Corrective Action Plans

Finding 1238432 (2025-002)

Material Weakness 2025

Jackson County, Missouri

MO

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.332

The County will download the sam.gov page for each subrecipient prior to issuing subawards for proof of verification.

View Audit 413296

Finding 1238428 (2025-001)

Material Weakness 2025

University Muslim Medical Association, INC

CA

Special Tests & Provisions Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions Management agrees with the findings and will implement the following actions to prevent future occurrences: • Immediate training for all front desk staff to ensure accurate application of the sliding fee process; • Continuous internal aud...

Views of Responsible Officials and Planned Corrective Actions Management agrees with the findings and will implement the following actions to prevent future occurrences: • Immediate training for all front desk staff to ensure accurate application of the sliding fee process; • Continuous internal audits to monitor compliance with the sliding fee discount program guidelines as stated in UMMA’s policies and procedures; and • Upon satisfactory completion of samples audited, UMMA will continue to provide quarterly training and periodic audits to ensure continued compliance. Responsible Officials Alejandra Murillo, Chief Financial Officer Expected Implementation Date December 31, 2025

View Audit 413294

Finding 1238425 (2025-002)

Material Weakness 2025

NAKNEK ELECTRIC ASSOCIATION, INC.

AK

Allowable Costs / Cost Principles § 200.302

Federal Finding 2025-002 – Allowability of Costs Name of Contact Person: Dianne King, CEO/GM Corrective Action: NEA will develop and implement a procedure on when and how to segregate unallowable costs from allowable costs. The procedure will include identification of federally-unallowable costs and...

Federal Finding 2025-002 – Allowability of Costs Name of Contact Person: Dianne King, CEO/GM Corrective Action: NEA will develop and implement a procedure on when and how to segregate unallowable costs from allowable costs. The procedure will include identification of federally-unallowable costs and the method used to ensure unallowable costs are fully removed from any accounts or job cost pools associated with federal awards. This procedure will be incorporated into NEA’s overall existing accounts payable procedures. Proposed Completion Date: March 31, 2027

View Audit 413292

Finding 1238424 (2025-001)

Material Weakness 2025

NAKNEK ELECTRIC ASSOCIATION, INC.

AK

Procurement, Suspension & Debarment

Federal Finding 2025-001 – Procurement, Suspension, and Debarment Name of Contact Person: Dianne King, CEO/GM Corrective Action: NEA will develop and implement a procurement policy and procedure. This policy/procedure will outline the required procurement actions for federal and state awards. This i...

Federal Finding 2025-001 – Procurement, Suspension, and Debarment Name of Contact Person: Dianne King, CEO/GM Corrective Action: NEA will develop and implement a procurement policy and procedure. This policy/procedure will outline the required procurement actions for federal and state awards. This includes investigation of a potential vendor’s debarment/suspension status, situations where competitive procurement processes would be required and how to complete the competitive process, and receiving and retaining documentation from potential vendors to ensure compliance with any applicable federal regulations (Build America Buy America act, etc.). The policy/procedure will outline the responsible parties for each process, the conditions for any potential exceptions to the policy, and how any exceptions will be appropriately handled. Proposed Completion Date: March 31, 2027

View Audit 413292

Finding 1238423 (2025-001)

Material Weakness 2025

THE LOOP WATER AUTHORITY

CO

Procurement, Suspension & Debarment § 200.317 § 200.327

Conditions – The Authority has a formalized procurement policy (the policy). However, the policy does not conform to applicable standards under Uniform Guidance because it does not include procedures to ensure the Authority does not enter into covered transactions with entities that are debarred, su...

Conditions – The Authority has a formalized procurement policy (the policy). However, the policy does not conform to applicable standards under Uniform Guidance because it does not include procedures to ensure the Authority does not enter into covered transactions with entities that are debarred, suspended, or otherwise excluded. We noted during our testing that there was limited documentation of the Authority's procedures for verifying that an entity with which it plans to enter into a covered transaction is not debarred, suspended, or otherwise excluded. Recommendation – We recommend that management strengthen their formal procurement policy using the guidance of 2 CFR 200.317 – 200.327. Additionally, management should follow this policy when procuring services or property and maintain the related documentation. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. Management is in the process of reviewing and revising its policies. Anticipated Date of Completion – Completed. Action Taken – In regard to the 2025 audit finding Procurement Procedure, the Loop Water Authority recognizes the shortcoming and has implemented the following action to remedy the finding: The sampled contract existed prior to the ARPA procurement requirements. The aforementioned contract was provided to legal representation for confirmation of compliance with all requirements and was stated to be, in compliance. The failure existed at the management level as not confirming SAM.gov or contractual verbiage. The Loop Water Authority corrective action was to hire a full-time Executive Director to provide oversight and operational compliance for all contracts. The Executive Director has implemented a checklist to review all new procurement contracts for compliance using standards from 2 CFR 200.317 – 200.327. Person Responsible for Corrective Action Plan – Jason Hann, Executive Director.

View Audit 413287

Finding 1238422 (2025-001)

Material Weakness 2025

Grupo Nexos, Inc.

PR

Reporting § 200.328

CORRECTIVE ACTION PLAN For the Year Ended December 31, 2025 Finding No.: 2025-001 Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.297 – Teenage Pregnancy Prevention Program (PROSa) Compliance Requirement: Reporting Responsible Entity: Grupo Nexos, Inc. – Finance Depa...

CORRECTIVE ACTION PLAN For the Year Ended December 31, 2025 Finding No.: 2025-001 Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.297 – Teenage Pregnancy Prevention Program (PROSa) Compliance Requirement: Reporting Responsible Entity: Grupo Nexos, Inc. – Finance Department and Program Management Reported Condition During the audit for the year ended December 31, 2025, it was identified that one (1) of the two (2) Federal Financial Reports (SF-425) selected as part of the audit sample was submitted five (5) days after the established due date. Management Response Grupo Nexos, Inc. acknowledges the finding and agrees with the need to maintain appropriate follow-up and monitoring procedures to ensure the timely preparation, review, and submission of all federal financial reports. The event identified during the 2025 audit occurred during the period in which the Organization was in the process of implementing the corrective measures related to Finding No. 2024-001. It is important to note that the scope of the conditions identified during 2025 was significantly reduced compared with the prior year. The other matters related to FFATA reporting and the Trans-NIH program identified in 2024 were corrected or did not result in similar findings during 2025. Corrective Actions 1. Centralized Compliance Calendar. An electronic calendar is maintained identifying the due dates for Federal Financial Reports (SF-425) and other reports required under each federal program. 2. Advance Alerts. Alerts have been established in advance of due dates to facilitate the timely preparation, review, and submission of reports. 3. Assignment of Responsibilities. Personnel have been designated as responsible for the preparation, follow-up, and submission of reports, along with backup personnel to ensure continuity in the event of an absence or staffing change. 4. Internal Review and Approval. Federal financial reports will be subject to internal review and approval by the Chief Financial Officer (CFO) prior to submission. 5.Documentation and Recordkeeping. Electronic evidence of the preparation, review, submission, and confirmation of receipt of each federal report will be maintained in a centralized compliance file. 6. Periodic Follow-Up. The Finance Department will periodically monitor the compliance calendar. Any situation that could result in a delay must be communicated to the CFO before the applicable due date. Status of Corrective Action The corrective measures related to this finding have been implemented and are part of Grupo Nexos, Inc.'s regular monitoring and compliance procedures. The Organization will continue to monitor the effectiveness of these controls to ensure that federal financial reports are prepared, reviewed, and submitted within the deadlines established by the federal awarding agencies. Implementation Date: 11/30/2025

View Audit 413286

Finding 1238421 (2025-002)

Material Weakness 2025

New Hope Housing, Inc.

TX

Significant Deficiency Internal Control / Segregation of Duties

Finding #2025-002 – Significant Deficiency and Other Noncompliance. Federal Awards: U. S. Department of Housing and Urban Development, Passed through City of Houston, Assistance Listing #: 14.239, Contract number: 4600016100, 4600008347, 4600015112, 4600013379, 460000866, 4600009893, 4600010749, and...

Finding #2025-002 – Significant Deficiency and Other Noncompliance. Federal Awards: U. S. Department of Housing and Urban Development, Passed through City of Houston, Assistance Listing #: 14.239, Contract number: 4600016100, 4600008347, 4600015112, 4600013379, 460000866, 4600009893, 4600010749, and 03-0774/FC55324, Contract period: Grant agreement expires 15-30 years from the date of completion. U. S. Department of Housing and Urban Development, Passed through Texas Department of Housing and Community Affairs, Assistance Listing #: 14.239, Contract number: 92230123418 and 1000084, Contract period: Grant agreement expires 20-30 years from the date of completion. Condition and context: In a sample of 40 tenant files, we noted four instances where the monthly rental rate recorded on the property’s rent roll did not match the rate authorized in the signed lease contract. Recommendation: Implement a secondary review of rental agreements and rates per the property management system. Consider periodic reconciliation compliance procedures that compares a sample of active rent rolls directly against executed lease files. Planned corrective action: Effective October 1, 2026, NHH’s Property Management team will conduct monthly reconciliations comparing a sample of active rent rolls and property management system records directly against executed lease agreements and amendments. A minimum of 10% of active tenant files at each property will be reviewed monthly. Any discrepancies identified will be corrected promptly. NHH’s Compliance team will perform quarterly oversight reviews beginning January 2027 to verify that the monthly reconciliations are completed and documented and that identified discrepancies are resolved. NHH’s Vice President of Property Management and Maintenance will review the quarterly reconciliations. Responsible officer: Stacey Lastovica, Vice President of Property Management and Maintenance. Estimated completion date: Monthly Property Management reconciliations will begin on October 1, 2026, with quarterly Compliance oversight beginning in January 2027. These controls will remain ongoing.

View Audit 413281

Finding 1238419 (2025-001)

Material Weakness 2025

Island County

WA

Subrecipient Monitoring Internal Control / Segregation of Duties

County staff has previously reached out to the granting agency on how to resolve the quarterly Project and Expenditures reporting issue. Staff will review quarterly reporting to ensure the data accurately reflects the accounting records. The County is committed to obtaining the necessary training an...

County staff has previously reached out to the granting agency on how to resolve the quarterly Project and Expenditures reporting issue. Staff will review quarterly reporting to ensure the data accurately reflects the accounting records. The County is committed to obtaining the necessary training and resource materials for future ARPA reporting and subrecipient monitoring.

View Audit 413279

Finding 1238417 (2025-002)

Material Weakness 2025

City of Bothell

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

The City places the utmost importance on safeguarding public funds and commits to improving internal controls over grant management. The City is committed to improving internal controls over complying with federal suspension and debarment requirements. The City commits to continuing training for sta...

The City places the utmost importance on safeguarding public funds and commits to improving internal controls over grant management. The City is committed to improving internal controls over complying with federal suspension and debarment requirements. The City commits to continuing training for staff with procurement and grant management duties. Finance will continue to highlight federal compliance requirements for staff. The Contracts and Procurement Officer will also create a new guidance and checklist document to help staff meet federal compliance requirements. Additionally, the City will update our contract templates to include language for contractors to certify they are not suspended or debarred from participation in federal programs. The City commits to improving internal controls and ensuring that federal funds are managed with the highest level of compliance and accountability. These changes will help the City meet federal compliance requirements and better safeguard use of public funds.

View Audit 413274

Finding 1238407 (2025-002)

Material Weakness 2025

Hancock Rural Telephone Corporation

IN

Reporting Significant Deficiency § 200.510

Management understands and agrees with the finding. The Cooperative recognizes that expenditures reported to Hancock County for the fiscal year ended December 31, 2025, inadvertently included federal award expenditures related to the prior fiscal year, resulting in an improper cut-off. To address th...

Management understands and agrees with the finding. The Cooperative recognizes that expenditures reported to Hancock County for the fiscal year ended December 31, 2025, inadvertently included federal award expenditures related to the prior fiscal year, resulting in an improper cut-off. To address this, management has implemented and documented procedures to ensure that only expenditures incurred within the current fiscal year are included in amounts reported to Hancock County. These procedures include a cutoff checklist completed by the preparer prior to each submission, which documents the date range verified for each expenditure line and confirms that all amounts fall within the current grant period. Submission of expense reports to Hancock County will be held until the checklist is fully completed and signed off. These controls will be applied to any future federal grants to prevent recurrence.

View Audit 413272

Finding 1238406 (2025-001)

Material Weakness 2025

Hancock Rural Telephone Corporation

IN

Allowable Costs / Cost Principles § 200.302

Management acknowledges the finding and agrees that written procedures for determining the allowability of costs were not formally documented as required. As the Cooperative continues to mature its federal grant management practices, this gap has been identified and addressed. Written procedures for...

Management acknowledges the finding and agrees that written procedures for determining the allowability of costs were not formally documented as required. As the Cooperative continues to mature its federal grant management practices, this gap has been identified and addressed. Written procedures for determining the allowability of costs have been developed and are now in place to be used for any future grants. Finance management will monitor adherence to these procedures and incorporate them into the broader financial policies framework to ensure continued compliance with applicable federal requirements going forward.

View Audit 413272

Finding 1238405 (2025-001)

Material Weakness 2025

Kittitas Reclamation District

WA

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring

The District acknowledges the auditor’s finding regarding the use of a cash advance during extreme and time sensitive circumstances. While cash advances are not part of the District’s normal financial practice, the situation required immediate action to ensure continuity of services funded by the fe...

The District acknowledges the auditor’s finding regarding the use of a cash advance during extreme and time sensitive circumstances. While cash advances are not part of the District’s normal financial practice, the situation required immediate action to ensure continuity of services funded by the federal granting agency. The District takes this recommendation very seriously. Throughout the period in which the cash advance remained unexpended, the District maintained complete documentation of all interest accrued, consistent with federal requirements. As soon as the auditors provided direction to remit interest exceeding the allowable $500 threshold, the District immediately issued a reimbursement check to the U.S. Department of Health and Human Services. This action was completed promptly to ensure full compliance with federal grant regulations. To prevent similar issues in the future, the District has formally adopted a written Cash Advance Policy. This policy establishes that cash advances are not standard procedure and may only be used under exceptional circumstances. It further requires monthly monitoring of any interest earned and mandates annual repayment of interest exceeding $500 to the granting agency. The policy ensures that any future need for a cash advance will be managed with clear controls, documented oversight, and strict adherence to federal guidelines. The District is committed to maintaining strong internal controls, complying with all federal grant requirements, and implementing corrective measures that strengthen financial stewardship moving forward.

View Audit 413271

Finding 1238380 (2025-001)

Material Weakness 2025

Elizabeth Seton Pediatric Center D/b/a Elizabeth Seton Children's Cent

NY

HUD Housing Programs Subrecipient Monitoring Reporting

1. Name of Contact person responsible for corrective action Carla Perruccio, Chief Financial Officer 300 Corporate Boulevard South Yonkers, NY 10701 (914) 294-6128 CPerruccio@setonchildrens.org 2. Corrective action planned Our organization will implement a documented checklist which will identify bo...

1. Name of Contact person responsible for corrective action Carla Perruccio, Chief Financial Officer 300 Corporate Boulevard South Yonkers, NY 10701 (914) 294-6128 CPerruccio@setonchildrens.org 2. Corrective action planned Our organization will implement a documented checklist which will identify both applicable filing deadlines—the earlier of 30 calendar days after receipt of the auditors’ reports or nine months after fiscal year-end—and will require management to document the calculated due date and submission confirmation. 3. Anticipated Completion Date This was completed in September 2026. 4. If the client does not agree with the findings or believes corrective action is not required, include an explanation and specific reasons. We agree with the finding reference # 2025-001

View Audit 413240

Finding 1238379 (2025-002)

Material Weakness 2025

RONALD MCDONALD HOUSE CHARITIES OF OKLAHOMA CITY, INC

OK

Procurement, Suspension & Debarment Eligibility Internal Control / Segregation of Duties

Finding 2025-002 Finding Number: 2025-002 Finding Title: Documentation of Procurement and Suspension and Debarment Control Procedures Corrective Action Planned: Management believes this finding resulted from the Organization’s assessment that compliance procedures implemented through the Constructio...

Finding 2025-002 Finding Number: 2025-002 Finding Title: Documentation of Procurement and Suspension and Debarment Control Procedures Corrective Action Planned: Management believes this finding resulted from the Organization’s assessment that compliance procedures implemented through the Construction Manager were sufficient to address the suspension and debarment requirements associated with direct vendor payments. The Organization incorporated applicable federal compliance requirements into its agreement with the Construction Manager and the related subcontractor arrangements and documented its rationale regarding whether additional verification was required for vendors paid directly to preserve the Organization's sales tax exemption. The Organization has subsequently confirmed that none of the material vendors paid directly by RMHC were listed as suspended, debarred, or otherwise excluded from participation in federal programs. Therefore, management believes the finding relates to compliance documentation and retention requirements rather than the engagement of ineligible vendors. To strengthen compliance documentation in this area, management will update its procurement and federal award compliance procedures to clearly address situations in which the Organization makes direct payments to vendors using federal funds, including circumstances where the Organization does not have a direct contractual relationship with those vendors and where project procurement activities are administered through a Construction Manager or other third party. Management will update applicable checklists and written guidance, provide training to personnel responsible for federal award compliance, and implement supervisory review of covered-transaction evaluations involving direct vendor payments. Management will also ensure that documentation supporting suspension and debarment determinations and related compliance conclusions is retained in the applicable procurement and payment files. In addition, management notes that the circumstances giving rise to this finding were unique to the capital project and the Organization's previous practice of paying certain material vendors directly in order to preserve its sales tax exemption. Pursuant to Oklahoma Senate Bill 44, effective in 2026, sales tax exemptions were expanded to expressly apply to contractors and subcontractors performing work for qualified tax-exempt entities. As a result, the Organization does not anticipate the need to make direct payments to material vendors for future construction projects solely to preserve sales tax-exempt treatment, thereby significantly reducing the likelihood of similar circumstances occurring in the future. Management further notes that no federal funds were expended by the Organization during 2026. Nevertheless, management has implemented procedural revisions described above so that controls will be in place for any future federally funded activities. Responsible Person: Jenna Morey, President Anticipated Completion Date: December 31, 2026

View Audit 413231

Finding 1238374 (2025-002)

Material Weakness 2025

American Indian Council on Alcoholism Inc.

WI

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.318

Management agrees with the finding. Management will spend additional time reviewing CFR section 200.318(i) for familarization. Assistance will again be requested to develop the additional proceudrement policies in accordance with Uniform Guidance. Policies will be reviewed and approved by the Board ...

Management agrees with the finding. Management will spend additional time reviewing CFR section 200.318(i) for familarization. Assistance will again be requested to develop the additional proceudrement policies in accordance with Uniform Guidance. Policies will be reviewed and approved by the Board regularly.

View Audit 413215

Finding 1238372 (2025-001)

Material Weakness 2025

American Indian Council on Alcoholism Inc.

WI

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.305 § 200.317 § 200.327 § 200.332

Management agrees with the finding. Management will spend additional time reviewing CFR Part 200 for familiarization. Policy templates will also be reviewed, and assistance will again be requested to develop/finalize the necessary policies in accordance with Uniform Guidance. Policies will be review...

Management agrees with the finding. Management will spend additional time reviewing CFR Part 200 for familiarization. Policy templates will also be reviewed, and assistance will again be requested to develop/finalize the necessary policies in accordance with Uniform Guidance. Policies will be reviewed and approved by the Board regularly.

View Audit 413215

Finding 1238366 (2025-001)

Material Weakness 2025

Pennsylvannia Certified Organic

PA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

Corrective Action Plan Steps & Status - Complete All planned remediation measures have been fully implemented, including strengthened authentication and access controls across ﬁnancial institutions, enhanced transaction monitoring, updated authorization policies, a reassessment of banking relationsh...

Corrective Action Plan Steps & Status - Complete All planned remediation measures have been fully implemented, including strengthened authentication and access controls across ﬁnancial institutions, enhanced transaction monitoring, updated authorization policies, a reassessment of banking relationships, and increased staff training and cyber insurance coverage. 1. Multi-factor Authentication for all ﬁnancial institutions and key business systems 2. Segregation of user controls for all ﬁnancial institutions 3. ACH/wire limit review of all ﬁnancial institutions 4. ACH and Positive Pay enabled for operating account 5. New Vendor / Vendor changes policy 6. Reassess Banking Institutions for security and alignment with PCO banking needs 7. Ongoing staff cyber security training 8. Increase Cyber insurance coverage

View Audit 413210

Finding 1238363 (2025-002)

Material Weakness 2025

CAPITAL CITY AREA COUNCIL FOR SPECIAL SERVICES

MO

Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Board of Directors be aware of the internal control deficiencies over financial reporting. And, if possible, implement procedures to ensure that the Organization has the expertise necessary to prevent, detect and correct misstatements and be capable of drafting ...

Recommendation: We recommend that the Board of Directors be aware of the internal control deficiencies over financial reporting. And, if possible, implement procedures to ensure that the Organization has the expertise necessary to prevent, detect and correct misstatements and be capable of drafting the financial statements, related footnote disclosures and SEFA in accordance with the accounting principles generally accepted in the United States of America (U.S. GAAP).

View Audit 413199

Finding 1238363 (2025-002)

Material Weakness 2025

CAPITAL CITY AREA COUNCIL FOR SPECIAL SERVICES

MO

Reporting Internal Control / Segregation of Duties

Views of responsible officials and planned corrective actions: The Board believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than...

Views of responsible officials and planned corrective actions: The Board believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than the competence required to prepare the financial statements, related footnote disclosures and SEFA in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP).

View Audit 413199

Finding 1238362 (2025-001)

Material Weakness 2025

CAPITAL CITY AREA COUNCIL FOR SPECIAL SERVICES

MO

Recommendation: We recommend the Organization immediately open a general ledger account for the unrecorded investment account and implement and enforce a formal policy requiring all investment accounts to be approved by the Board of Directors and recorded in the general ledger immediately upon openi...

Recommendation: We recommend the Organization immediately open a general ledger account for the unrecorded investment account and implement and enforce a formal policy requiring all investment accounts to be approved by the Board of Directors and recorded in the general ledger immediately upon opening.

View Audit 413199

Finding 1238362 (2025-001)

Material Weakness 2025

CAPITAL CITY AREA COUNCIL FOR SPECIAL SERVICES

MO

View of responsible officials and planned corrective actions: The Board concurs with the recommendation that the Organization establish a formal policy requiring all investment accounts be recorded in the general ledger immediately upon opening. The investment account was set up on the general ledge...

View of responsible officials and planned corrective actions: The Board concurs with the recommendation that the Organization establish a formal policy requiring all investment accounts be recorded in the general ledger immediately upon opening. The investment account was set up on the general ledger as soon as the finding was discussed with management.

View Audit 413199

Finding 1238361 (2025-006)

Material Weakness 2025

Boys & Girls Club of Athens INC

GA

Allowable Costs / Cost Principles

Management will reimburse the County for unallowable costs. Management will also strengthen internal controls over cost allowability, including staff training, implementation of formal pre-approval process, and a documented review checklist prior to reimbursement submission related to federal progra...

Management will reimburse the County for unallowable costs. Management will also strengthen internal controls over cost allowability, including staff training, implementation of formal pre-approval process, and a documented review checklist prior to reimbursement submission related to federal programs to ensure compliance.

View Audit 413198

Finding 1238360 (2025-005)

Material Weakness 2025

Boys & Girls Club of Athens INC

GA

Procurement, Suspension & Debarment

Management will update the written conflict of interest policy to clearly define disclosure requirements. All employees and board members involved in procurement will complete an annual conflict of interest disclosure form. The Chief Executive Officer and Director of Finance will review and maintain...

Management will update the written conflict of interest policy to clearly define disclosure requirements. All employees and board members involved in procurement will complete an annual conflict of interest disclosure form. The Chief Executive Officer and Director of Finance will review and maintain all conflict of interest disclosures prior to awarding any contract. Staff training on conflict of interest compliance with be conducted by December 31, 2026.

View Audit 413198

Finding 1238359 (2025-004)

Material Weakness 2025

Open Cities Health Center, Inc. and Affiliate

MN

Material Weakness Reporting

Finding 2025-004 Compliance Requirement: Reporting Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: The report for the year ending December 31, 2024, was not filed within the required report...

Finding 2025-004 Compliance Requirement: Reporting Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: The report for the year ending December 31, 2024, was not filed within the required report submission period. Action Planned in Response to the Finding: The new management team has established transparency with the Finance Committee and the Governing Board to increase accountability and have established a regiment which includes timely audit engagement and monthly and annual checklists that ensure deadlines are met. Implementation of this new process was completed after the 2024 audit report was due. Official Responsible for Ensuring the CAP: Bruce Craven Planned Completion Date: December 2025 Planned Completion Date: December 2025

View Audit 413186

Finding 1238356 (2025-003)

Material Weakness 2025

Open Cities Health Center, Inc. and Affiliate

MN

Special Tests & Provisions Eligibility Material Weakness

Finding 2025-003 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testing th...

Finding 2025-003 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Material Weakness Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testing the Federal Poverty Guideline (FPG), thirteen files did not contain verification that the patient had no income. Also, 5 files did not contain evidence of review by the Health Center’s staff. Action Planned in Response to the Finding: In 2025, the collection and retention of sliding fee discount qualifying documents were integrated and the calculation performed by the clinic’s electronic medical record system so the prior paper system of documentation was replaced by the EMR’s audit trail reporting. Since HRSA chapter 9 Demonstrating Compliance section G states patients refusing to provide income or family size is an exception to the need for records, this input cell was left blank. Going forward, if a patient declines to provide proof requested, we will request patient sign a form and will add a comment that patient declines to provide this information. To address the evidence of review issue, this was a potential issue when we had the paper process but now that we are electronic, all access to determine sliding fee discount is captured with name of employee and a time stamp. Official Responsible for Ensuring the CAP: Darian Davis Planned Completion Date: December 2026

View Audit 413186

Corrective Action Plans

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