Corrective Action Plans

Finding 1215691 (2025-002)

Material Weakness 2025

Vaughn College of Aeronautics and Technology

NY

Student Financial Aid

Finding No. 2025-002 – Special Tests and Provisions – NSLDS Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The registrar will complete a 100% audit of the withdrawals for Fall 2025 and Spring 2026 to verify that the dates the students were withdrawn in t...

Finding No. 2025-002 – Special Tests and Provisions – NSLDS Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The registrar will complete a 100% audit of the withdrawals for Fall 2025 and Spring 2026 to verify that the dates the students were withdrawn in the Student Information System matches the dates the students signed the Total Withdrawal or Add/Drop forms. Anticipated Completion Date: The audit should be completed by the end of June 2026. Starting the Summer 2026 semester, the withdrawal dates in Sonis and the dates the students sign the Total Withdrawal or Add/Drop forms will be verified on a weekly basis. Person(s) Responsible for Corrective Action: Evelyn M. Bryant Assistant Vice President of Registrar Services 910-257-3452

View Audit 402343

Finding 1215689 (2025-001)

Material Weakness 2025

Vaughn College of Aeronautics and Technology

NY

Student Financial Aid Internal Control / Segregation of Duties Reporting

Finding No. 2025-001 – Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The discrepancies identified during the current audit were determined to be timing-related issues associated with the transition and implementation of revised disbursement reporting an...

Finding No. 2025-001 – Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The discrepancies identified during the current audit were determined to be timing-related issues associated with the transition and implementation of revised disbursement reporting and reconciliation procedures in order to address a similar compliance finding that was identified in the 2024 Single Audit. These discrepancies occurred while updated controls and monitoring processes were being fully integrated into daily operations. During the prior audit conducted on April 6, 2025, auditors identified discrepancies between institutional disbursement dates and the dates reflected in the Common Origination and Disbursement (COD) system for the 2023-2024 award year. Immediately upon identification of the issue in the 2024 Single Audit, the institution implemented corrective measures to ensure that institutional disbursement dates matched Common Origination and Disbursement (COD) reporting. Since May 2025, the following corrective actions have already been fully implemented: 1. Revised and strengthened reconciliation procedures between the Student Information System and COD to ensure accurate disbursement date reporting. 2. Implemented secondary review controls prior to transmitting disbursement records to COD. 3. Established ongoing internal monitoring and periodic reconciliation reviews to identify and resolve discrepancies promptly. 4. Conducted additional staff training regarding Title IV disbursement reporting requirements and COD reconciliation procedures. 5. Assigned designated personnel responsibility for continuous oversight and verification of disbursement date accuracy. 6. Corrected disbursement reporting processes to ensure institutional records align with COD reporting requirements moving forward. Anticipated Completion Date: Since May 2025, the institution has taken all necessary measures to address and correct the identified issues on a prospective basis. All corrective actions outlined above are currently in place and operational. The institution continues to monitor disbursement reporting and reconciliation processes to ensure ongoing compliance with federal Title IV regulations and accurate reporting to COD. Person(s) Responsible for Corrective Action: Beatriz Novoa-Cruz Associate Vice President of Enrollment 718-429-6600 ext. 114

View Audit 402343

Finding 1215687 (2025-003)

Material Weakness 2025

CITY OF LICKING

MO

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management

The City agrees with the finding and will implement the following: (1) develop written policies and procedures to ensure compliance with Uniform Guidance (2 CFR 200), (2) formally adopt the policies and procedures, and (3) distribute policies and train staff on the new procudures.

View Audit 402340

Finding 1215686 (2025-002)

Material Weakness 2025

Renton School District No. 403

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

To address this issue and strengthen compliance controls, the District has implemented and will continue the following corrective actions: 1. Standardized Time-and-Effort Procedures The District has revised and standardized procedures for collecting, reviewing, and retaining time-and-effort document...

To address this issue and strengthen compliance controls, the District has implemented and will continue the following corrective actions: 1. Standardized Time-and-Effort Procedures The District has revised and standardized procedures for collecting, reviewing, and retaining time-and-effort documentation for all federally funded employees and substitutes charged to Title I and other federal programs. 2. Training and Guidance District staff responsible for payroll processing, federal program oversight, and school-level administration will receive annual training regarding federal time-andeffort requirements, including requirements for semiannual certifications, personnel activity reports, signature and date requirements, and retention expectations. 3. Centralized Monitoring and Review The District has updated its centralized review process to verify that all required timeand- effort documentation is completed accurately and retained timely before payroll expenditures are finalized and charged to federal programs. This review includes periodic monitoring by Business Services and Program staff. 4. Tracking and Documentation Controls The District is updating its tracking mechanisms, including standardized forms, submission deadlines, and periodic compliance checklists, to ensure required certifications are collected and retained for all applicable employees each reporting period. 5. Ongoing Compliance Monitoring District management will conduct periodic internal reviews of federally funded payroll documentation throughout the fiscal year to ensure continued compliance and to promptly address any deficiencies identified. The District expects these corrective actions to strengthen internal controls and ensure ongoing compliance with federal and OSPI requirements for time-and-effort documentation.

View Audit 402334

Finding 1215677 (2025-001)

Material Weakness 2025

Legal Aid of Western Ohio, INC

OH

Procurement, Suspension & Debarment

Legal Services Corporation Grant – Assistance Listing No. 09.436183 Recommendation: We recommend that the Organization update its procurement and vendor approval procedures to require documented suspension and debarment verification prior to entering into covered transactions, in accordance with 2 C...

Legal Services Corporation Grant – Assistance Listing No. 09.436183 Recommendation: We recommend that the Organization update its procurement and vendor approval procedures to require documented suspension and debarment verification prior to entering into covered transactions, in accordance with 2 CFR §§ 180.300 and 180.320. Documentation of the verification should be retained in the procurement or contract file to demonstrate compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding. During 2025, periodic suspension and debarment reviews were performed; however, the process did not require verification prior to entering into covered transactions. Management will revise its procurement policies and procedures to require suspension and debarment verification before execution of covered contracts, including contracts funded with LSC or other federal funds that are expected to equal or exceed $25,000, contracts requiring LSC or federal approval, and other covered transactions. Documentation of the verification will be retained with the procurement file and must be dated prior to contract execution. Corrective Action: Effective immediately, LAWO will require a SAM.gov Exclusions search, vendor certification, or suspension/debarment clause before entering into covered transactions. The preferred method will be a SAM.gov Exclusions search. Procurement policies and procedures will be updated to include this required step. The staff member responsible will retain the dated verification in the procurement file. Name(s) of the contact person(s) responsible for implementing corrective action: Scot Henshaw, Manager of Business Operations Planned completion date for corrective action plan: July 1, 2026

View Audit 402332

Finding 1215673 (2025-005)

Material Weakness 2025

Oakland County, Michigan

MI

HUD Housing Programs Material Weakness Reporting § 200.307

Reporting of Prior Year Program Income Auditor Description of Criteria, Condition, and Effect: In accordance with 2 CFR § 200.307, program income must be used in accordance with the terms and conditions of the federal award and must be accounted for and reported accurately. Recipients are required t...

Reporting of Prior Year Program Income Auditor Description of Criteria, Condition, and Effect: In accordance with 2 CFR § 200.307, program income must be used in accordance with the terms and conditions of the federal award and must be accounted for and reported accurately. Recipients are required to reconcile program income received and expended during the grant period to ensure it is used for allowable purposes and properly reflected in financial reports. Failure to reconcile and report program income may result in noncompliance with federal grant regulations and could impact the allowability of costs charged to the award. The County recognized a substantial amount of program income during the fiscal year ended September 30, 2025, for program income that was received in prior periods but incorrectly reported as unearned over many years. It is unclear what portion of this prior year unearned revenue was reported to the Department of Housing and Urban Development ("HUD") through the Integrated Disbursement and Information System ("IDIS") now that the revenue has been properly recognized in the general ledger. The County has a risk of inaccurately reporting program income to HUD. The County is also exposed to an increased risk noncompliance could occur and not be prevented or detected by the County's internal controls. Auditor Recommendation: We recommend the County review its prior year records to determine which portion of the currently recognized revenue has already been reported to HUD. Additionally, the County's Neighborhood and Housing Development ("NHD") department should coordinate with HUD to establish the appropriate approach for reporting and expending this program income going forward. Corrective Action: An in-depth review of all program income activity dating back to 1995 is currently underway within both the general ledger and the IDIS system. The purpose of this review is to determine the total amount of program income received and reported to HUD. Upon completion of the review, the County will collaborate with HUD to determine the appropriate use and expenditure of the identified funds in accordance with applicable program requirements. Responsible Persons: Khadija Walker-Fobbs Neighborhood and Housing Development Officer, Curtis Smith, Chief, Neighborhood and Housing Development and Brian J. Lefler, Chief Financial Officer Anticipated Completion Date: September 2026

View Audit 402331

Finding 1215654 (2025-004)

Material Weakness 2025

Oakland County, Michigan

MI

Reporting Material Weakness

Inaccurate Reporting/Lack of Independent Review and Approval of Reporting (Repeat) Auditor Description of Criteria, Condition, and Effect: Recipients of federal awards are required to report periodically on financial information, as specified by the grant agreement. Reported information should be su...

Inaccurate Reporting/Lack of Independent Review and Approval of Reporting (Repeat) Auditor Description of Criteria, Condition, and Effect: Recipients of federal awards are required to report periodically on financial information, as specified by the grant agreement. Reported information should be supported by the entity’s accounting records and subjected to an independent review and approval prior to submission in order to detect and correct any errors or omissions. Additionally, the PR-26 financial summary reports are submitted as part of the Consolidated Annual Performance Evaluation Report (CAPER) and should be properly reconciled to present all inflows and outflows of resources related to the program including the appropriate unexpended balance. During our audit procedures over the County's CDBG reporting, we noted that none of the reports were subject to an independent review and approval prior to submission in order to detect and correct potential errors or omissions until partway through the year under audit. We also noted that the PR-26 was submitted as required, but contained financial data that did not agree to the County's underlying accounting records. Expenditures were properly reported for the year under audit, but it was identified that the County had incorrectly reported its unexpended balance going back to 2020, when the unexpended balance was not properly carried over from the 2019 report to the 2020 report. This resulted in an incorrect unexpended balance which presented as a net negative unexpended balance in the current year report. The County submitted inaccurate reporting in its PR-26 that was inconsistent with other financial reports submitted and with the County's general ledger. The County is also exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the County's internal controls until controls are consistently implemented across fiscal years. Auditor Recommendation: We recommend that the County implement necessary internal controls to ensure that proper review and approval is documented and reports agree to accounting records. Financial information being submitted to outside entities should be reviewed and approved by the Financial Services department to ensure that it is in agreement with the County's general ledger and consistent with other required financial reporting. Corrective Action: Management acknowledges that financial reporting requires enhanced controls and reconciliation procedures. A review of detailed reconciliation steps will be conducted to identify areas within current processes where regular reviews can be implemented to ensure accuracy and completeness. The County plans to implement this process by July FY2026, which will provide two full quarters of reviewed and monitored activity prior to year-end reporting. Responsible Persons: Khadija Walker-Fobbs Neighborhood and Housing Development Officer, Curtis Smith, Chief, Neighborhood and Housing Development and Brian J. Lefler, Chief Financial Officer Anticipated Completion Date: September 2026

View Audit 402331

Finding 1215635 (2025-003)

Material Weakness 2025

The Montrose Center

TX

Reporting

Finding #2025-003 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: All programs. Condition and context: The SEFA originally provided by the Montrose Center did not reconcile to the underlying accounting records. Additionally, some funding was incorrectly rep...

Finding #2025-003 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: All programs. Condition and context: The SEFA originally provided by the Montrose Center did not reconcile to the underlying accounting records. Additionally, some funding was incorrectly reported as state funding instead of federal. the Montrose Center failed to have procedures in place to identify and reflect all federal grants on the SEFA, have timely procedures to reconcile the federal expenditures to the federal program revenue or have timely review. Recommendation: Develop policies and procedures to identify and reflect all federal programs on the SEFA, reconcile the federal expenditures to the federal program revenue on a routine basis, and formalize the independent review process for the SEFA and grant billings. Planned corrective action: Management will develop written procedures to identify all federal awards, including federal funding received indirectly through state and other pass-through entities, by confirming the funding source tagging each award in the CYMA general ledger with a federal/state/local indicator. Federal expenditures will be reconciled to federal program revenue and grant billings on a routine basis, and the draft SEFA, supporting reconciliations, and grant billings will be subject to documented independent review by the Controller. Responsible officer: Michael McIntyre, Chief Administrative Officer. Estimated completion date: August 31, 2026.

View Audit 402329

Finding 1215621 (2025-004)

Material Weakness 2025

The Montrose Center

TX

Reporting Allowable Costs / Cost Principles HUD Housing Programs

Finding #2025-004 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: U.S. Department of Health and Human Services, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Recovery Support Services, Contract Number: HHS00013050...

Finding #2025-004 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: U.S. Department of Health and Human Services, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Recovery Support Services, Contract Number: HHS000130500013, Contract Year: 09/01/24-08/31/25; Prevention and Behavioral Health Promotion Youth Prevention Services, Contract Number: HHS001344700032, Contract Year: 09/01/24-08/31/25. Condition and context: During our testing of the Federal Financial Reports, we noted that the final financial status reports were submitted late and the reports did not have evidence of review and approval. Additionally, a recoupment of $33,541 was required by the funder upon review of the closeout report for contract number HHS000130500013. Recommendation: Re-emphasize policies and procedures to meet the grant reporting requirements and ensure that all reports are independently reviewed prior to submission. Planned corrective action: Management will maintain a grant reporting deliverables calendar covering all federal and state reporting requirements, with internal due dates set in advance of funder deadlines and assigned to a specific grant manager. No Federal Financial Report or closeout report will be submitted without documented independent review and approval by the Controller, with preparer, reviewer, and approver sign-off retained in the grant file alongside the supporting reconciliation to the CYMA general ledger. Responsible officer: Michael McIntyre, Chief Administrative Officer. Estimated completion date: August 31, 2026.

View Audit 402329

Finding 1215597 (2025-001)

Material Weakness 2025

Greater Boston Chinese Golden Age Center, Inc.

MA

Significant Deficiency

The Organization will plan to begin its audit for the year ended June 30, 2026 earlier than the prior year, allowing sufficient time to file the Organization's Data Collection Form before its due date.

View Audit 402305

Finding 1215595 (2025-002)

Material Weakness 2025

Winter Grove, Inc.

CT

Internal Control / Segregation of Duties

CP-1011 CORRECTIVE ACTION PLAN Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 Signature: The ...

CP-1011 CORRECTIVE ACTION PLAN Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 Signature: The following is a recommended format to be followed by the auditee for preparing a corrective action plan: 2. Finding 2025-002 a. Comments on the Finding and Each Recommendation During the year ended December 31, 2025, the project did not make the required monthly deposits to the replacement reserve in the amount of $2,521. b. Action(s) Taken or Planned on the Finding This finding has been corrected and the deposit was made within the first quarter of 2026.

View Audit 402286

Finding 1215593 (2025-001)

Material Weakness 2025

Winter Grove, Inc.

CT

Cash Management Eligibility HUD Housing Programs

Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 The following is a recommended format to be fo...

Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation During the year ended December 31, 2025, the Corporation paid expenses in the amount of $305 on behalf of an affiliate from project cash without HUD approval. The amount due to the Project as of December 31, 2025 is $305. b. Action(s) Taken or Planned on the Finding This finding has been corrected and the affiliate reimbursed the property within the first quarter of 2026.

View Audit 402286

Finding 1215591 (2025-001)

Material Weakness 2025

Granite Falls School District No. 332

WA

Procurement, Suspension & Debarment School Nutrition Programs Subrecipient Monitoring

Going forward we have already put in place the following action items: • In order to maintain eligibility records in a location that is easy to locate, we will create a main, online depository to house all eligibility forms by year so that we can readily access proof of eligibility for all future au...

Going forward we have already put in place the following action items: • In order to maintain eligibility records in a location that is easy to locate, we will create a main, online depository to house all eligibility forms by year so that we can readily access proof of eligibility for all future audits. • In order to ensure that we don’t exceed federal procurement thresholds due to unforeseen increases in meal demand, we will be far more conservative in our meal forecasts and follow federal procurement guidelines any time we think we might get close to meeting threshold requirements. • In order to meet federal procurement requirements around receiving three bids for purchases, we will add an additional step to our procurement process that ensures we receive at least three formal bids or can document that we placed a formal request for bids in a regional publication such as the Seattle Journal of Commerce and did not receive three formal bids. We currently request bids from all vendors that service our area but we don’t always receive at least three formal bids back. This additional step will ensure that we made every effort to reach out to all possible vendors in the state even if they do not service our area.

View Audit 402278

Finding 1215588 (2025-001)

Material Weakness 2025

Community Action Partnership of Huntsville/madison &limestone Counties

AL

Eligibility § 200.303

CAPHMLC is implementing corrective actions to ensure full compliance and strengthen internal controls. 1. CAPHMLC will reinforce its requirement that all LIHEAP participant files include complete hard-copy documentation supporting eligibility determinations. 2. A standardized documentation checklist...

CAPHMLC is implementing corrective actions to ensure full compliance and strengthen internal controls. 1. CAPHMLC will reinforce its requirement that all LIHEAP participant files include complete hard-copy documentation supporting eligibility determinations. 2. A standardized documentation checklist will be implemented and required in each file to verify completeness prior to approval. 3. A documented supervisory review will be required for all applications. Evidence of this review must include the reviewer's initials or signature and the date ofreview. 4. Applications will not be processed until the required review is completed and documented. CAPHMLC will provide mandatory trammg to all LIHEAP staff and supervisors on documentation requirements, record retention standards, and supervisory review procedures. Updated policies will be formally communicated, and staff will be required to acknowledge their unde-rstanding e fc-these-requirements. To ensure ongoing compliance, CAPHMLC will implement monthly quality assurance reviews of a sample of participant files to verify completeness of documentation and evidence of supervisory review. Results will be reported to management, and any identified deficiencies will be addressed promptly. Procedures will also be strengthened to ensure consistency between electronic records maintained in F ACSPro and hard-copy files. These corrective actions will be implemented within 90 days, with trammg and policy reinforcement completed within 30 days, and monitoring procedures initiated within 60 days. Supervisors will be responsible for enforcing compliance, and instances of noncompliance will be addressed in accordance with CAPHMLC personnel policies and procedures. Management will monitor the effectiveness of these corrective actions through ongoing quality assurance activities and periodic internal reviews to ensure sustained compliance with applicable requirements.

View Audit 402270

Finding 1215586 (2025-001)

Material Weakness 2025

Hazelden Betty Ford Foundation and Subsidiaries

MN

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend Hazelden Betty Ford Graduate School review their policies and procedures relating to return of Title IV calculations to ensure the calculations are properly set up to round. Explanation of disagreement ...

Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend Hazelden Betty Ford Graduate School review their policies and procedures relating to return of Title IV calculations to ensure the calculations are properly set up to round. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) Rounding rules have been applied to the Return of Title IV calculation worksheets according to the federal Title IV regulations. 2) Discrepancies in R2T4 calculations due to the rounding issue have been corrected on COD on a student by student basis Name(s) of the contact person(s) responsible for corrective action: Yuan Fang Planned completion date for corrective action plan: April 1, 2026

View Audit 402265

Finding 1215585 (2025-006)

Material Weakness 2025

Independent School District No. 622

MN

Reporting § 200.512

REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2025-006 Federal Reporting Deadline Finding Summary Criteria – 2CFR Part 200, Subpart F, § 200.512(a)(1) requires the District’s audited Schedule of Expenditures Federal Awards (SEF...

REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2025-006 Federal Reporting Deadline Finding Summary Criteria – 2CFR Part 200, Subpart F, § 200.512(a)(1) requires the District’s audited Schedule of Expenditures Federal Awards (SEFA) and federal reporting package to be submitted to the federal audit clearinghouse within the earlier of 30 calendar days after the receipt of the auditor’s report(s), or 9 months after the end of the audit period. Condition – The District’s audited SEFA and federal reporting package for the fiscal year ended June 30, 2025, were not submitted to the federal audit clearinghouse within nine months after the end of the audit period. Corrective Action Plan Actions Planned – The completion of the District’s audited annual financial statements for the year ended June 30, 2025, which is a required component of the federal reporting package, was delayed beyond the nine-month deadline, primarily due to turnover in the District’s finance department. District management will ensure that all information required to comply with federal reporting requirements will be completed and submitted in a timely manner going forward. Official Responsible – Josh Anderson, the District’s Director of Finance. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – Josh Anderson, the District’s Director of Finance, will monitor the year‑end financial closing and reporting process to ensure all federal and state reporting requirements are complied with in the future.

View Audit 402250

Finding 1215568 (2025-005)

Material Weakness 2025

Red Cloud Indian School, Inc.

SD

Allowable Costs / Cost Principles § 200.303

Federal Agency name: Department of Education Assistance Listing Number: 84.365C Program Name: English Language Acquisition, Language Enhancement, and Academic Achievement Program for Limited English Proficient Children Finding Summary: Indirect costs charged to the federal award did not agree to the...

Federal Agency name: Department of Education Assistance Listing Number: 84.365C Program Name: English Language Acquisition, Language Enhancement, and Academic Achievement Program for Limited English Proficient Children Finding Summary: Indirect costs charged to the federal award did not agree to the underlying direct costs for the award for the fiscal year ended June 30, 2025. Corrective Action Plan: Approved indirect costs on federal grants will be drawn down in the same fiscal year that the direct costs were incurred. If the draw down is not completed by the end of the fiscal year, a receivable will be recorded in the financial statements. Responsible Individuals: Andrea Eagle Bull, VP for Finance and John Hussman, Grants Manager Anticipated Completion Date: July 2026

View Audit 402247

Finding 1215567 (2025-004)

Material Weakness 2025

Change Happens!

TX

Reporting

Finding #2025-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01...

Finding #2025-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: Civic Heart had not performed a reconciliation of federal expenditures resulting in errors in reported expenditures. Additionally, subrecipient expenditures were not identified for two programs. There was no independent review of the SEFA. Recommendation: Emphasize adherence to established policies and procedures to reconcile the federal expenditures to the federal program revenue on a routine basis and formalize the independent review process for the SEFA and grant billings. Planned corrective action: Management has implemented strengthened federal reporting and reconciliation procedures to improve accuracy and oversight related to federal expenditures and SEFA preparation. Corrective actions include: 1) Implementation of a formal SEFA preparation and reconciliation process requiring reconciliation of federal expenditures to the general ledger and supporting documentation. 2) Quarterly federal expenditure reviews to identify discrepancies and improve reporting accuracy throughout the fiscal year. 3) Development of centralized federal awards tracking procedures to monitor expenditures, reimbursement activity, subrecipient activity, grant balances, and reporting requirements. 4) Independent review procedures for preparation and review of the SEFA prior to annual audit submission. 5) Strengthened coordination between accounting personnel and program leadership to improve federal reporting accuracy and monitoring of subrecipient activity. 6) Periodic internal compliance reviews to evaluate federal reporting accuracy and compliance with grant requirements. Responsible officer: Anita Bates, Chief Executive Officer. Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.

View Audit 402238

Finding 1215566 (2025-003)

Material Weakness 2025

Change Happens!

TX

Allowable Costs / Cost Principles Period of Performance HUD Housing Programs

Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-0...

Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost and other non-compliance: AL #93.092 Affordable Care Act (ACA) Personal Responsibility Education Program. In a sample of 40 non-payroll transactions tested for internal controls and compliance for allowable cost we found one instance of an annual subscription for the term ending May 2026 charged to a grant which ended September 29, 2025 resulting in eight months, or approximately $1,200, charged outside the period of performance. Partial repeat of finding #2024-004. Controls over period of performance and other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges. In a period-of-performance sample of 18 vendor transactions with grant charges close to grant beginning or ending dates during the audit period, we found 3 instances or $1,003 of vendor costs charged outside the grant period of performance. Additionally, testing of payroll charged at the end of the grant period revealed that approximately $6,693 was charged outside the period of performance. Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance and review of payroll spreadsheets and general ledger coding for all transactions. Planned corrective action: Management has implemented strengthened procedures related to payroll allocations, grant coding, allowable costs review, and monitoring of grant periods of performance. Corrective actions include: 1) Enhanced review procedures to ensure expenditures are charged to the appropriate funding source and grant period. 2) Review of payroll allocations against approved grant budgets and supporting time and effort certifications where applicable. 3) Monthly review meetings between finance personnel and program leadership to review coding accuracy, budget status, payroll allocations, and grant compliance requirements. 4) Additional staff training related to Uniform Guidance cost principles, allowable costs, grant periods of performance, and GAAP financial reporting requirements. 5) Improved grant expenditure tracking and monitoring procedures to identify coding errors or compliance concerns timely. 6) Strengthened documentation retention procedures to ensure expenditures are properly supported and audit ready. Responsible officer: Anita Bates, Chief Executive Officer. Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.

View Audit 402238

Finding 1215565 (2025-002)

Material Weakness 2025

Change Happens!

TX

Allowable Costs / Cost Principles Cash Management Reporting

Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/2...

Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: Civic Heart’s internal controls over grant billing requests were not sufficient to ensure that grant billing requests were consistently independently reviewed and approved. Transaction testing for details and internal controls revealed the following: 1) 3 out of 12 grant billing requests did not have evidence of independent review and approval. 2) 3 of 3 pay period journal entries used to allocate payroll expense between departments and funding sources did not have evidence of independent review and approval. Recommendation: Same as finding reported as #2025-001. Planned corrective action: Management has implemented enhanced grant reimbursement and compliance procedures designed to strengthen oversight, documentation standards, and review procedures. Corrective actions include: 1) Implementation of a formal grant reimbursement and drawdown review process requiring complete supporting documentation prior to submission. 2) Required supporting documentation now includes invoices, proof of payment, payroll documentation, time and effort certifications where applicable, budget verification, and grant period review. 3) All federal reimbursement requests require independent review and approval by the Chief Executive Officer prior to submission to ensure compliance with grant terms and conditions, Uniform Guidance requirements, federal regulations, and GAAP reporting standards. 4) Monthly grant compliance meetings are conducted to review reimbursement activity, grant expenditures, reporting deadlines, allowable costs, and budget variances. 5) Program and finance staff are participating in ongoing grant compliance training related to federal regulations, grant-specific requirements, documentation standards, allowable costs, and financial management procedures. Training efforts include periodic reviews and testing where applicable to reinforce compliance expectations. 6) Implementation of standardized grant tracking and reimbursement monitoring procedures to improve accountability and strengthen oversight. 7) Periodic internal compliance reviews of grant files, reimbursement requests, and supporting documentation to identify and address deficiencies proactively. Responsible officer: Anita Bates, Chief Executive Officer Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.

View Audit 402238

Finding 1215561 (2025-004)

Material Weakness 2025

General John J Pershing Memorial Hospital Association

MO

Cash Management Procurement, Suspension & Debarment Subrecipient Monitoring § 200.305

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. The Hospital will strengthen it...

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. The Hospital will strengthen its federal grant cash management procedures and will perform and document cost verification prior to all federal grant drawdowns beginning in fiscal year 2026.

View Audit 402223

Finding 1215560 (2025-003)

Material Weakness 2025

General John J Pershing Memorial Hospital Association

MO

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.303

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will implement a review and ...

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will implement a review and reconciliation process of the required reports to the underlying grant and accounting records.

View Audit 402223

Finding 1215559 (2025-002)

Material Weakness 2025

General John J Pershing Memorial Hospital Association

MO

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.320

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will modify and strengthen o...

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will modify and strengthen our policy and procedure regarding the procurement process to reflect the alignment with federal regulations. The Hospital will begin performing and documenting suspension and debarment checks on all vendors/contracts funded with grants in fiscal year 2026.

View Audit 402223

Finding 1215558 (2025-005)

Material Weakness 2025

General John J Pershing Memorial Hospital Association

MO

Matching / Level of Effort / Earmarking § 200.303

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: Completed. Views of Responsible Officials and Planned Corrective Action: The Hospital now has an automatic monthly transfer set to move $4,400 fro...

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: Completed. Views of Responsible Officials and Planned Corrective Action: The Hospital now has an automatic monthly transfer set to move $4,400 from the operating account to the debt service account. Additionally, the fiscal year 2026 budget includes an expense assumption to set aside $4,400 per month into the debt service account.

View Audit 402223

Finding 1215557 (2025-002)

Material Weakness 2025

Nexus Recovery Center Inc.

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2025-002: Reporting – Significant Deficiency in Internal Controls Over Compliance Programs: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) and SMART Innovation Program Management Response: Management concurs with the finding. Although grant reporting submissions we...

Finding 2025-002: Reporting – Significant Deficiency in Internal Controls Over Compliance Programs: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) and SMART Innovation Program Management Response: Management concurs with the finding. Although grant reporting submissions were not subject to a formal documented secondary review and approval process prior to submission, compensating controls existed. The Chief Executive Officer and Controller were copied on submissions and reviewed amounts charged to grants as part of monthly financial reporting and close procedures. No instances of noncompliance or questioned costs were identified. To strengthen controls over compliance reporting, management has implemented a formal review and approval process requiring the Chief Executive Officer to review all grant invoices and reporting submissions prior to submission to the grantor. Documentation of review and approval will be maintained to evidence compliance with established procedures. Corrective Action Planned/Implemented: • Formalized secondary review and approval procedures for all grant reporting submissions prior to submission. • Chief Executive Officer review and approval now required before grant invoices and reports are submitted. • Documentation of review and approval retained to support compliance with internal control procedures. Responsible Party: Chief Executive Officer / Controller / Accounting Department Implementation Date: Implemented as of April 2026

View Audit 402221

Corrective Action Plans

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