Corrective Action Plans

Finding 1164260 (2025-001)

Material Weakness 2025

Lake Villa Community Consolidated School District No. 41

IL

Finding No.: 2025-001 Condition: It was noted that the District did not complete the documentation of personnel expenses. Plan: Management will implement procedures to ensure that the documentation of personnel expenses is completed. Anticipated Date of Completion: 6/30/2026 Name of Contact Person: ...

Finding No.: 2025-001 Condition: It was noted that the District did not complete the documentation of personnel expenses. Plan: Management will implement procedures to ensure that the documentation of personnel expenses is completed. Anticipated Date of Completion: 6/30/2026 Name of Contact Person: Anna Kasprzyk, Business Manager/CSBO Management Response: N/A

View Audit 373566

Finding 1164225 (2025-002)

Material Weakness 2025

Stillwater Central School District

NY

Procurement, Suspension & Debarment School Nutrition Programs § 200.214 § 200.314 § 200.318

CAP: The District will establish processes and procedures to ensure compliance with executive orders 12549 and 12689, and 2 CFR Part 180 regarding disbarred vendors. Date: June 30, 2025 Who: Michael Cavanaugh, Business Administrator

View Audit 373523

Finding 1164221 (2025-001)

Material Weakness 2025

Appalachian Mountain Community Health Centers

NC

Special Tests & Provisions Internal Control / Segregation of Duties

In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s s...

In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended June 30, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee policy.

View Audit 373521

Finding 1164219 (2025-003)

Material Weakness 2025

Independent School District No. 001

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties School Nutrition Programs

Recommendation: We recommend the District implement additional procedures to ensure suspension and debarment documentation is retained. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will cont...

Recommendation: We recommend the District implement additional procedures to ensure suspension and debarment documentation is retained. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to evaluate their policies and procedures and retain documentation of their review. Official Responsible for Ensuring CAP: Heather Hipp, Business Manager Planned Completion Date for CAP: June 30, 2026

View Audit 373519

Finding 1164211 (2025-001)

Material Weakness 2025

Sherburne and Northern Wright Special Education Cooperative

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency

SUSPENSION AND DEBARMENT Recommendation: We recommend the District implement additional procedures to ensure suspension and debarment documentation is retained. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Findin...

SUSPENSION AND DEBARMENT Recommendation: We recommend the District implement additional procedures to ensure suspension and debarment documentation is retained. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The Cooperative will retain documentation of their review Official Responsible for Ensuring CAP: Amy Stahlback, Controller Planned Completion Date for CAP: June 30, 2026

View Audit 373505

Finding 1164205 (2025-001)

Material Weakness 2025

Muncie Community Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.430

Admin Offices 4301 S Cowan Rd Muncie, IN 47302 765-747-5222 office CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2025 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Progr...

Admin Offices 4301 S Cowan Rd Muncie, IN 47302 765-747-5222 office CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2025 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2025 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Significant Deficiency Context: During testing of allowable activities and costs, it was observed that the School Corporation allocated payroll and benefit expenses to the school lunch fund for the employee overseeing the food service management company. Five payroll transactions totaling $5,476 were selected for testing. For each transaction tested, the School Corporation allocated 18% of the employee’s time to the school lunch fund. Although the employee completed an annual self-certification estimating time spent on food service duties, there was no detailed time and effort log to support actual hours worked. Additionally, no internal control existed to provide a documented secondary review of the self-certification for accuracy and completeness. Contact Person Responsible for Corrective Action: Brad DeRome Contact Phone Number: 765-747-5222 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The School Corporation will no longer charge any payroll and benefit expenses to the school lunch fund. Anticipated Completion Date: July 1, 2025.

View Audit 373490 Questioned Costs: $1

Finding 1163628 (2025-002)

Material Weakness 2025

Housing Authority of the City of Imperial, Nebraska

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2025-002 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and ac...

Finding 2025-002 The Authority agrees with the finding and responds stating that our project is relatively small with only one administrative staff. The Board has reviewed this issue and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies and accepts them.

View Audit 373449

Finding 1163627 (2025-001)

Material Weakness 2025

Kleeman Village Housing Corporation, Nfp

IL

Subrecipient Monitoring Internal Control / Segregation of Duties

Kleeman Village Housing Corporation, NFP respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2025. The findings from the June 30, ...

Kleeman Village Housing Corporation, NFP respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: MCK CPAs & Advisors, Decatur, Illinois. Audit period: Year ended June 30, 2025. The findings from the June 30, 2025 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings - Financial Statement Audit: 2025 - 001 Response: Management agent and sponsor will continue to monitor financial reports and accounting information as correction is not practical.

View Audit 373443

Finding 1163625 (2025-001)

Material Weakness 2025

Unified School District No. 397

KS

Reporting Subrecipient Monitoring § 200.502

Management plans to develop proper written policies and procedures for internal control over compliance to ensure accuracy and completeness in the preparation of the schedule as required by Uniform Guidance.

View Audit 373437

Finding 1163624 (2025-001)

Material Weakness 2025

The Meadows

MN

Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 373433

Finding 1163623 (2025-001)

Material Weakness 2025

Realife Cooperative of St. Peter

MN

Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 373430

Finding 1163620 (2025-004)

Material Weakness 2025

Capac Community Schools

MI

Questioned Costs Cash Management Student Financial Aid

SEE CORRECTIVE ACTION PLAN

View Audit 373396 Questioned Costs: $1

Finding 1163619 (2025-003)

Material Weakness 2025

Capac Community Schools

MI

Questioned Costs Cash Management Subrecipient Monitoring

SEE CORRECTIVE ACTION PLAN

View Audit 373396 Questioned Costs: $1

Finding 1163618 (2025-001)

Material Weakness 2025

Westwood Community School District

MI

Cash Management

Westwood Community Schools respectfully submits the following corrective action plan for the year ended June 30, 2025. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, Michigan 48912 Audit Period: Year ended June 30, 2025 District Contact Person: Jennie Li Jiang, Director of Fi...

Westwood Community Schools respectfully submits the following corrective action plan for the year ended June 30, 2025. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, Michigan 48912 Audit Period: Year ended June 30, 2025 District Contact Person: Jennie Li Jiang, Director of Finance and Operations The findings from the June 30, 2025 schedule of findings and responses are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding - Federal Award Findings and Question Costs Finding 2025-001: Considered a significant deficiency in internal control over compliance. Recommendation: The District should conduct a thorough review of cash drawdown procedures to ensure that drawdowns align with the expenditures incurred prior to the withdrawal of funds. Action to be taken: Management concurs with this finding and is implementing procedures to ensure compliance with cash management guidelines.

View Audit 373392

Finding 1163616 (2025-001)

Material Weakness 2025

Oklahoma Public School Resource Center INC

OK

Subrecipient Monitoring Reporting Significant Deficiency

Action to be taken in response to the finding: To ensure timely submission of all required federal grant reports, the following procedures will be implemented immediately: 1. Centralized Federal Reporting Calendar ○ All federal grant reporting deadlines will be entered into a shared compliance calen...

Action to be taken in response to the finding: To ensure timely submission of all required federal grant reports, the following procedures will be implemented immediately: 1. Centralized Federal Reporting Calendar ○ All federal grant reporting deadlines will be entered into a shared compliance calendar maintained by the grants team. ○ Reminder alerts will be scheduled for 30 days, 14 days, and 7 days before each reporting deadline.2. Assignment of Responsible Parties ○ Primary Responsible Staff: Dr. Jenny Jasper (CFO) will be responsible for preparing and submitting all federal grant reports. ○ Secondary Reviewer: Adrian Lovett (Operations Director) will review each report for accuracy and ensure that deadlines are met. ○ This dual responsibility ensures continuity in case of staff absence. 3. Internal Early Deadline Requirement ○ All federal reports must be completed and ready for review no later than five business days prior to the official deadline. ○ This internal buffer will allow time for revisions, approval, and confirmation of submission. 4. Verification and Documentation of Submission ○ Both the primary and secondary staff members will verify that the report has been successfully submitted in the federal reporting system. ○ Submission confirmations will be saved in a designated grants compliance folder as part of our official record. Management view of the finding: We recognize the importance of timely and accurate submission of all federal grant reports. The delay identified in the audit does not reflect our expectations for compliance, and we are committed to implementing corrective measures to prevent recurrence. Therefore, we do not disagree with the finding.

View Audit 373378

Finding 1163615 (2025-003)

Material Weakness 2025

Cci Health & Wellness Services and Affiliate

MD

Special Tests & Provisions Eligibility Internal Control / Segregation of Duties

2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g...

2025-03/2024-003 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS10591 Program Years 17 and 18 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Recommendation – We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual. Views of Responsible Officials and Planned Corrective Actions – CCI is implementing a system update within eCW to ensure the sliding fee schedule is accurately configured and consistently applied across all service locations. As part of this corrective action, CCI is developing a formal training program to ensure that all applicable employees understand the sliding fee requirements and possess the necessary knowledge to follow the established procedures. CCI is also establishing an internal review process to monitor compliance with the sliding fee policy. This process will include periodic sampling and review of sliding fee scale assessments to verify that eligibility determinations and discounts are being applied correctly and in accordance with policy. Any identified discrepancies will be addressed through targeted staff retraining or process adjustments, as appropriate. These corrective actions are designed to strengthen internal controls, ensure consistent application of the sliding fee program, and maintain compliance with regulatory and organizational requirements. Reason for Recurrence – CCI experienced significant turnover within the Revenue Cycle Department during fiscal year 2025, which contributed to delays in updating system configurations and conducting required reviews. Anticipated Completion/Implementation Date: End of Fiscal Year 2026

View Audit 373376

Finding 1163612 (2025-002)

Material Weakness 2025

Cci Health & Wellness Services and Affiliate

MD

Reporting

2025-002/2024-002/2023-009 Health Center Program Cluster – ALN Nos. 93.224 and 93.527U.S. Department of Health and Human Services Award No. H80CS10591Program Year 16 and 17 Family Planning Services – ALN No. 93.217 U.S. Department of Health and Human Services Award No. FPHPA006584 Program Year 3 and...

2025-002/2024-002/2023-009 Health Center Program Cluster – ALN Nos. 93.224 and 93.527U.S. Department of Health and Human Services Award No. H80CS10591Program Year 16 and 17 Family Planning Services – ALN No. 93.217 U.S. Department of Health and Human Services Award No. FPHPA006584 Program Year 3 and 4 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained. Views of Responsible Officials and Planned Corrective Actions – CCI Health Services will strengthen its processes to ensure all UDS, FFR, and FCTR reports are prepared using accurate financial information supported by appropriate documentation. A standardized federal reporting checklist is being developed to identify required data sources, outline reconciliation steps, and document preparer and reviewer responsibilities. All reports will be reconciled to the system reports and reviewed by both the Controller and CFO before submission to ensure accuracy and completeness. Supporting documentation for all federal reports will be maintained in a centralized location to ensure consistency and future audit readiness. Reason for Recurrence – CCI experienced significant turnover in the Finance Department during fiscal year 2025, which contributed to delays and difficulties in locating supporting documentation for federal reports. Anticipated Completion/Implementation Date: End of Fiscal Year 2025

View Audit 373376

Finding 1163596 (2025-001)

Material Weakness 2025

Housing Authority of the City Or River Falls

WI

Internal Control / Segregation of Duties

Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.

View Audit 373356

Finding 1163593 (2025-001)

Material Weakness 2025

The Housing Authority of the City of Ozark, Alabama

AL

HUD Housing Programs

Corrective Action Plan (CAP) The Housing Authority of the City of Ozark, Alabama (Housing Authority) To the Department of Housing and Urban Development, During the audit of the Housing Authority’s fiscal year ended March 31, 2025 financial statements, it was determined that the Housing Authority did...

Corrective Action Plan (CAP) The Housing Authority of the City of Ozark, Alabama (Housing Authority) To the Department of Housing and Urban Development, During the audit of the Housing Authority’s fiscal year ended March 31, 2025 financial statements, it was determined that the Housing Authority did not perform annual HQS inspections for all units or conduct HQS re-inspections during the 30-day period required by HUD. Dannie Walker, Executive Director is responsible for implementing the corrective action plan. CAP developed to resolve audit findings: Finding 2025-001 - Section 8 HQS Inspection Deficiencies We concur with the recommendation and we will establish controls that ensure that annual inspection are performed, re-inspections are performed within the 30-day requirement and that HAP abatements are properly assessed. The Housing Authority is also planning on additional training for employees to make sure they are qualified to meet the HQS re-inspection requirements.

View Audit 373339

Finding 1163564 (2025-002)

Material Weakness 2025

Jasper County Rural Electric Membership Corporation

IN

Management of Jasper County REMC will implement procedures to ensure that required documents are obtained prior to services being performed. Management agrees with the findings.

View Audit 373288

Finding 1163563 (2025-001)

Material Weakness 2025

Jasper County Rural Electric Membership Corporation

IN

Management of Jasper County REMC was aware of lack of segregation of duties. It would not be cost effective to hire additional employees to properly segregate duties at this time. Management agrees with the findings.

View Audit 373288

Finding 1163562 (2025-001)

Material Weakness 2025

Housing Authority of Elgin

IL

Internal Control / Segregation of Duties Subrecipient Monitoring

Corrective Action Management has responded to all of the Department of Labor’s Findings as of October 9, 2025, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of the date of this Report. The Authority’s Chief Executive Officer has assumed the ...

Corrective Action Management has responded to all of the Department of Labor’s Findings as of October 9, 2025, outlining specific corrective actions and considers the corrective actions satisfactorily implemented as of the date of this Report. The Authority’s Chief Executive Officer has assumed the responsibility of continued execution of the corrective actions.

View Audit 373283

Finding 1163561 (2025-001)

Material Weakness 2025

Old Town Voa Affordable Housing, Inc. (penobscot River House) Me36-H0173

ME

Questioned Costs HUD Housing Programs

FINDING 2025-001 Corrective Action Plan Management will implement a process of identifying any surplus cash to be deposited into its residual receipts reserve account and a timeline to provide reasonable assurance that the remittance of the required deposits are done within the specified timeframe s...

FINDING 2025-001 Corrective Action Plan Management will implement a process of identifying any surplus cash to be deposited into its residual receipts reserve account and a timeline to provide reasonable assurance that the remittance of the required deposits are done within the specified timeframe set by HUD. Responsible party: Kayla Thurlow, Controller; (207) 373-1140 Anticipated completion date: No later than September 30, 2025

View Audit 373280 Questioned Costs: $1

Finding 1163543 (2025-001)

Material Weakness 2025

San Francisco Medical Center Outpatient Improvement Programs, Inc.

CA

Special Tests & Provisions Eligibility

2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discou...

2025-001 Sliding Fee Discount Determination Name of Contact Person: Interim Chief Financial Officer: Shigeyuki Murota, Patient Accounts Manager: George Ward Corrective Action: San Francisco Medical Center Outpatient Improvement Programs, Inc. d/b/a Equity Health will: - Update the Sliding Fee Discount Program (SFDP) policies, procedures, and forms for better clarity and tracking. - Continue to perform monthly internal audits of sliding fee transactions and document audit findings, corrective actions, and report results to leadership. - Retrain current staff quarterly based on the monthly internal audit results. - Train all new staff at new hire orientations. - Validate staff understanding through annual knowledge checks and competency assessments. - Integrate SFDP compliance into staff performance evaluations. - Maintain centralized log of all SFDP applications and determinations. Proposed Completion Date: December 31, 2025

View Audit 373229

Finding 1163540 (2025-002)

Material Weakness 2025

Independent School District No. 31

MN

Internal Control / Segregation of Duties Eligibility School Nutrition Programs

1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring C...

1. Correcting Plan Food and Nutrition Service Coordinator will review applications and supporting documentation for completion and eligibility accuracy. 2. Explanation of Disagreement with the Audit Finding There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Food and Nutrition Service Coordinator. 4. Planned Completion Date for CAP The CAP was implemented immediately during audit fieldwork performed in October 2025. 5. Plan to Monitor Completion of CAP The Food and Nutrition Service Coordinator will continually review applications and supporting documentation for completion and eligibility accuracy. Any issues noted will be communicated to appropriate staff and fixed immediately.

View Audit 373219

Corrective Action Plans

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