Corrective Action Plans

Finding Reference: 2025-002 - Special Tests and Provisions — Accountability for USDA Foods— Questioned Costs: None Responsible Person: Todd Frease, CFO Actions & Timelines: 1. Valuation Policy (within 30 days from report issuance): Adopt an approved USDA valuation method (WBSCM price or rolling aver...

Finding Reference: 2025-002 - Special Tests and Provisions — Accountability for USDA Foods— Questioned Costs: None Responsible Person: Todd Frease, CFO Actions & Timelines: 1. Valuation Policy (within 30 days from report issuance): Adopt an approved USDA valuation method (WBSCM price or rolling average) and document the policy. 2. Formal Inventory SOPs (within 60 days of report issuance): Issue written SOPs covering count preparation, reconciliation, and documentation retention per 7 CFR §250.19. 3. Training (within 60 days): Train finance and inventory staff on valuation requirements and new SOPs. 4. Annual Monitoring (ongoing): Review valuation application and inventory reconciliations annually and report results to leadership. Anticipated Completion Date: Initial policy and SOPs within 60 days of report issuance; ongoing monitoring thereafter.

View Audit 384843

Finding 1171871 (2025-001)

Material Weakness 2025

Central Texas Food Bank

TX

Allowable Costs / Cost Principles § 200.403 § 200.405

Finding Reference: 2025-001 – Activities Allowed or Unallowed Costs/Cost Principles — Food Distribution Cluster (TEFAP/CCC/CSFP) — Questioned Costs: 188,459 Responsible Person: Todd Frease, CFO Planned Actions & Timelines: 1. Allocation Methodology Correction (by 30 days from report issuance): We wi...

Finding Reference: 2025-001 – Activities Allowed or Unallowed Costs/Cost Principles — Food Distribution Cluster (TEFAP/CCC/CSFP) — Questioned Costs: 188,459 Responsible Person: Todd Frease, CFO Planned Actions & Timelines: 1. Allocation Methodology Correction (by 30 days from report issuance): We will redesign our administrative cost allocation model to remove the CCC double-counting and ensure each program’s share is based on documented, reasonable measures of benefit, consistent with 2 CFR §200.405. The revised workbook will include locked formulas and version control. 2. Secondary Review Control (effective next monthly close): We will implement a two-step review: preparer signs off on the allocation workbook, and an independent reviewer validates sources, bases, and formula ranges before posting entries or submitting claims. Evidence of review will be retained in monthly share drive by indicating approval through email. Anticipated Completion Date: Within 60 days of report issuance

View Audit 384843

Finding 1171866 (2025-001)

Material Weakness 2025

Cleveland State University

OH

Student Financial Aid Subrecipient Monitoring Significant Deficiency § 200.303

Name of the contact person responsible for corrective action planned: Brenda Wendt Controller Cleveland State University 2121 Euclid Avenue Cleveland, OH 44115 Phone: 216.687.3676 Email: b.wendt@csuohio.edu Corrective actions planned: Finding Number: 2025-001 The University did not have adequate con...

Name of the contact person responsible for corrective action planned: Brenda Wendt Controller Cleveland State University 2121 Euclid Avenue Cleveland, OH 44115 Phone: 216.687.3676 Email: b.wendt@csuohio.edu Corrective actions planned: Finding Number: 2025-001 The University did not have adequate controls in place to ensure that credit balances were refunded in a timely manner within the 14-calendar-day requirement. Management has implemented a process to ensure that credit balances are processed within the 14-calendar-day requirement. A workflow hierarchy is in place to ensure adequate staffing and training, preventing processing delays. Any deviations from the normal processing of credit balances will be sent to the relevant department immediately for further action. Anticipated completion date: December 2025

View Audit 384835

Finding 1171861 (2025-002)

Material Weakness 2025

The Russell Child Development Center, Inc.

KS

Subrecipient Monitoring

2025-002 - Child and Adult Care Food Program - Subrecipient Monitoring Condition Five providers were found not to have met the review frequency and type requirements. Recommendation We recommend that new staff members undergo both internal and external training relevant to their position, wherever p...

2025-002 - Child and Adult Care Food Program - Subrecipient Monitoring Condition Five providers were found not to have met the review frequency and type requirements. Recommendation We recommend that new staff members undergo both internal and external training relevant to their position, wherever possible. Additionally, we recommend that the Center review its policies and procedures to ensure that compliance requirements are clearly documented and communicated to all relevant staff. Comments on the Finding Recommendation The CACFP at The Russell Child Development Center, acknowledges its recommendation and agrees with the importance of ensuring that staff receive adequate training and that policies and procedures clearly outline compliance requirements. RCDC recognizes that thorough training and clear documentation are essential to maintaining program integrity and supporting staff in carrying out their responsibilities effectively. Action Taken: As of October 31 , 2025, The Russell Child Development Center, has ceased participation in the Child and Adult Care Food Program. During the final grant award year, CACFP staff participated in available internal and external training courses relevant to their roles, including state-provided guidance and technical assistance when available. Program policies and procedures were reviewed to ensure compliance requirements were documented and communicated to staff to the extent applicable during program close-out. All CACFP-related training documentation, policies, and records from the final grant award year will be retained for the required record-keeping timeframe in accordance with federal and state regulations.

View Audit 384834

Finding 1171860 (2025-001)

Material Weakness 2025

The Russell Child Development Center, Inc.

KS

Cash Management Eligibility Internal Control / Segregation of Duties

2025-001 - Child and Adult Care Food Program - Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. A seventh provider did not have the proper documentation on file to support their Tier determination. Recommendation Controls should be re...

2025-001 - Child and Adult Care Food Program - Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. A seventh provider did not have the proper documentation on file to support their Tier determination. Recommendation Controls should be reviewed and updated to ensure that reimbursements are only requested for complete and accurate meals counts at the correct rate of reimbursement, and that only eligible participants are submitted to the State for reimbursement. Comments on the Finding Recommendation The CACFP at The Russell Child Development Center acknowledges the findings and understands the importance of ensuring that all meal reimbursements are based on complete, accurate meal counts and correct reimbursement rates, and that Tier determinations are fully supported by proper documentation. Action Taken: As of October 31 , 2025, Russell Child Development Center, has ceased participation in the Child and Adult Care Food Program. During the final grant award year, CACFP staff reviewed and updated Tier Determination forms and supporting documentation when it was identified that documentation was missing or incomplete. In addition, staff corrected provider license types within the CACFP files when discrepancies were identified to ensure accurate reimbursement rates. No further claims have been submitted since the program's closure. All CACFP-related records, including Tier documentation, meal count records, and reimbursement data, will be retained for the required record-keeping timeframe in accordance with federal and state regulations.

View Audit 384834

Finding 1171859 (2025-001)

Material Weakness 2025

Local Area of Labor Development Southwest

PR

Matching / Level of Effort / Earmarking

Reportable Condition: See Condition 2025-001 Recommendation We recommend the Local Area monitoring the earmarking procedures for the Youth Program on a quarterly basis to ensure that at the end of the to two years meet the requirement establish. If deviations or failure to meet the earmark are noted...

Reportable Condition: See Condition 2025-001 Recommendation We recommend the Local Area monitoring the earmarking procedures for the Youth Program on a quarterly basis to ensure that at the end of the to two years meet the requirement establish. If deviations or failure to meet the earmark are noted, communications must be generated to youth program staff to take corrective actions before the elapse of the funding period. Action Taken The Executive Director has begun meetings with staff to establish a short-term plan to discuss strategies to increase the number of youth participants in the Program. In addition, at these meetings, the Executive Director has instructed the Program Executive and Program Manager to maintain control over the budget allocated and the activities to be carried out and to coordinate the planning of future activities. With regard to the Finance Area, the Financial Director is instructed that at least every two months or at the request of the Assistance Manager submit the “Encumbrance Budget Report” to see the changes in budget and be able to make decisions related to changes in the approved budget by the Labor Department Program. In the meetings to be held, the results obtained and the status of the activities carried out in order to be accountable for the actions carried out must be reported. This to maintain continuous monitoring of the program, before the end of the validity of the funds. We expect to comply with the requirements this next year.

View Audit 384821

Finding 1171858 (2025-003)

Material Weakness 2025

Children's Learning Centers of Fairfield County, Inc.

CT

Subrecipient Monitoring § 200.332

Finding 2025.003 - Subrecipient Monitoring - Material Weakness Recommendation We recommend that management review the Uniform Guidance requirements for subrecipient monitoring and update its policies and procedures as appropriate. We recommend that CLC develop and implement a standardized checklist ...

Finding 2025.003 - Subrecipient Monitoring - Material Weakness Recommendation We recommend that management review the Uniform Guidance requirements for subrecipient monitoring and update its policies and procedures as appropriate. We recommend that CLC develop and implement a standardized checklist outlining all required subrecipient monitoring compliance requirements. The checklist should clearly identify the individual responsible for monitoring and the individual responsible for review, and supporting documentation should be retained to evidence that monitoring requirements have been performed. Planned Corrective Action: Management concurs with the finding and will enhance its subrecipient monitoring process. Corrective actions include: • Update the Financial Policies and Procedures Manual and subaward agreement templates to conform to current Uniform Guidance requirements, including all required subaward data elements (such as Assistance Listing Number, UEI, award identification, and applicable compliance requirements). • Develop and implement a standardized subrecipient monitoring checklist that includes (a) pre-award risk assessment, (b) ongoing monitoring of invoices and programmatic reports, (c) verification of allowable costs, (d) confirmation and review of subrecipient audit requirements and Uniform Guidance reports, as applicable, and (e) documented management review. • Ensure required FFATA subaward reporting is completed timely when applicable, and maintain documentation supporting all monitoring activities. Name of Contact Person: Neil Shah, Interim CFO, neilshah@clcstamford.org Anticipated Completion Date: May 31, 2026 If there are any questions regarding this plan, please contact Neil Shah at neilshah@clcstamford.org.

View Audit 384819

Finding 1171855 (2025-002)

Material Weakness 2025

Children's Learning Centers of Fairfield County, Inc.

CT

Subrecipient Monitoring Reporting § 200.328 § 200.329

Finding 2025.002 - Reporting - Material Weakness Recommendation We recommend that management establish and formally document comprehensive policies and procedures for the reporting process. These policies and procedures should clearly outline all required reports, filing timelines, and the method fo...

Finding 2025.002 - Reporting - Material Weakness Recommendation We recommend that management establish and formally document comprehensive policies and procedures for the reporting process. These policies and procedures should clearly outline all required reports, filing timelines, and the method for maintaining supporting documentation. We recommend that CLC develop and implement a standardized checklist outlining all required grant compliance requirements. The checklist should clearly identify the individual responsible for preparation and the individual responsible for review. Additionally, both the preparer and reviewer should document their completion of the review to provide evidence that compliance requirements have been appropriately verified. Planned Corrective Action: Management concurs with the finding and will strengthen controls over federal reporting for the Head Start Cluster. Corrective actions include: • Establish and document a grant reporting calendar and compliance checklist covering all required submissions (including SF-425 and FFATA subaward reporting, as applicable), due dates, and responsible parties. • Require all reports to be supported by underlying accounting records and retained with supporting schedules in a centralized repository. • Implement documented preparer and independent reviewer sign-off prior to submission; the reviewer will verify tie-outs to the general ledger and supporting documentation. • Provide training and cross-training to ensure continuity of compliance responsibilities during personnel changes. Name of Contact Person: Neil Shah, Interim CFO, neilshah@clcstamford.org Anticipated Completion Date: March 31, 2026

View Audit 384819

Finding 1171852 (2025-001)

Material Weakness 2025

Pine Bush Central School District

NY

Allowable Costs / Cost Principles

Corrective Action Plan: While progress has been made in this area, the District agrees that the process still requires enhancements. The District will ensure that all applicable employees complete required certifications in accordance with federal guidelines. The personal activity reports will be co...

Corrective Action Plan: While progress has been made in this area, the District agrees that the process still requires enhancements. The District will ensure that all applicable employees complete required certifications in accordance with federal guidelines. The personal activity reports will be collected and reviewed on a monthly basis, and this practice will be the responsibility of Executive Director of Human Resources, Angela Wise-Landman. This practice was implemented as of 8/1/2025. Responsible Official: Angela Wise-Landman, Executive Director of Human Resources Anticipated Completion Date: 8/1/2025

View Audit 384814

Finding 1171849 (2025-002)

Material Weakness 2025

Legacy Community Health Services, Inc.

TX

Eligibility Internal Control / Segregation of Duties

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to a lack of verification of whether the patient had active eligibility or not. Steps have been implemented to remedy the issue in FY 2026. The Director of Financial Services-IAT reporting team is e...

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to a lack of verification of whether the patient had active eligibility or not. Steps have been implemented to remedy the issue in FY 2026. The Director of Financial Services-IAT reporting team is enhancing training and communication to improve understanding of eligibility and documentation requirements. Furthermore, procedures will be implemented to systematically monitor all medications billed to Ryan White and State HIV Services Programs, as well as verify participants' current eligibility status on a biweekly basis. The organization expects these processes to run efficiently by April 30th, 2026.

View Audit 384790

Finding 1171846 (2025-001)

Material Weakness 2025

Legacy Community Health Services, Inc.

TX

Allowable Costs / Cost Principles

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to personnel costs for certain employees being allocated based on a budgeted full-time equivalent basis without subsequent reconciliation to time and effort records. Legacy did not have a time and e...

The Organization acknowledges the identified gap and concurs with the finding. The issue occurred due to personnel costs for certain employees being allocated based on a budgeted full-time equivalent basis without subsequent reconciliation to time and effort records. Legacy did not have a time and effort certification process established until recently. All costs have been determined as allowable costs, and the finding is a result of administrative challenges. Steps have already been taken to remedy the issue. In July 2025, the Organization implemented a risk-based attestation process to capture time allocation across grant programs. Following this, The Director of Grant Accounting and Director of Payroll have established a time and effort certification process within the company's time-keeping software. This process, effective from Nov 14th, 2025, requires the certification to be signed by the employee and approved by their supervisor at the end of each pay period.

View Audit 384790

Finding 1171825 (2025-001)

Material Weakness 2025

Family Health Center of Clark County, Inc.

IN

Special Tests & Provisions Eligibility

The Family Health Centers of Clark County, Inc. dba The Family Health Centers of Southern Indiana will institute a further refined 2nd review of all newly assigned or changed sliding fee assignments. This review will be completed by individuals who are briefed on all related sliding fee policies and...

The Family Health Centers of Clark County, Inc. dba The Family Health Centers of Southern Indiana will institute a further refined 2nd review of all newly assigned or changed sliding fee assignments. This review will be completed by individuals who are briefed on all related sliding fee policies and procedures. Any discrepancies will be sent to the billing manager for updates and aggregation of discrepancy type for further personnel training. The Accounting department will also institute a monthly internal audit process and review a random sample of patients with claims in each particular month that has a sliding fee profile and forwarding to billing manager for correction and aggregation of discrepancy type for further personnel education and possible process changes to ease issues. The Family Health Centers of Clark County, Inc., doing business as The Family Health Centers of Southern Indiana, will adjust secondary review of all newly assigned or modified sliding fee scale determinations, assigning this review to designated staff members who are trained and knowledgeable in all applicable sliding fee scale policies and procedures. Any discrepancies found during the secondary review will be sent to the Billing Manager for timely correction. The Billing Manager will document, categorize, and aggregate discrepancies by type to identify trends and support targeted staff education and retraining efforts. This corrective action will be maintained on an ongoing basis to ensure continued compliance with sliding fee scale requirements and to strengthen internal controls.

View Audit 384777

Finding 1171822 (2025-001)

Material Weakness 2025

The Catholic University of America

DC

Equipment & Real Property Management

Views of Responsible Officials and Corrective Action Plan: Responsible Officials: ● Michael Zeleny, Senior Vice President and Chief Financial Officer Corrective Action: Laptop Receipt and Custody Controls - As of the date of this letter, the University has already discontinued the exemption for rece...

Views of Responsible Officials and Corrective Action Plan: Responsible Officials: ● Michael Zeleny, Senior Vice President and Chief Financial Officer Corrective Action: Laptop Receipt and Custody Controls - As of the date of this letter, the University has already discontinued the exemption for receipt of laptops at the off-campus sponsor location and implemented immediate routing of all laptops through on‑campus Technology Services for standardized asset tagging and custody assignment. All laptops will be shipped to the University’s on‑campus Technology Services department, where they will be asset‑tagged upon receipt, assigned to a responsible custodian, and entered into the asset management system before distribution. Upon employee separation or reassignment, assets must be returned to the home department, which will notify Asset Management of all returns and transfers to maintain accurate records. Inventory and Monitoring - All laptops will continue to be included in the University’s bi‑annual inventory process in accordance with University policy. Training and Communication - Departments and employees will receive updated guidance on equipment distribution and return requirements by the Research Administration and Asset Management by March 31, 2026. Training will reinforce responsibilities related to safeguarding and managing federally funded equipment. Individual(s) Responsible for Corrective Action: ● Matthew McNally, Senior Associate Vice President and Chief Information Officer mcnally@cua.edu 202-319-4374 Anticipated Completion Date for Corrective Action: March 31, 2026

View Audit 384772

Finding 1171719 (2025-001)

Material Weakness 2025

Blue Mountain Community College District

OR

Student Financial Aid Special Tests & Provisions

Condition and Criteria: Institutions are required to timely report enrollment information under the Pell Grant and Direct Loan programs via the NSLDS. Institutions must review, update, and certify student enrollment statuses, program information, and effective dates. During our testing of the inform...

Condition and Criteria: Institutions are required to timely report enrollment information under the Pell Grant and Direct Loan programs via the NSLDS. Institutions must review, update, and certify student enrollment statuses, program information, and effective dates. During our testing of the information submitted to NSLDS, we noted 2 students out of the 40 tested that had errors of status reporting for summer term. Effect: The College is not in compliance with the federal NSLDS reporting requirements described in the OMB Compliance Supplement and required by the Department of Education. Cause: In the College’s software transition to PowerFaids, the system automatically coded all students to full-time status and students that are less than full time had to be adjusted manually. Some students were missed in this manual process. Questioned Costs: None reported Context/Sampling: The College disbursed Federal financial aid to approximately 736 students in the 2024-2025 school year. A non-statistical sample of 40 students was selected for testing. Repeat Finding: No Auditor’s recommendation: The College should implement additional processes to review, update, and verify that student enrollment statuses are reported to NSLDS accurately and timely. Corrective Action to be Taken: Once the issue was identified, students’ statuses were adjusted manually. An automated process has been created to compare student status with the Student Information System (SIS) before the file is sent to NSLDS. Anticipated Completion Date: The status corrections and the new review process was implemented in Fall of 2024. Name and Title of Responsible Person: Angela Rios, Director of Student Financial Aid

View Audit 384765

Finding 1171715 (2025-003)

Material Weakness 2025

Simpson University

CO

Student Financial Aid Cash Management

Cash Management Planned Corrective Action: The University agrees with the finding. The University determined that certain federal drawdowns during the audit period were initiated based on authorized amounts rather than confirmed student disbursements, resulting in excess cash on hand beyond allowabl...

Cash Management Planned Corrective Action: The University agrees with the finding. The University determined that certain federal drawdowns during the audit period were initiated based on authorized amounts rather than confirmed student disbursements, resulting in excess cash on hand beyond allowable timeframes. To address this, the University has reviewed its cash management procedures and strengthened processes to ensure that federal funds are drawn only after student disbursements have been posted to student accounts. The University has reviewed the identified transactions, confirmed that excess funds were fully disbursed or returned as required, and will calculate and remit any applicable interest in accordance with federal regulations. Ongoing monitoring has been implemented to ensure drawdowns are consistently aligned with actual disbursement activity and compliance with cash management requirements is maintained. Person Responsible for Corrective Action Plan: Ken Macur, Interim Chief Financial Officer Anticipated Date of Completion: September 1, 2026

View Audit 384755

Finding 1171713 (2025-002)

Material Weakness 2025

Simpson University

CO

Student Financial Aid

2025-002 Incorrect and Untimely Return of Title IV Funds (R2T4) Calculations Planned Corrective Action: The University agrees mostly with these findings. The University determined that delays in certain Return of Title IV (R2T4) calculations were primarily the result of gaps in the timing and consis...

2025-002 Incorrect and Untimely Return of Title IV Funds (R2T4) Calculations Planned Corrective Action: The University agrees mostly with these findings. The University determined that delays in certain Return of Title IV (R2T4) calculations were primarily the result of gaps in the timing and consistency of withdrawal information communicated between offices during the audit period. To address this, the University has strengthened procedures between the Registrar’s Office and the Financial Aid Office to ensure timely identification of official and unofficial withdrawals and prompt initiation of R2T4 calculations. The University has reviewed the affected student accounts and confirmed that Title IV funds were returned appropriately. With respect to the student in the modular program, the Pell Grant adjustment was required because the student had already received Pell Grant funds at another institution during the same award year and was not eligible for the additional amount; this adjustment was not the result of an R2T4 calculation. The University will continue to monitor withdrawal reporting and R2T4 processing to ensure ongoing compliance with federal requirements. Person Responsible for Corrective Action Plan: Adrienne Currington, University Registrar and Shondra Dickson, Director of Financial Aid Anticipated Date of Completion: September 1, 2026

View Audit 384755

Finding 1171711 (2025-001)

Material Weakness 2025

Northwest Compass

IL

Subrecipient Monitoring Reporting Significant Deficiency

SECTION 5 – CORRECTIVE ACTION PLAN Finding 2025 – 001: Grant Administration Condition: During our current audit fieldwork, we noted that the Organization does not have adequate procedures in place for tracking and monitoring grant activities. Each grant has unique reporting and compliance requiremen...

SECTION 5 – CORRECTIVE ACTION PLAN Finding 2025 – 001: Grant Administration Condition: During our current audit fieldwork, we noted that the Organization does not have adequate procedures in place for tracking and monitoring grant activities. Each grant has unique reporting and compliance requirements, which is handled inconsistently among the Organization’s departments. Plan: The Executive Director, along with staff, will create better policies and procedures around the tracking and monitoring of grant funding throughout the year. Anticipated Date of Completion: Fiscal Year 2026 Name of Contact Person: Sonia Ivanov, Executive Director Management Response: Northwest Compass Inc is currently in the process of formally putting inn writing the policies and procedures we are currently following in this regard. We anticipate having this completed in the current fiscal year.

View Audit 384740

Corrective Action Plans

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