Corrective Action Plans

Finding 1158250 (2024-003)

Material Weakness 2024

WA

Subrecipient Monitoring

Management acknowledges the findings related to compliance with GLBA requirements. The missing elements were primarily due to existing policies and procedures not specifically covering the information technology system utilized by the School of Nursing. Management will update their information techn...

Management acknowledges the findings related to compliance with GLBA requirements. The missing elements were primarily due to existing policies and procedures not specifically covering the information technology system utilized by the School of Nursing. Management will update their information technology policies and procedures to ensure full compliance with the 7 required elements outlined by the GLBA. This will include updating risk assessment procedures, designing safeguards based on risk assessments procedures, monitoring these safeguards, and documenting the results. These policy and procedure updates will be implemented by December 31, 2025.

View Audit 370126

Finding 1158248 (2024-002)

Material Weakness 2024

Providence St. Joseph Health

WA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying an...

Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying and documenting disbursement and enrollment dates, academic year parameters, and cost of attendance calculations prior to COD submission. This will include additional layers of review to ensure timely and accurate reporting. These policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158246 (2024-001)

Material Weakness 2024

Providence St. Joseph Health

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158233 (2024-001)

Material Weakness 2024

Hawaii Public Health Institute

HI

Subrecipient Monitoring Reporting

Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the sub...

Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the subrecipient's name, subaward date, and subaward amount on SAM.gov website prior to the completion of this federal grant, which ended on June 30, 2025. The funder confirmed receipt of our reporting and did not specify any implications for late submission. As recommended by the auditors, HIPHI has developed a process to help identify the subawards subject to the FFATA reporting requirements prior to the start of the grant, and to ensure that reporting is reviewed, approved for completeness and accuracy, and filed in a timely manner. The Director of Finance, Finance and Accounting Manager, Program Managers and contract signers will be responsible for implementing these corrective actions by the end of 2025.

View Audit 370124

Finding 1158232 (2024-003)

Material Weakness 2024

New York College of Traditional Chinese Medicine

NY

Special Tests & Provisions Student Financial Aid Significant Deficiency

Finding 2025-003: Campus Crime Awareness Requirements Not Met Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of 1. a burglary crime was reported in the Annual Security Report when it should have been reported as a motor vehicle theft. The issue was du...

Finding 2025-003: Campus Crime Awareness Requirements Not Met Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of 1. a burglary crime was reported in the Annual Security Report when it should have been reported as a motor vehicle theft. The issue was due to error entry, neighboring lines. 2. motor vehicle theft and a weapons violation was not reported to the Department of Education. The issue was due to carelessness. These were correctly reported in the Annual Security Report. Usually, the Annual Security Report and report to the Department of Education is prepared and completed by the Student Services Coordinator and the Administrative Dean based on the statistic report from the school and the Police Department in August/September. Because the college was engaged in the self-study for accreditation, everyone was extremely busy at that time. Errors might occur when doing things in a hassle way. Actions Taken or Planned: 1. Corrections were made in the Annual Security Report and in the report to the Department of Education. Two corrections were made in the DOE website: Criminal Offenses - Public Property: For 2023, line J (motor vehicle theft) was changed from 0 to 1. Arrests - Public Property: For 2023, line a (weapon) was changed from 0 to 2 2. New Hire: The college is in the process of hiring a new Student Services Coordinator. This individual will work with the Administrative Dean for ensuring the accuracy and timelines of reporting moving forward. 3. A strengthen double-check system will be established to ensure the accuracy of all reporting. Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu

View Audit 370123

Finding 1158231 (2024-002)

Material Weakness 2024

New York College of Traditional Chinese Medicine

NY

Questioned Costs Student Financial Aid Special Tests & Provisions

Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balan...

Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balance Authorization Form was on file, the refund was processed after the award year had ended, rather than within the required timeframe. In the past, students were always allowed to keep funds in their Populi accounts for future use regardless of the loan award year, and it had not previously been indicated that this practice was not allowed. Actions Taken or Planned: We have reviewed our internal procedures and will strengthen oversight of award year deadlines to ensure that all credit balances are refunded within the required timeframe. Moving forward, the financial aid and accounting teams will implement a compliance checklist and establish calendar reminders to prevent similar delays. Additionally, we will revise the wording on our Credit Balance Authorization Form to read: “Leave the funds in my account and any remaining funds from the current award year in my account up to the end of the loan period.” Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu

View Audit 370123 Questioned Costs: $1

Finding 1158230 (2024-001)

Material Weakness 2024

New York College of Traditional Chinese Medicine

NY

Student Financial Aid Reporting Special Tests & Provisions

Finding 2025-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendations: Statement of Concurrence: We concur with the finding of Inaccurate and Untimely Enrollment Status Reporting The inaccuracies and delays were mainly the result of our scheduling process. Cur...

Finding 2025-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendations: Statement of Concurrence: We concur with the finding of Inaccurate and Untimely Enrollment Status Reporting The inaccuracies and delays were mainly the result of our scheduling process. Currently, we update enrollment maintenance every two months, typically on the day prior to the scheduled dates. We now understand that enrollment status updates must be completed within 15 days after the scheduled date. Actions Taken or Planned: We have reviewed the enrollment maintenance schedule and adjusted our process to ensure compliance with the requirement. Moving forward, enrollment status will be updated within 15 days after the scheduled date. This adjustment will be fully implemented starting from the next scheduled update on 09/30/2025. 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu

View Audit 370123

Finding 1158229 (2024-004)

Material Weakness 2024

Native Sun Community Power Development

MN

Equipment & Real Property Management § 200.313

Planned Corrective Action: We will maintain a detailed listing of all real property and equipment purchased with federal funding. We will also continue to have executed agreements dictating the treatment of real property and equipment with beneficiaries of all items that ownership is transferred fro...

Planned Corrective Action: We will maintain a detailed listing of all real property and equipment purchased with federal funding. We will also continue to have executed agreements dictating the treatment of real property and equipment with beneficiaries of all items that ownership is transferred from the Organization to ensure compliance. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: October 1, 2025

View Audit 370119

Finding 1158228 (2024-003)

Material Weakness 2024

Native Sun Community Power Development

MN

Procurement, Suspension & Debarment

Planned Corrective Action: The Organization will document and retain records of all bids and quotes solicited in keeping with their procurement policy to ensure compliance. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: October 1, 2025

View Audit 370119

Finding 1158227 (2024-002)

Material Weakness 2024

Native Sun Community Power Development

MN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to b...

Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to be Completed by October 1, 2025

View Audit 370119

Finding 1158226 (2024-001)

Material Weakness 2024

Native Sun Community Power Development

MN

Allowable Costs / Cost Principles § 200.303

Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of nonc...

Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of noncompliance since using this platform. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: Done ‐ July 31, 2024

View Audit 370119

Finding 1158225 (2024-004)

Material Weakness 2024

St Bernard Parish Government

LA

Questioned Costs Procurement, Suspension & Debarment

Name of contact person responsible for corrective action plan: Justin Frank Corrective action planned: The Parish will review all policies and procedures to ensure that proper internal controls are in place, with an emphasis on Federal procurement guidelines. Anticipated Completion Date: December 31...

Name of contact person responsible for corrective action plan: Justin Frank Corrective action planned: The Parish will review all policies and procedures to ensure that proper internal controls are in place, with an emphasis on Federal procurement guidelines. Anticipated Completion Date: December 31, 2025

View Audit 370116 Questioned Costs: $1

Finding 1158224 (2024-001)

Material Weakness 2024

Housing Authority of the City of Yakima

WA

HUD Housing Programs Reporting Internal Control / Segregation of Duties § 200.512

Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Authority has reviewed and updated its financial reporting and closing processes and controls he preparation of the final trial balances and related schedules...

Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Authority has reviewed and updated its financial reporting and closing processes and controls he preparation of the final trial balances and related schedules. As part of this process, we will create a year-end checklist with deadlines established and set up status meetings to monitor the progress. Name(s) of the contact person(s) responsible for corrective action: Lowel Kruger, Executive Director. Planned completion date for corrective action plan: December 31, 2024

View Audit 370115

Finding 1158222 (2024-004)

Material Weakness 2024

The Family Place

TX

Reporting Internal Control / Segregation of Duties § 200.320

Auditor’s Recommendation: “We recommend management implement internal controls to ensure ﬁnancial reports are submitted accurately, with supporting documentation retained.” Management response: The Family Place has reviewed its ﬁnancial reporting procedures and concurs with the ﬁnding. During the au...

Auditor’s Recommendation: “We recommend management implement internal controls to ensure ﬁnancial reports are submitted accurately, with supporting documentation retained.” Management response: The Family Place has reviewed its ﬁnancial reporting procedures and concurs with the ﬁnding. During the audit period, staffing deﬁciencies in grants management and compliance oversight contributed to supporting documentation of ﬁnancial reports submitted not having been retained. In 2025, The Family Place created a new internal compliance department and hired a Grants Manager to provide dedicated oversight of grant drawdowns and reporting. These changes, together with updated procedures and training, are designed to ensure all future ﬁnancial reports comply with Uniform Guidance requirements and supporting documentation is retained. Corrective actions: The Executive Leadership Team has prioritized strengthening reporting controls and has already implemented several measures: The newly hired Grants Manager and internal compliance department are responsible for reviewing and approving all ﬁnancial reports to conﬁrm that expenditures have been incurred and liquidated prior to request. Finance sta􀀁 and program managers are being trained on reporting requirements under 2 CFR 200.320. All ﬁnancial reports will be reconciled to the general ledger with supporting documentation and will be reviewed by the Grants Manager and The Chief Financial Officer or Chief Executive Officer before submission. These processes will receive additional oversight by the Chief Financial Officer, the Chief Executive Officer, and the Board of Trustees. Responsible parties for corrective actions: The Grants Manager, working within the internal compliance department, will have direct responsibility for ensuring ﬁnancial reports are accurate and supporting documentation is retained. The Chief Financial Officer will review and approve reconciliations prior to drawdown. The Chief Executive Officer, Tiffany A. Tate, with assistance from the newly established Compliance Department, will conﬁrm timely compliance and will receive regular status updates. Separately, the Chief Financial Officer will report progress to the Audit & Finance Committee of the Board of Trustees. Anticipated completion date: The new internal compliance department and Grants Manager began operating together in September 2025. Full compliance monitoring is currently in place.

View Audit 370113

Finding 1158220 (2024-003)

Material Weakness 2024

The Family Place

TX

Procurement, Suspension & Debarment § 200.214 § 200.320

Auditor’s Recommendation: “We recommend management review all contracts with vendors and review the procurement policy to ensure compliance with the procurement and suspension and debarment standards within their policy and the Uniform Guidance.” Management response: The Family Place has reviewed it...

Auditor’s Recommendation: “We recommend management review all contracts with vendors and review the procurement policy to ensure compliance with the procurement and suspension and debarment standards within their policy and the Uniform Guidance.” Management response: The Family Place has reviewed its procurement and suspension/debarment procedures and concurs with the ﬁnding. During the period covered by the audit, staffing turnover and performance issues within departments responsible for procurement and grant compliance contributed to inconsistent application of policies and incomplete documentation. Since that time, The Family Place has replaced staff where needed due to performance problems and initiated training to ensure compliance and consistency with existing procurement policy for all organizational expenses of $10,000 or more. Corrective actions: The Executive Leadership Team has reviewed procurement responsibilities and clariﬁed the roles of staff who approve or execute purchases and contracts. Hiring, training, and coaching were prioritized in early 2025 to address the identiﬁed deﬁciencies, and staff replacements have already been completed where necessary. Going forward: All staff responsible for procurement or contract approval will complete training on the Uniform Guidance procurement and suspension/debarment standards, including requirements for organizational purchases of $10,000 or more. Finance staff will review procurement documentation, vendor suspension/debarment veriﬁcation, and contract approvals prior to payment to ensure full compliance with policy and federal regulations. These processes will receive additional oversight by the Chief Executive Officer, with assistance from the newly established Compliance Department, and the Board of Trustees. Responsible parties for corrective actions: The Chief Financial Officer will have direct responsibility for ﬁnance review of procurement documentation and vendor status veriﬁcation prior to payment. The Chief Operations Officer will ensure that all required procurement and suspension/debarment checks are performed and documented. The Chief Executive Officer, Tiffany A. Tate, with assistance from the newly established Compliance Department, will conﬁrm that compliance occurs on a timely basis. Separately, the Chief Financial Officer will report on progress to the Audit & Finance Committee of the Board of Trustees. Anticipated completion date: Refresher training of relevant staff and implementation of the strengthened procurement and suspension/debarment procedures has already been completed. Going forward, quarterly training will take place for team members directly involved in the procurement process.

View Audit 370113

Finding 1158217 (2024-002)

Material Weakness 2024

The Family Place

TX

Procurement, Suspension & Debarment Cash Management Reporting § 200.303

Auditor’s Recommendation: “We recommend management ensure sufficient staffing and oversight to abide by internal processes and procedures which require prior approval of expenditures and reports prior to drawdown or submission.” Management response: The Family Place has reviewed its award compliance...

Auditor’s Recommendation: “We recommend management ensure sufficient staffing and oversight to abide by internal processes and procedures which require prior approval of expenditures and reports prior to drawdown or submission.” Management response: The Family Place has reviewed its award compliance procedures and concurs with the ﬁnding. During the period, responsible departments—including the ﬁnance and accounting and human resources teams—experienced unexpected turnover, a signiﬁcant shortage of staffing, and a time reporting system conversion. As a result, certain compliance procedures were not performed consistently and timely, resulting in unintentional noncompliance with respect to allowable costs, cash management, and reporting controls. Corrective actions: The Executive Leadership Team reviewed the staffing needs of the ﬁnance and accounting and human resources teams in 2024. Hiring and training staff to achieve a full team was established as key objectives for the Executive Leadership Team in early 2025. As of September 2025, all vacant positions in both teams have either been ﬁlled or have been posted and are in active hiring process. The Chief Financial Officer and Chief of Human Resources have reviewed all internal procedures related to award compliance and will ensure that compliance is timely and well documented going forward. Speciﬁcally, the Chief Financial Officer will ensure that purchase orders, invoices, ﬁnancial reports, and performance reports are completed, reviewed, and approved prior to submission and funding. These processes will have additional oversight by the Chief Executive Officer, with assistance from the newly established Compliance Department, and the Board of Trustees. Responsible parties for corrective actions: The Chief Financial Officer will have direct responsibility for award compliance and will be supported by Chief of Human Resources. The Chief Executive Officer, Tiffany A. Tate, with assistance from the newly established Compliance Department, will conﬁrm that compliance occurs on a timely basis and prior to submission and funding. Separately, the Chief Financial Officer will report on progress to the Audit & Finance Committee of the Board of Trustees. The Executive Leadership Team will be responsible for ensuring the ﬁnance and accounting and human resources teams achieve and maintain full staffing levels. Anticipated completion date: The organization is actively implementing the corrective actions by ensuring sufficient staffing as mentioned above and training to ensure prior approval of all grant reports and drawdown requests. As of October 1, 2025, all grant reports will be appropriately approved and documented as such.

View Audit 370113

Finding 1158212 (2024-003)

Material Weakness 2024

Jesuit Refugee Service/usa, INC

DC

Reporting

Finding Tax Disclosure Submission. Per the grant agreements to the above awards section 19 Reporting Taxes on Foreign Assistance Funds. The Recipient is required to submit a report detailing foreign taxes assessed under this award during the prior U.S. Government fiscal year (10/01 - 09/30). The rep...

Finding Tax Disclosure Submission. Per the grant agreements to the above awards section 19 Reporting Taxes on Foreign Assistance Funds. The Recipient is required to submit a report detailing foreign taxes assessed under this award during the prior U.S. Government fiscal year (10/01 - 09/30). The report must be submitted to the Grants Officer on an annual basis by February 15. Management had processes in place to submit each tax report on a timely basis; however these processes did not occur. Grant countries impacted: Cameroon, South Sudan, Uganda, Ethiopia, Iraq, and Thailand. Corrective Action Plan Management concurs with the findings. Although internal procedures for timely submission of the foreign tax reports were previously in place, the organization experienced significant turnover in key management positions during the reporting period. This transition disrupted the continuity of compliance processes and led to failure to meet the tax disclosure reporting deadlines. To prevent recurrence of this compliance lapse, JRS/USA is taking the following corrective measures: 1. Formalized Tax Reporting SOP A formal Standard Operating Procedure (SOP) will be developed for the Foreign Tax Disclosure Reporting Process, outlining: a) Roles and responsibilities (JRS/USA and country offices) b) Required data sources c) Timeline for data collection and submission d) Review and approval workflows This SOP will be distributed to all relevant compliance, finance, and grant management staff. 2. Centralized Calendar and Tracker A centralized compliance calendar and submission tracker will be implemented, incorporating the February 15 foreign tax report deadline. Automated reminders will be sent to responsible staff beginning in January each year to initiate the reporting process well in advance. 3. Designated Focal Point A single point of contact at JRS/USA has been assigned as the Tax Disclosure Focal Point, responsible for: a) Coordinating data collection from field offices b) Ensuring timely submission to the Grants Officer c) Maintaining documentation of the submission and confirmation of receipt 4. Training and Onboarding Updates Compliance and finance staff, both at JRS/USA and in the field, will be trained on the tax disclosure requirements and the new SOP. This training will also be integrated into the onboarding process for new hires in relevant roles to reduce the risk of future disruptions due to staff turnover. 5. Quarterly Internal Compliance Check-ins Although the report is submitted annually, quarterly check-ins will be held by the JRS/USA Compliance Team to review upcoming deadlines, including the tax report, to ensure ongoing visibility and proactive planning. Timeline for Implementation All corrective actions have been implemented or will be fully in effect by October 30, 2025. Responsible Party Samira Ahmed, Senior Grants and Compliance Specialist, will be responsible for overseeing the tax disclosure process and ensuring timely and accurate submissions going forward.

View Audit 370111

Finding 1158209 (2024-002)

Material Weakness 2024

Jesuit Refugee Service/usa, INC

DC

Subrecipient Monitoring

Finding: Subrecipient Single Audits. The Organization’s grant and subgrant agreements explicitly require subgrantees to undergo a single audit if they expend $750,000 or more in a fiscal year, as stipulated by the Department of State. However, audits were not performed for subgrantees exceeding this...

Finding: Subrecipient Single Audits. The Organization’s grant and subgrant agreements explicitly require subgrantees to undergo a single audit if they expend $750,000 or more in a fiscal year, as stipulated by the Department of State. However, audits were not performed for subgrantees exceeding this threshold in Cameroon, South Sudan, and Iraq. This non-compliance was caused by failures in the subrecipient control monitoring process. Corrective Action Plan JRS/USA recognizes the risk presented when Country Offices (COs) or Regional Offices (ROs) are unable to meet audit requirements, particularly when receiving U.S. federal funds. While JRS/USA does not have direct authority to mandate CO/RO audits in all regions, we recognize our responsibility to ensure federal compliance across the global network. To address this, JRS/USA will implement a stricter due diligence and pre-award assessment process. Specifically, going forward, COs/ROs must demonstrate the ability to meet audit and financial reporting requirements as a condition for receiving federal funding. If these requirements are not met, JRS USA will take corrective action, which may include suspending their inclusion in federal awards until compliance can be assured. JRS/USA will also revisit the previously proposed “go/no-go” framework and explore its formal adoption as part of a broader compliance risk management strategy. To address this gap and strengthen subrecipient oversight related to audit compliance, JRS/USA is implementing the following measures: 1. Reinforced Audit Clause Communication JRS/USA has reviewed and re-communicated the audit requirements to all subrecipients (country offices), particularly those with high federal expenditures. Subgrantees are being reminded annually in writing of their obligation to procure a Single Audit or Program-Specific Audit if they meet the $750,000 threshold. 2. Enhanced Subrecipient Monitoring Process The subrecipient monitoring framework has been updated to include: a) Annual tracking of total federal expenditures by each subrecipient (country office) b) Flagging of subrecipients approaching the $750,000 threshold c) A review checkpoint at year-end to determine audit applicability d) Clear documentation requirements and timelines for submitting audit report 3. Audit Compliance Checklist and Tracker A standardized checklist has been created to track audit requirements and receipt of audit documentation from all subrecipients (country offices). This checklist is maintained centrally by the JRS/USA compliance or grants team and reviewed quarterly. 4. Technical Support to Subrecipients Subrecipients (country offices) that may lack familiarity with the Single Audit requirement are being offered guidance and support on: a) Identifying qualified auditors b) Understanding scope and timing of required audits c) Budgeting for audit costs appropriately 5. Subaward Risk Assessments Updated The risk assessment conducted during subaward issuance and annual monitoring now includes specific indicators for federal expenditure levels and audit compliance risk. This ensures earlier detection and mitigation for high-risk subrecipients. Timeline for Implementation All corrective actions have been implemented or will be fully in effect by January 30, 2026. Responsible Party Samira Ahmed, Senior Grants and Compliance Specialist, will be responsible for ensuring subrecipient audit compliance and ongoing monitoring.

View Audit 370111

Finding 1158202 (2024-002)

Material Weakness 2024

National Council for Community Development, Inc.

NY

Subrecipient Monitoring Reporting Significant Deficiency

Finding No. 2024-002 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-t...

Finding No. 2024-002 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-through Entity (if applicable): Nassau County Condition: During our testing, we noted that the Organization did not provide the required monthly reports to Nassau County. Recommendation: We recommend that the Organization establish policies, procedures, and controls to ensure that the required information is submitted on a timely basis. Action Taken: Management has incorporated procedures into our grant compliance and administration policies and procedures to ensure that a Project Director reviews, understands and takes the necessary steps to comply with reporting requirements or other, as set forth by the client agreements. This step includes but is not limited to the Project Director completing a Grant Award File Checklist. Anticipated completion date: Immediately.

View Audit 370110

Finding 1158201 (2024-001)

Material Weakness 2024

National Council for Community Development, Inc.

NY

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding No. 2024-001 - Procurement, Suspension and Debarment - Material Weakness Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not a...

Finding No. 2024-001 - Procurement, Suspension and Debarment - Material Weakness Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-through Entity (if applicable): City of Irving Condition: During our testing, we noted that the Organization did not provide adequate supporting documentation for ensuring proper suspension and debarment checks were performed. Recommendation: We recommend that the Organization establish written suspension and debarment policies and procedures to ensure that the Organization is in compliance with the Uniform Guidance and that all staff are trained on this policy to ensure compliance and related internal controls over compliance are operating effectively. Action Taken: Management has clarified the necessary roles and responsibilities for this requirement in our grant compliance and administration policies and procedures that includes appropriate searches for suspension and debarment, amongst others. prior to executing any financial transactions with individuals and/or organizations. Anticipated completion date: Immediately.

View Audit 370110

Finding 1158197 (2024-003)

Material Weakness 2024

Bering Sea Fisheries Research Foundation

WA

Procurement, Suspension & Debarment § 200.317 § 200.327

Management has since developed and formally implemented a written procurement policy that meets the standards of 2 CFR 200 Subpart D, including required controls over procurement and suspension and debarment. The policy is effective as of the date of this corrective action plan. Management will revi...

Management has since developed and formally implemented a written procurement policy that meets the standards of 2 CFR 200 Subpart D, including required controls over procurement and suspension and debarment. The policy is effective as of the date of this corrective action plan. Management will review the policy periodically to ensure ongoing compliance with federal requirements.

View Audit 370102

Finding 1158192 (2024-006)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Cash Management Period of Performance

Corrective Action Plan: Atrium Health CMHA management in the future will ensure that all correspondence, including notes from review meetings and approvals of key decisions, will be documented and retained as part of the support records for FEMA related awards. Proposed Completion Date: No further a...

Corrective Action Plan: Atrium Health CMHA management in the future will ensure that all correspondence, including notes from review meetings and approvals of key decisions, will be documented and retained as part of the support records for FEMA related awards. Proposed Completion Date: No further action is required until future needs arise for Atrium Health CMHA to obtain FEMA funding awards at which time management will ensure all documentation supporting the process and key decisions are retained.

View Audit 370096

Finding 1158191 (2024-005)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that appropriate training and process design for Jenzabar Financial Aid (JFA) system are implemented to accurately capture and retain all data required for FISAP report...

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that appropriate training and process design for Jenzabar Financial Aid (JFA) system are implemented to accurately capture and retain all data required for FISAP reporting. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

View Audit 370096

Finding 1158190 (2024-004)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT sys...

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

View Audit 370096

Finding 1158189 (2024-003)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are ma...

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are maintained. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

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Corrective Action Plans

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