must update all information included in the report and re...

Saint Mary's University of Minnesota Corrective Action Plan For the Year Ended May 31, 2025 Finding 2025-002 Criteria: Title IV regulations (34 CFR 685.309(b)) require that upon receipt of an enrollment report from the Secretary, institutions must update all information included in the report and return the report to the Secretary: (i) in the manner and format prescribed by the Secretary; and (ii) within the timeframe prescribed by the Secretary. Unless it expects to submit its next updated enrollment report to the Secretary within the next 60 days, an institution must notify the Secretary within 30 days after the date the institution discovers that: (i) a loan under Title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the institution, and the student has ceased to be enrolled on at least a half-time basis or failed to enroll on at least a half-time basis for the period for which the loan was intended; or (ii) a student who is enrolled at the institution and who received a loan under Title IV of the Act has changed his or her permanent address. Condition/Context: The change in student status for 8 of 26 students tested was not reported to the National Student Loan Data System (NSLDS) within 30 days or included in a response to a roster file within 60 days. The student status for 1 of 26 students tested was reported as a withdrawal although the student was on a leave of absence. In addition, for 7 of 26 students tested, the University was unable to provide sufficient support for the status change. The sample was not statistically valid. Cause: The University’s procedures for reporting all students was not designed appropriately in order to allow for timely reporting to the NSLDS. Effect: The accuracy of Title IV student loan records depends heavily on the accuracy of the enrollment information reported by institutions. If an institution does not review, update and verify student enrollment statuses, effective dates of the enrollment status and the anticipated completion dates, then the Title IV student loan records will be inaccurate. Questioned Costs: Not applicable. Recommendation: The University should revise its procedures to ensure accurate enrollment information is sent to the NSLDS within the required timeframe. Management Response: The University agrees with this finding. The University has been actively taking measures with the new student information system, Jenzabar, and procedures have been standardized across the University. An audit will be preformed to discover the inefficiencies. Corrective Action Plan Corrective Action Planned: The Registrar Office will submit the names of students to the Audit Resource team at NSC so they can research why these students were not reported to NSLDS. As a result of their response, we will meet with the financial aid team to determine the next course of action to audit files. Any changes needed for NSC reporting will be implemented in May 2026 new submission. The University will also work with the system provider to rectify these discrepancies systematically to avoid further conflicts. Name(s) of Contact Person(s) Responsible for Corrective Action: Alison Block, Director of Academic Records and Systems and Holly Weberg, Director of Financial Aid. Anticipated Completion Date: Tentative completion date May 2026.

View Audit 389644

Finding 1175719 (2025-002)

Material Weakness 2025

Montana Cancer Consortium

MT

Internal Control / Segregation of Duties § 200.303

Finding 2025-002: U.S. Department of Health and Human Service, National Institutes for Health Research and Development Cluster, Cancer Control, Assistance Listing #93.399; Lack Inadequate Documentation and Lack of Independent Review of Expenditures Corrective Action: We agree with the recommendation...

Finding 2025-002: U.S. Department of Health and Human Service, National Institutes for Health Research and Development Cluster, Cancer Control, Assistance Listing #93.399; Lack Inadequate Documentation and Lack of Independent Review of Expenditures Corrective Action: We agree with the recommendation. We do currently require complete supporting documentation for all expenditures. MCC has updated the Financial Process Procedure to include language related to receipt management, and allowable and disallowed grant expenses. MCC has created a Travel Reimbursement Procedure that addresses approval of Director expenses. Timeline: This was implemented on December 1, 2025. Responsible Parties: MCC Director, Principal Investigators

View Audit 389640

Finding 1175718 (2025-001)

Material Weakness 2025

Montana Cancer Consortium

MT

Allowable Costs / Cost Principles Cash Management Matching / Level of Effort / Earmarking § 200.302 § 200.305 § 200.313 § 200.430

Finding 2025-001: U.S. Department of Health and Human Service, National Institutes for Health Research and Development Cluster, Cancer Control, Assistance Listing #93.399; Lack of Required Written Policies Corrective Action: We agree with the recommendation. We do currently require complete supporti...

Finding 2025-001: U.S. Department of Health and Human Service, National Institutes for Health Research and Development Cluster, Cancer Control, Assistance Listing #93.399; Lack of Required Written Policies Corrective Action: We agree with the recommendation. We do currently require complete supporting documentation for all expenditures. Montana Cancer Consortium (MCC) has updated the Financial Process Procedure to include language related to receipt management, allowable and disallowed grant expenses, and timing of payment requests. Timeline: This was implemented on December 1, 2025. Responsible Parties: MCC Director, Principal Investigators

View Audit 389640

Finding 1175717 (2025-003)

Material Weakness 2025

Beaufort Jasper Hampton Comprehensive Services, Inc.

SC

Reporting

We concur with the auditor’s findings. The Organization will develop written procedures for preparing, certifying, and submitting annual federal financial reports, including deadlines and responsible staff.

View Audit 389630

Finding 1175712 (2025-001)

Material Weakness 2025

D'youville University

NY

Student Financial Aid Reporting

The University identified certain automated COD communication and reporting rules in the Student Information System (SIS) that were not functioning properly during the 2024-2025 aid year. The breakdown of these automated rules required manual interventions to have all Pell Grant disbursements and R2...

The University identified certain automated COD communication and reporting rules in the Student Information System (SIS) that were not functioning properly during the 2024-2025 aid year. The breakdown of these automated rules required manual interventions to have all Pell Grant disbursements and R2T4 adjustments reported to COD, in certain cases exceeding the 15-day requirement. The University has re-trained all financial aid staff to ensure the export process to COD is now completed after each R2T4 adjustment calculation. In addition, the financial aid office now has a dedicated employee running this process at minimum twice a week to ensure that all Pell records get successfully captured and reported to COD within the 15 day window.

View Audit 389612

Finding 1175710 (2025-003)

Material Weakness 2025

Marymount University

VA

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that Key Line Items are reviewed and accurately reported to Department of Education as required by regulations. ...

Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that Key Line Items are reviewed and accurately reported to Department of Education as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This finding resulted from inaccuracies introduced through enhancements made to a Workday-delivered report, which ultimately did not produce correct information. Going forward, we will review and validate the Workday report to ensure it aligns with Student Accounts’ reports and accurately reflects tuition and fees for the academic year. Name(s) of the contact person(s) responsible for corrective action: Jacob Witt, AVP of Financial Aid, 703-284-1532 Planned completion date for corrective action plan: June 2026 If the U.S. Department of Education have questions regarding this plan, please contact the individual(s) noted above.

View Audit 389607

Finding 1175705 (2025-002)

Material Weakness 2025

Marymount University

VA

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

Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its return of Title IV fund procedures to ensure that calculations are performed with correct inputs as required by regulations. Explanation of dis...

Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its return of Title IV fund procedures to ensure that calculations are performed with correct inputs as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This finding was driven by incorrect MSMS program start and end dates configured in the University’s new Student Information System (Workday). When processing Return of Title IV (R2T4) calculations, Workday relies on the program start and end dates stored in the system. Due to these dates being incorrect, the R2T4 process calculated an inaccurate number of days enrolled, which resulted in an incorrect earned percentage of Title IV aid and, consequently, an incorrect amount of aid the student was eligible to retain. To address this issue, the University has implemented internal controls to review and verify the start and end dates of each academic year in Workday prior to the start of each semester. In addition, an internal control has been added to ensure the start and end dates of each academic year are reviewed and validated as part of the Return of Title IV processing. Name(s) of the contact person(s) responsible for corrective action: Jacob Witt, AVP of Financial Aid, 703-284-1532 Courtney Carey, University Registrar, 703-284-1523 Planned completion date for corrective action plan: Completed December 2025.

View Audit 389607

Finding 1175700 (2025-001)

Material Weakness 2025

Marymount University

VA

Student Financial Aid Reporting Significant Deficiency

Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Explanation ...

Student Financial Aid Cluster – Assistance Listing Numbers 84.007, 84.033, 84.038, 84.063, and 84.268 Recommendation: We recommend the University review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The findings were primarily driven by the University’s transition to a new Student Information System (Workday), including the Workday-delivered National Student Clearinghouse (NSC) integrations. These constraints resulted in delays and gaps in enrollment reporting processes, increased processing timelines with the National Student Clearinghouse (NSC), and impacted the timely and accurate transmission of enrollment data to the National Student Loan Data System (NSLDS). In response, Marymount University has developed a formal Standard Operating Procedure (SOP) for National Student Clearinghouse reporting and has begun implementing these procedures during the 2025–2026 academic year. Name(s) of the contact person(s) responsible for corrective action: Courtney Carey, University Registrar, 703-284-1523 Jacob Witt, AVP of Financial Aid, 703-284-1532 Planned completion date for corrective action plan: Completed December 2025.

View Audit 389607

Finding 1175691 (2025-002)

Material Weakness 2025

Educational Associates, Inc.

PR

Subrecipient Monitoring Special Tests & Provisions Significant Deficiency § 200.303

The Institution implements a formal validation and review process for all Quarterly Progress Reports. As part of this corrective action: • Copies of all checks and/or disbursements included in the report will be attached to each Quarterly Progress Report. • All reported expenditures will be verified...

The Institution implements a formal validation and review process for all Quarterly Progress Reports. As part of this corrective action: • Copies of all checks and/or disbursements included in the report will be attached to each Quarterly Progress Report. • All reported expenditures will be verified against the Institution’s accounting system. • Each Quarterly Progress Report will be reviewed, verified, and certified by the President of the Institution or the Compliance Officer prior to submission to COR3/FEMA. Implementation Plan: • Develop and formalize a written procedure for the preparation, validation, and review of Quarterly Progress Reports. • Designate a responsible official to perform an independent review of the report. • Require supporting documentation, including copies of checks and accounting system reports, as mandatory attachments. • Obtain written certification and signature from the President or Compliance Officer prior to submission. IMPLEMENTATION DATE Immediately RESPONSIBLE PERSON Compliance Officer President of the Institution

View Audit 389579

Finding 1175690 (2025-003)

Material Weakness 2025

Wood County Children's Services Association

OH

Procurement, Suspension & Debarment § 200.318 § 200.327 § 200.510

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: Implementation of a formal procurement and suspension and debarment policy that includes procedures over review of the federal suspension and debarred listing, that is in compliance with the Uniform Gui...

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: Implementation of a formal procurement and suspension and debarment policy that includes procedures over review of the federal suspension and debarred listing, that is in compliance with the Uniform Guidance. Procurement policy should include general procurement standards as described by the Uniform Guidance, that include standards on conduct covering conflicts of interest; method of procurement for micro-purchases, small purchases, sealed bids, and proposals; and all other criteria as outlined in 2CFR 200.318 through 200.327. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will develop and implement a procurement policy that is in compliance with the Uniform Guidance. Name(s) of the contact person(s) responsible for corrective action: Sydney Falk, CFO Planned completion date for corrective action plan: February 28, 2026

View Audit 389578

Finding 1175689 (2025-001)

Material Weakness 2025

Furman University

SC

Student Financial Aid

NSLDS Reporting Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in ...

NSLDS Reporting Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During a typical reporting cycle, all students’ degree information is transmitted to the National Student Clearinghouse (NSC) through a standardized report generated by our Student Information System (Workday). In the instance identified, one student’s graduation status was still pending at the time we submitted degree records for all May 2025 graduates. Once the student’s status was finalized and the degree was officially conferred, we submitted the student’s information manually to the NSC. However, the degree conferral date was reported incorrectly; the actual conferral date was submitted instead of the last day of the student’s final term, which is the required standard. To prevent this issue from recurring, we will discontinue all manual degree submissions to the NSC. Going forward, we will rely exclusively on Workday-generated reports to ensure that all graduation dates are accurate, consistent, and aligned with institutional reporting standards. Name(s) of the contact person(s) responsible for corrective action: James Patton, Assistant Vice President for Academic Affairs and University Registrar Planned completion date for corrective action plan: This change in our data-reporting procedure has already been implemented. The updated process was in place for the most recent degree verification cycle, which was reported to the National Student Clearinghouse on 01-02-2026. If the U.S. Department of Education has questions regarding these plans, please call Dawn Durham at 864-294-2429.

View Audit 389564

Finding 1175688 (2025-002)

Material Weakness 2025

VILLAGE OF ELMIRA HEIGHTS

NY

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.112 § 200.317 § 200.326

The Village Mayor will provide an updated policy to be approved by the Village Board in 2026.

View Audit 389546

Finding 1175686 (2025-004)

Material Weakness 2025

Iberia Comprehensive Community Health Center

LA

Management has currently implemented procedures to have sliding fee application information reconciled to the applicable information in the billing system.

View Audit 389534

Finding 1175686 (2025-004)

Material Weakness 2025

Iberia Comprehensive Community Health Center

LA

Management has is currently implementing procedures to have all staff responsible for sliding fee eligibility trained in areas of converting pay information to monthly or annual income for sliding fee determinations. Management will also implement quality review processes to ensure that correct pay ...

Management has is currently implementing procedures to have all staff responsible for sliding fee eligibility trained in areas of converting pay information to monthly or annual income for sliding fee determinations. Management will also implement quality review processes to ensure that correct pay frequency and conversion factors are used.

View Audit 389534

Finding 1175685 (2025-003)

Material Weakness 2025

Iberia Comprehensive Community Health Center

LA

Management has currently implemented procedures to communicate the approved current sliding fee schedule to the appropriate personnel.

View Audit 389534

Finding 1175684 (2025-002)

Material Weakness 2025

Iberia Comprehensive Community Health Center

LA

Cash Management

Management has currently implemented procedures for grant funded expenditures to ensure that complete documentation supporting the funds requests are available and at the time of the drawdown of the grant funds.

View Audit 389534

Finding 1175683 (2025-001)

Material Weakness 2025

Millville Public Charter School

NJ

School Nutrition Programs

Reviewing the fund balance monthly and purchasing necessary supplies and staff to keep the balance down.

View Audit 389519

Finding 1175672 (2025-001)

Material Weakness 2025

Margaret B. MacK Supportive Housing Corporation Hud Proj. #017-Hd038

CT

Internal Control / Segregation of Duties Significant Deficiency

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management review the rates used to calculate management fees to ensure that they agree to the agreed upon percentages outlined in the agreem...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management review the rates used to calculate management fees to ensure that they agree to the agreed upon percentages outlined in the agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure that calculated management fees match the agreed upon rates. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Completed on January 31, 2026.

View Audit 389507

Finding 1175670 (2025-002)

Material Weakness 2025

Continuum of Care, Inc. and Affiliates

CT

Internal Control / Segregation of Duties Significant Deficiency

Supportive Housing for Persons With Disabilities Assistance Listing No. 14.181 Criteria or Specific Requirement: Department of Housing and Urban Development requires any surplus funds in the project funds account at the end of the fiscal year to be deposited in a federally insured account within 6...

Supportive Housing for Persons With Disabilities Assistance Listing No. 14.181 Criteria or Specific Requirement: Department of Housing and Urban Development requires any surplus funds in the project funds account at the end of the fiscal year to be deposited in a federally insured account within 60 days following the end of the fiscal year. Condition: As of June 30, 2024, Continuum Supportive Housing of West Hartford, Inc. has a surplus cash of $50,759. The required deposit into a residual receipt account was not made within 60 days following the end of the fiscal year. Questioned costs: None Context: We reviewed the surplus cash calculation noting that the Project has a surplus cash of $50,759 at the end of the fiscal year 24. Surplus cash should have been deposited within 60 days following the end of the fiscal year. Cause: This was an oversight by management. Effect: The required deposit was not made as required by the Department of Housing and Urban Development. Repeat Finding: Yes Recommendation: We recommend management to ensure that required deposits are made 60 days following the fiscal year-end. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Required deposit made by March 31, 2025. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: January 31, 2026.

View Audit 389506

Finding 1175668 (2025-001)

Material Weakness 2025

Continuum of Care, Inc. and Affiliates

CT

Significant Deficiency Internal Control / Segregation of Duties

Supportive Housing for Persons With Disabilities Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon p...

Supportive Housing for Persons With Disabilities Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon performing testing over payroll disbursements, we noted that there was no approval of the timesheets for the payroll disbursements tested. Questioned costs: None Context: The timesheet for 1 out of 5 payroll disbursements tested was not properly approved by the property manager. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over payroll disbursements. Effect: There is no evidence of proper approval of payroll disbursement. Repeat Finding: Yes Recommendation: We recommend that management strengthen controls over review of payroll. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Although other controls assist to safeguard and mitigate compensation errors, the property manager will ensure that all time sheets are properly approved prior to payment, and if necessary the VP of Operations or the President of the managing agent will provide further assurance of internal controls through reviews. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: January 31, 2026.

View Audit 389506

Finding 1175666 (2025-004)

Material Weakness 2025

Loyalsock Township School District

PA

School Nutrition Programs

Child Nutrition Cluster, National School Lunch Program – Assistance Listing 10.555; passed through the Pennsylvania Department of Education; Grant Period – Year Ended June 30, 2025 Significant deficiency: See deficiency 2025-002 listed below. 2025-002. FOOD SERVICE RECEIVABLES Planned Corrective Act...

Child Nutrition Cluster, National School Lunch Program – Assistance Listing 10.555; passed through the Pennsylvania Department of Education; Grant Period – Year Ended June 30, 2025 Significant deficiency: See deficiency 2025-002 listed below. 2025-002. FOOD SERVICE RECEIVABLES Planned Corrective Action: The Staff Accountant Amber Whited will review receipts after year end to ensure receivables are accurately identified and recorded as receivables. Person Responsible: Staff Accountant (Amber Whited) Anticipated Completion date: Immediately

View Audit 389501

Finding 1175664 (2025-001)

Material Weakness 2025

Behavioral Health Solutions of South Texas

TX

Reporting § 200.329

Finding #2025-001: Type of Finding: Other Finding Responsible Person Abigail Ramos – Program Director Implementation Date January 12, 2026 Views of responsible officials and planned corrective actions Management disagrees with the finding as the assigned Grant Program Official (GPO) with SAMHSA acce...

Finding #2025-001: Type of Finding: Other Finding Responsible Person Abigail Ramos – Program Director Implementation Date January 12, 2026 Views of responsible officials and planned corrective actions Management disagrees with the finding as the assigned Grant Program Official (GPO) with SAMHSA accepted and approved the report and did not note this singular incident as a finding nor did the GPO find BHSST as being non-compliant. Consideration was extended due to the change in Program Director and the impact of the government shutdown affecting access to the assigned GPO. Change in key personnel required prior approval by SAMHSA before the new Program Director could begin working on the project. The new Program Director did have limited access to the assigned GPO due to the impact of the government shutdown and misunderstood that an extension filed was extended to the eRA Commons report versus this report. Reporting deadlines are met by submitting reports prior to the deadline. Challenges that led to the delayed submission have been remedied as clarification was obtained regarding the submission deadlines and process for requesting an extension for both the annual performance and eRA Commons reports. Further management notes this report did not impact the program's ability to continue nor delay any fiscal processes and is not considered a finding by the funder. Auditor Response Based on review and consideration of documentation and responses provided by Management, no documented evidence was available to address the finding of noncompliance.

View Audit 389500

Finding 1175663 (2025-001)

Material Weakness 2025

Marana Health Center, INC

AZ

The sliding fee determination will be reviewed by the front desk staff thoughtfully to ensure the proper charge to the patient. o Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office, the patient will complete the Sliding Fee application and self...

The sliding fee determination will be reviewed by the front desk staff thoughtfully to ensure the proper charge to the patient. o Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office, the patient will complete the Sliding Fee application and self-declaration of income and family size. The front office will verify the application, determine the scale for which the patient qualifies, and verify with the Center’s practice management system. The lead biller will review all uploaded documents and approve the sliding fee in real time. o Additional training will take place with front desk personnel. The corrective action outlined above will be monitored on an ongoing basis. The CFO and the Controller will oversee the implementation and report progress to the CEO and Board . Regular internal reviews and reconciliations will be conducted to ensure continued compliance with internal controls and federal requirements.

View Audit 389495

Finding 1175662 (2025-004)

Material Weakness 2025

Florida College, INC

FL

Student Financial Aid Significant Deficiency

Incorrect Pell Calculations Planned Corrective Action: Management acknowledges the error in calculation. As a result of change in student information software and financial aid software in conjunction with manual processes employed during transition of academic years, timing of review and misinterpr...

Incorrect Pell Calculations Planned Corrective Action: Management acknowledges the error in calculation. As a result of change in student information software and financial aid software in conjunction with manual processes employed during transition of academic years, timing of review and misinterpretation of Summer Pell regulations, this error was not identified timely. This may have carried over to the subsequent term. Management receives this as opportunity to improve upon processes to ensure higher visibility and oversight to reduce any further risk making certain to align policies with DOE. Person Responsible for Corrective Action Plan: Kristina Elmore, Director of Financial Aid Anticipated Date of Completion: February 2026

View Audit 389486

Corrective Action Plans

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