Corrective Action Plans

Finding 1227154 (2025-002)

Material Weakness 2025

Edison Arms Housing Development Fund Co., Inc.

NY

Cash Management HUD Housing Programs Significant Deficiency

Response: Management concurs with the findings. Although the Organization does not currently use an interestbearing account for project funds, due to the ongoing operation of the program and continuous activity within the project funds account, any interest earned in such an account would be negligi...

Response: Management concurs with the findings. Although the Organization does not currently use an interestbearing account for project funds, due to the ongoing operation of the program and continuous activity within the project funds account, any interest earned in such an account would be negligible. Management is in the process of evaluating this recommendation to determine the appropriate course of action. Name of Responsible Person: Peyton Vang, Director of Finance Name of Contact: John Reilly Anticipated Completion Date: September 2026

View Audit 409323

Finding 1227152 (2025-001)

Material Weakness 2025

Senior Citizens Housing Development Corporation of Mt. Lebanon

FL

Cash Management HUD Housing Programs Reporting

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Mt. Lebanon, Inc., respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive,...

Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Mt. Lebanon, Inc., respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2025 through December 31, 2025 The finding from the December 31, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to monitor the expiration of all contracts to ensure timely preparation and approval. Additionally, the Project should obtain reimbursement for any amounts paid subsequent to the expiration of form HUD-9839-B. Action Taken: Management is in the process of renewing all management certifications and will provide the accountant extra training to monitor and not charge fees for expired certifications. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO

View Audit 409319

Finding 1227151 (2025-002)

Material Weakness 2025

Beaumont Cherry Valley Water District

CA

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303 § 200.328

The District concurs with the finding. Although the District's review process identified corrections, the process did not require a final verification that all reviewer comments had been incorporated into the version submitted. The District will take the following actions: 1. Require the preparer to...

The District concurs with the finding. Although the District's review process identified corrections, the process did not require a final verification that all reviewer comments had been incorporated into the version submitted. The District will take the following actions: 1. Require the preparer to reconcile reported expenditures to the general ledger, reimbursement requests or invoices, and relevant project records before submitting the report for review. The reconciliation will be retained with the report. 2. Use a version-controlled Quarterly Report Review Checklist and corrections log that identifies each reviewer comment, the required correction, the preparer's disposition, and the date completed. 3. Require the preparer to certify that all review comments have been resolved and incorporated into the final report. 4. Require the independent reviewer to perform and document a final comparison of the approved report to the reconciliation and corrections log. No report may be submitted until the reviewer has marked the final version 'Approved for Submission.' 5. Retain the signed checklist, reconciliation, corrections log, approved final report, and proof of submission. The Finance Manager will periodically review grant-reporting files to verify that the control is operating as designed. Person Responsible for Corrective Action: William Clayton, Finance Manager Anticipated Completion Date for Corrective Action: September 30, 2026. Final reviewer approval and document-retention controls will be effective immediately, with the revised checklist, written procedures, and staff training completed by this date.

View Audit 409318

Finding 1227150 (2025-001)

Material Weakness 2025

Beaumont Cherry Valley Water District

CA

Reporting Subrecipient Monitoring Significant Deficiency § 200.328

The District concurs with the finding. Following the 2024 Single Audit, the District assigned separate report preparation and review responsibilities and implemented a report review checklist. However, the procedures did not include a comprehensive mechanism for tracking recurring, final, and closeo...

The District concurs with the finding. Following the 2024 Single Audit, the District assigned separate report preparation and review responsibilities and implemented a report review checklist. However, the procedures did not include a comprehensive mechanism for tracking recurring, final, and closeout reports or a requirement to resolve uncertain reporting obligations sufficiently in advance of the deadline. The District will take the following actions: 1. Establish and maintain a Grant Reporting Requirements Matrix and calendar for each federal award and pass-through grant. The matrix will identify each recurring, final, and closeout report; the applicable grant provision; reporting period; due date; submission method; assigned preparer; assigned reviewer; and evidence of submission. 2. Set documented reminder dates in advance of each deadline and require the assigned preparer to confirm, for every reporting period, whether a report is required. Final and closeout reporting requirements will be reconfirmed before project completion. When a requirement is uncertain, the District will request written clarification from the grantor or passthrough entity as soon as the uncertainty is identified. Unless written confirmation is received that a report is not required, the District will prepare and submit the report. 3. Require the Finance Manager or designated supervisory reviewer to review the reporting calendar at least monthly while an award is active and to verify completion of each required submission. 4. Retain the completed review checklist, approved report, supporting documentation, correspondence concerning reporting requirements, and proof of timely submission in the grant file. 5. Incorporate these controls into written grant-reporting procedures and provide training to staff assigned to federal award administration. Person Responsible for Corrective Action: William Clayton, Finance Manager Anticipated Completion Date for Corrective Action: September 30, 2026. The reporting matrix, advance reminders, and supervisory monitoring will be used immediately for all open federal and pass-through awards, with written procedures and staff training completed by this date.

View Audit 409318

Finding 1227149 (2025-001)

Material Weakness 2025

Ohio Valley Educational Cooperative

KY

Reporting

The late submission of SF-425 reports resulted from a backlog that accumulated during prior finance management turnover. During fiscal year 2025, management worked to bring all outstanding reports current. OVEC has implemented procedures to ensure timely submission of all required SF-425 reports. Au...

The late submission of SF-425 reports resulted from a backlog that accumulated during prior finance management turnover. During fiscal year 2025, management worked to bring all outstanding reports current. OVEC has implemented procedures to ensure timely submission of all required SF-425 reports. Automated calendar reminders have been established to monitor reporting deadlines, and management reviews reporting requirements on an ongoing basis. In addition, backup personnel have been identified and trained to assist with preparation and submission of reports if primary staff are unavailable. As of fiscal year 2026, all required SF-425 reports have been submitted timely. Anticipated Completion Date: Implemented February 1, 2025 and ongoing.

View Audit 409310

Finding 1227128 (2025-013)

Material Weakness 2025

City of Manchester, Nh

NH

Subrecipient Monitoring § 200.303 § 200.322

2025-013 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen internal controls and procedures to ensure that all subrecipient monitoring checks are performed and documented. Such procedures should include identify...

2025-013 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen internal controls and procedures to ensure that all subrecipient monitoring checks are performed and documented. Such procedures should include identifying subrecipients subject to Single Audit requirements, obtaining and reviewing applicable Single Audit Reports, documenting the results of the review, retaining evidence of the review, and tracking any required follow-up or corrective action related to findings impacting the Federal award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  CIP will create a Standard Operating Procedure for ensuring ARPA subrecipients are appropriately monitored, who is responsible for monitoring, and how documentation will be retained on file. Name(s) of the contact person(s) responsible for corrective action:  Chelcie Pinsonneault, Community Grants Manager Planned completion date for corrective action plan:  Planning and Community Development will ensure the implementation of this corrective action plan is completed by October 31, 2026.

View Audit 409307

Finding 1227127 (2025-012)

Material Weakness 2025

City of Manchester, Nh

NH

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.303

2025-012 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its internal controls over Federal Financial reporting by developing and implementing written procedures requiring all cumulative expenditure line items...

2025-012 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its internal controls over Federal Financial reporting by developing and implementing written procedures requiring all cumulative expenditure line items reported in the Project and Expenditure Reports to be reconciled to underlying accounting records prior to submission. The procedures should also require retention of a point-in-time support package for each report, including the source reports, reconciliations, explanations for adjustments, evidence of supervisory review, and documentation of report certification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  CIP identified this deficiency in FY26. Since then, the Financial Analyst now saves all Project Reports in relation to the Quarterly Report in the appropriate reconciliation files when completing a reconciliation. This process is being followed as reconciliations are being completed monthly and quarterly, and being signed off on by all appropriate individuals. Name(s) of the contact person(s) responsible for corrective action:  Chelcie Pinsonneault, Community Grants Manager Planned completion date for corrective action plan:  Planning and Community Development has already completed this corrective action.

View Audit 409307

Finding 1227126 (2025-011)

Material Weakness 2025

City of Manchester, Nh

NH

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.214 § 200.303 § 200.517

2025-011 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its written policies, procedures, and internal controls to require suspension and debarment verifications before entering into Federally funded contract...

2025-011 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its written policies, procedures, and internal controls to require suspension and debarment verifications before entering into Federally funded contracts and that verification be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  Soundthinking LLC – Police Department  The Manchester Police Department will follow its SOP - Sam.gov Verification for Subrecipients and Vendors Standard Operation Procedure (enclosed) confirming Entity Registration Status (Active / Inactive), Exclusion Status (Suspended, Debarred, Ineligible), and the Expiration Date of all vendors. This process will be completed by the Grant Coordinator in coordination with the Project Manager (if applicable). All documentation will be maintained within the official electronic grant file complying with federal retention dates. Name(s) of the contact person(s) responsible for corrective action:  Whitney Dade, Grant Coordinator, MPD Action taken in response to finding:  Environmental Partners – DPW-Highway: 712522 – DPW agrees with findings and will create a prequalification SOP to complete and record SAM.gov queries on suspensions and debarment verifications prior to entering into contracts. This will be completed within 90 days of today.  Denisco Electric - DPW-Highway: 71222 – DPW agrees with findings and will create a prequalification SOP to complete and record SAM.gov queries on suspensions and debarment verifications prior to entering into contracts. This will be completed within 90 days of today.  GMI Asphalt LLC - DPW-Highway: 712522 – DPW agrees with findings and will create a prequalification SOP to complete and record SAM.gov queries on suspensions and debarment verifications prior to entering into contracts. This will be completed within 90 days of today.  All future prequalification packages will include a requirement for Manchester DPW to complete the SAM.gov verification in addition to the other assertions already made by the contractor/engineering firm.  In addition an SOP will be created to detail how the SAM.gov verification will be conducted prior to contract and where this info for each entity will be archived for a minimum of 3 years following the end of the program. Name(s) of the contact person(s) responsible for corrective action:  Caleb Dobbins – Chief Highway Engineer, DPW Planned completion date for corrective action plan:  9/30/2026 Action taken in response to finding:  39 Beech Street LLC – Mayor’s Office / Fire Department - agrees with the finding and will create a prequalification SOP to complete, record SAM.gov queries on suspensions and debarment verifications as part of a checklist prior to entering into contracts. Name(s) of the contact person(s) responsible for corrective action:  Mayors office - Kathleen Pelissier, Grants Coordinator  Fire Department – Melissa Paulhamus, Administrative Services Manager Planned completion date for corrective action plan:  9/30/2026

View Audit 409307

Finding 1227125 (2025-010)

Material Weakness 2025

City of Manchester, Nh

NH

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.517

2025-010 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its internal controls over procurement and contract documentation for Federal awards. Such procedures should require that complete contract files, inclu...

2025-010 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its internal controls over procurement and contract documentation for Federal awards. Such procedures should require that complete contract files, including executed agreements, procurement method documentation, vendor selection support, approvals, and other required supporting documentation, be retained in a centralized location and reviewed for completeness. The City should also establish monitoring procedures to ensure documentation is maintained in accordance with Federal requirements and is available timely for audit or other oversight review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  Soundthinking LLC – Police Department  The Manchester Police Department will follow the City’s procurement policy as well as its own internal Procurement Standard Operating Procedure (enclosed). Complete contract files will be maintained to include executed agreements, procurement method documentation, vendor selection support, approvals, and other required supporting documentation. Documentation will be kept in the official electronic grant file and reviewed for completeness by the Business Services Manager, Project Manager (if applicable), and Grant Coordinator. Name(s) of the contact person(s) responsible for corrective action:  Kristy Goodman, Business Services Manager and  Whitney Dade, Grant Coordinator. Planned completion date for corrective action plan:  09/30/2026 Explanation of disagreement with audit finding:  Environmental Partners – DPW-Highway: 712522 – DPW DOES NOT CONCUR with these findings. Request for documentation of Environmental Partners contract was not clearly understood by contracting agency (DPW) and was not submitted.  Requested contract documentation for the Environmental Partners contract attached. This will also be included in the CAP to be provided later to have a single document with all information. Name(s) of the contact person(s) responsible for corrective action:  Caleb Dobbins – Chief Highway Engineer, DPW

View Audit 409307

Finding 1227120 (2025-009)

Material Weakness 2025

City of Manchester, Nh

NH

Equipment & Real Property Management § 200.303 § 200.313

2025-009 Airport Improvement Program, Infrastructure Investments and Jobs Act Programs, and COVID-19 Airports Programs - Assistance Listing Number 20.106 Recommendation: We recommend the City strengthen procedures and internal controls to ensure that all equipment acquired under the Federal program ...

2025-009 Airport Improvement Program, Infrastructure Investments and Jobs Act Programs, and COVID-19 Airports Programs - Assistance Listing Number 20.106 Recommendation: We recommend the City strengthen procedures and internal controls to ensure that all equipment acquired under the Federal program is accurately recorded and included in the annual inventory list, and that the annual physical inventory is reconciled to the equipment records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  Airport created a new SOP for AIP Property Name(s) of the contact person(s) responsible for corrective action:  Kim Waldecker Planned completion date for corrective action plan:  7/30/2026

View Audit 409307

Finding 1227107 (2025-008)

Material Weakness 2025

City of Manchester, Nh

NH

Special Tests & Provisions HUD Housing Programs Significant Deficiency § 200.303

2025-008 Community Development Block Grants/Entitlement Grants - Assistance Listing Number 14.218 Recommendation: We recommend the City strengthen procedures and internal controls to ensure that environmental review certifications are prepared and retained, evidencing that the environmental reviews ...

2025-008 Community Development Block Grants/Entitlement Grants - Assistance Listing Number 14.218 Recommendation: We recommend the City strengthen procedures and internal controls to ensure that environmental review certifications are prepared and retained, evidencing that the environmental reviews were completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  CIP will update the Environmental Review section of the CIP Procedures Manual to ensure Environmental Reviews are completed and documentation is kept on file. Additionally a SOP will also be created for how to conduct an Environmental Review. Name(s) of the contact person(s) responsible for corrective action:  Chelcie Pinsonneault, Community Grants Manager Planned completion date for corrective action plan:  Planning and Community Development will ensure the implementation of this corrective action plan is completed by October 31, 2026

View Audit 409307

Finding 1227106 (2025-007)

Material Weakness 2025

City of Manchester, Nh

NH

Reporting Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

2025-007 Community Development Block Grants/Entitlement Grants - Assistance Listing Number 14.218 Recommendation: We recommend the City strengthen procedures and internal controls to ensure that all required subawards are reported timely and accurately no later than the end of the month following th...

2025-007 Community Development Block Grants/Entitlement Grants - Assistance Listing Number 14.218 Recommendation: We recommend the City strengthen procedures and internal controls to ensure that all required subawards are reported timely and accurately no later than the end of the month following the month of issuance of each subaward. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  Planning and Community Development’s Community Improvement Program (CIP) will update the CIP Procedures Manual to ensure that FFATA reporting is identified as a required step when providing subawards. Additionally, a Standard Operating Procedure (SOP) will be created on how, when and why to complete FFATA reporting, who will be responsible, and how we will ensure the required reporting is completed. Name(s) of the contact person(s) responsible for corrective action:  Chelcie Pinsonneault, Community Grants Manager Planned completion date for corrective action plan:  Planning and Community Development will ensure the implementation of this corrective action plan is completed by October 31, 2026.

View Audit 409307

Finding 1227089 (2025-002)

Material Weakness 2025

Le Mars Community School District

IA

School Nutrition Programs Cash Management Eligibility

Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance: Meal Count Reporting and Reconciliation U.S Department of Agriculture Child Nutrition Cluster Passed through State of lowa Department of Education Federal Assistance Listing Number: 10.555, 10.559, 10.553 Feder...

Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance: Meal Count Reporting and Reconciliation U.S Department of Agriculture Child Nutrition Cluster Passed through State of lowa Department of Education Federal Assistance Listing Number: 10.555, 10.559, 10.553 Federal Award Year: 2025Criteria: Districts are required are required to submit accurate claims for reimbursement and maintain records supporting the number of meals claimed for reimbursement for the National School Lunch Program. Condition: During audit procedures over the School Nutrition Cluster, we identified multiple instances in the National School Lunch Program in which the number of claims submitted was incorrect. Cause: The District did not have an effective review and reconciliation control in place to compare meal-count support to the claim summary reports before reimbursement claims were submitted. In addition, meal-count and eligibility reports were not consistently generated and retained at the time the claims were prepared. As a result, subsequent changes in student eligibility status may have affected the reports available to support the meal counts claimed during the applicable reporting periods. Effect: Meal counts reported for reimbursement were not fully supported by contemporaneous records, resulting in noncompliance with reporting and recordkeeping requirements. Without an effective review and reconciliation control, errors in meal counts or claim summary reports may not be identified before reimbursement claims are submitted, increasing the risk that federal reimbursement claims could be inaccurate. Questioned Costs: Known questioned costs identified were below the reporting threshold and are not reported in this finding. Recommendation: We recommend that the District implement a documented monthly review and reconciliation process before reimbursement claims are submitted. The reconciliation should compare meal-count and eligibility support to the claim summary reports, identify and explain any differences, retain support for adjustments, and include evidence of review and approval by an individual independent of claim preparation. We also recommend that management generate and retain meal-count and eligibility report for each applicable reporting period at the time claims are prepared to ensure support reflects student eligibility status as of the applicable claim period. Management Response: Management acknowledges the finding and the District will generate and retain monthly meal-count and eligibility reports at the time reimbursement claims are prepared. The District will also implement a documented review and reconciliation process for National School Lunch Program reimbursement claims.

View Audit 409272

Finding 1227086 (2025-003)

Material Weakness 2025

City of Poplar Bluff

MO

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Name of Contact Person: Lori Phelps, City Clerk/Treasurer and Acting City Manager. Recommendation: We recommend that the City check the Excluded Parties List System or collect certification from the entity for any vendor in which the City expects to spend more than $25,000 of federal grant funds for...

Name of Contact Person: Lori Phelps, City Clerk/Treasurer and Acting City Manager. Recommendation: We recommend that the City check the Excluded Parties List System or collect certification from the entity for any vendor in which the City expects to spend more than $25,000 of federal grant funds for the year. Corrective Action: We will ensure we comply going forward. Proposed Completion Date: Immediately.

View Audit 409271

Finding 1227083 (2025-002)

Material Weakness 2025

Newhalen Tribal Council

AK

Reporting § 200.512

Management will ensure that future audits are completed timely. Communication protocols have been updated to ensure all relevant parties are explicitly notified of audit report approvals in future periods.

View Audit 409267

Finding 1227078 (2025-002)

Material Weakness 2025

CITY OF MATTHEWS

MO

Procurement, Suspension & Debarment Cash Management

Name of Contact Person: April Spraggs, City Clerk. Recommendation: It is recommended that the City develop written policies and procedures related to cash management, cost allowability, procurement, and conflict of interest provisions for federal funds it receives. Corrective Action: The City will d...

Name of Contact Person: April Spraggs, City Clerk. Recommendation: It is recommended that the City develop written policies and procedures related to cash management, cost allowability, procurement, and conflict of interest provisions for federal funds it receives. Corrective Action: The City will develop and adopt the required written policies and procedures. Proposed Completion Date: Immediately.

View Audit 409265

Finding 1227069 (2025-002)

Material Weakness 2025

The Township of Upper Darby

PA

Procurement, Suspension & Debarment § 200.213 § 200.303

The Township has created a proceudre to regularly check Sam.gov for suspension and debarment prior to issuing purchase orders or contracts.

View Audit 409258

Finding 1227066 (2025-001)

Material Weakness 2025

County of Franklin, Pennsylvania

PA

Special Tests & Provisions Student Financial Aid Allowable Costs / Cost Principles

The County has implemented procedures to ensure all future foster care maintenance for which reimbursement is sought is allowable.

View Audit 409256

Finding 1227062 (2025-001)

Material Weakness 2025

Souris Basin Planning Council

ND

Reporting § 200.303

Corrective Action Plan – December 31, 2025 2025-001 Contact Person: Beth Calderon, Program & Finance Manager Corrective Action Plan: During 2026, the Council implemented a formal review process for the preparation and submission of the Federal Financial Report (SF-425). The Program & Finance Manager...

Corrective Action Plan – December 31, 2025 2025-001 Contact Person: Beth Calderon, Program & Finance Manager Corrective Action Plan: During 2026, the Council implemented a formal review process for the preparation and submission of the Federal Financial Report (SF-425). The Program & Finance Manager prepares the SF-425 and supporting documentation, and the Organizational Development & Program Manager performs and documents an independent review of the completed report for accuracy, completeness, and compliance with grant reporting requirements prior to submission. This process was implemented to strengthen internal controls over federal reporting and provide appropriate segregation of duties. Completion Date: July 14, 2026 Briselda Hernandez Executive Director

View Audit 409252

Finding 1227061 (2025-004)

Material Weakness 2025

White Mountain Communities Hospital, Inc. Dba White Mountain Regional

AZ

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214

Finding 2025-004 Federal Agency Name: United States Department of Health and Human Services Program Name: Congressional Directives FFAL #93.493 Finding Summary: The Hospital does not have an internal control policy in place to ensure covered transactions are with vendors that are not suspended or de...

Finding 2025-004 Federal Agency Name: United States Department of Health and Human Services Program Name: Congressional Directives FFAL #93.493 Finding Summary: The Hospital does not have an internal control policy in place to ensure covered transactions are with vendors that are not suspended or debarred, and no evidence was retained regarding ensuring the vendor was not suspended or debarred. Corrective Action Plan: For Finding 2025-004, the Hospital has implemented corrective actions to address the lack of internal controls related to suspended and debarred vendor verification. The Hospital revised its Capital Request Form to require documented verification that vendors involved in federally funded procurements are not suspended or debarred prior to contract award or purchase. Additionally, the Federal Procurement Policy and Procedure was updated to establish formal internal controls for screening vendors against applicable federal exclusion lists and retaining evidence of the verification process. Effective immediately, no procurement involving federal funds will be approved until suspended and debarred status verification has been completed and documented. Management will provide education to all managers on August 5, 2026, regarding the revised requirements and documentation standards. Hospital leadership will conduct ongoing monitoring and review of procurement files to ensure compliance with federal regulations and to prevent recurrence of this finding. Responsible Individuals: Wesley Babers, Chief Executive Officer and Ashley Jaramillo, Chief Financial Officer Anticipated Completion Date: August 2026

View Audit 409249

Finding 1227060 (2025-003)

Material Weakness 2025

White Mountain Communities Hospital, Inc. Dba White Mountain Regional

AZ

Procurement, Suspension & Debarment § 200.317 § 200.318 § 200.327

Finding 2025-003 Federal Agency Name: United States Department of Health and Human Services Program Name: Congressional Directives FFAL #93.493 Finding Summary: Testing of the federal program identified the following: 􀁸 The Hospital’s formally documented procurement policy was missing the required e...

Finding 2025-003 Federal Agency Name: United States Department of Health and Human Services Program Name: Congressional Directives FFAL #93.493 Finding Summary: Testing of the federal program identified the following: 􀁸 The Hospital’s formally documented procurement policy was missing the required elements detailed under Uniform Guidance. 􀁸 Instances where the Hospital did not follow the procurement process, and/or retain documentation for reasoning of selection of vendor. Corrective Action Plan: For Finding 2025-003, the Hospital has updated and approved its Federal Procurement Policy and Procedure to incorporate all required elements of Uniform Guidance and strengthen compliance with federal grant requirements. In addition, the Hospital revised its Capital Request process to include formal procurement requirements, vendor selection documentation, and approval workflows. Effective immediately, no federal funds will be expended until the procurement process has been fully completed and documented in accordance with the revised policy. Management has implemented controls to ensure procurement records are maintained, including documentation supporting vendor selection and purchasing decisions. To support compliance and consistent application of the new requirements, education and training on the revised procurement and capital request processes will be provided to all managers on August 5, 2026. Hospital leadership will monitor adherence to these procedures through ongoing review and oversight to ensure compliance with federal regulations and prevent future occurrences of this finding. Responsible Individuals: Wesley Babers, Chief Executive Officer and Ashley Jaramillo, Chief Financial Officer Anticipated Completion Date: August 2026

View Audit 409249

Finding 1227056 (2025-005)

Material Weakness 2025

County of Columbus

NC

Reporting Cash Management

2025-005 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principle (Repeat Finding) Information on the federal program: Temporary Assistance Needy Families Cluster (TANF), Assistance Listing Number 93.558, U.S. Department of Health and Human Services, passed thr...

2025-005 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principle (Repeat Finding) Information on the federal program: Temporary Assistance Needy Families Cluster (TANF), Assistance Listing Number 93.558, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Medical Assistance. Criteria: Per the NCDHHS policy manual, salaries, wages, and fringe benefits of Department of Social Service employees hired under the state merit system are allowable. Salaries shall be allocated to programs by time distribution methods and supported by payroll and attendance records for individuals. Name of Contact Person: Dwella Hall, Social Services Director Corrective Action Plan: The County’s Department of Social Services is committed to strengthening internal controls to ensure the accurate reporting of time and program coding. The agency has implemented enhanced review protocols requiring supervisors to verify that weekly timesheets accurately reflect the time recorded on employee’s daily activity sheets prior to approval. In addition, the agency is reinforcing staff training on proper time distribution and coding requirement, increasing supervisory oversight, and establishing standardized review procedures to promote consistency and compliance. These measures are designed to improved documentation accuracy, strengthen accountability, and ensure that program reimbursements are supported by complete and accurate records. Proposed Completion Date: June 30, 2027

View Audit 409231

Finding 1227052 (2025-004)

Material Weakness 2025

County of Columbus

NC

HUD Housing Programs

2025-004 Significant Deficiency over Reporting (Repeat Finding) Information on the Federal Program: Low Income Housing Assistance Program (Section 8), Assistance Listing Number 14.871, U.S. Department of Housing and Urban Development. Criteria: Public Housing Agencies (PHAs) are required to submit t...

2025-004 Significant Deficiency over Reporting (Repeat Finding) Information on the Federal Program: Low Income Housing Assistance Program (Section 8), Assistance Listing Number 14.871, U.S. Department of Housing and Urban Development. Criteria: Public Housing Agencies (PHAs) are required to submit timely a Financial Assessment Sub-system (FASS-PH): GAAP-based unaudited and audited financial information electronically to HUD. Name of Contact Person: Heather Woody, Finance Director Corrective Action Plan: The County will continue its efforts to complete audits in a timely manner. The Section 8 program is audited in conjunction with the audit of the county. Proposed Completion Date: December 31, 2026

View Audit 409231

Finding 1227051 (2025-005)

Material Weakness 2025

Harvard Townhouse, Inc.

NE

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking

Finding 2025-004 See response to finding 2025-001.

View Audit 409230

Finding 1227050 (2025-004)

Material Weakness 2025

Harvard Townhouse, Inc.

NE

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking

Finding 2025-004 Management of the project is actively working to reinsure the Project in compliance with 7 CFR 3560.105(h). Management is also actively reviewing Its internal control policies and procedures to mitigate the risk of noncompliance in the future.

View Audit 409230

Corrective Action Plans

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