Corrective Action Plans

Finding 1236508 (2025-005)

Material Weakness 2025

AK

Procurement, Suspension & Debarment § 200.317 § 200.319 § 200.320 § 200.327

Finding 2025-005: Noncompliance over Procurement Name of Contact: Chris Pallister, Executive Director Corrective Action: Management will establish and maintain written procurement procedures as specified in the Uniform Guidance procurement standards. For purchases and contracts exceeding $50,000 ann...

Finding 2025-005: Noncompliance over Procurement Name of Contact: Chris Pallister, Executive Director Corrective Action: Management will establish and maintain written procurement procedures as specified in the Uniform Guidance procurement standards. For purchases and contracts exceeding $50,000 annually the Organization will publish RFP’s on SAM.gov at least 60 days prior to the project start date. The RFP’s will include the following aspects: • Scope of Work (SOW) or Performance Work Statement (PWS): The RFP should clearly define the project objectives, tasks, and expected deliverables. • Instructions to Bidders: Detail how proposals must be formatted, page limits, and precise submission directions. • Evaluation Criteria: State how bids will be scored (e.g., technical approach, past performance, and price weighting). • Federal Provisions: Include required federal clauses (such as Buy American requirements or Uniform Guidance standards. Any proposals received in response to the RFP will be considered. Proposed Completion Date: November 15, 2026.

View Audit 412036

Finding 1236507 (2025-004)

Material Weakness 2025

GULF OF ALASKA KEEPER

AK

Allowable Costs / Cost Principles § 200.1 § 200.516

Finding 2025-004: Noncompliance Over Activities Allowed or Unallowed/Allowable Costs/Cost Principles Name of Contact: Eileen Zaiser, Controller Corrective Action: Management will set-forth in writing its long-standing implicit policy that charges to federal awards will be disallowed without adequate...

Finding 2025-004: Noncompliance Over Activities Allowed or Unallowed/Allowable Costs/Cost Principles Name of Contact: Eileen Zaiser, Controller Corrective Action: Management will set-forth in writing its long-standing implicit policy that charges to federal awards will be disallowed without adequate documentation to support compliance with grant and regulatory requirements. Proposed Completion Date: October 1, 2026.

View Audit 412036

Finding 1236506 (2025-003)

Material Weakness 2025

GULF OF ALASKA KEEPER

AK

Reporting Significant Deficiency

Finding 2025-003: Noncompliance over Reporting Name of Contact: Eileen Zaiser, Controller Corrective Action: Controller will maintain a digital calendar with multiple reminders of program reporting dates to begin one month in advance of each due date. He/she will relay due-date reminders to responsi...

Finding 2025-003: Noncompliance over Reporting Name of Contact: Eileen Zaiser, Controller Corrective Action: Controller will maintain a digital calendar with multiple reminders of program reporting dates to begin one month in advance of each due date. He/she will relay due-date reminders to responsible staff and monitor status of report completion to ensure timely submission. Proposed Completion Date: September 10, 2026.

View Audit 412036

Finding 1236505 (2025-002)

Material Weakness 2025

GULF OF ALASKA KEEPER

AK

Cash Management Subrecipient Monitoring § 200.305

Finding 2025-002: Noncompliance over Cash Management Name of Contact: Chris Pallister, Executive Director Corrective Action: Federal cash drawdowns will be based on cash needs not to exceed 30 days. In collaboration with the Exec Director, Controller will prepare a report of anticipated cash disburs...

Finding 2025-002: Noncompliance over Cash Management Name of Contact: Chris Pallister, Executive Director Corrective Action: Federal cash drawdowns will be based on cash needs not to exceed 30 days. In collaboration with the Exec Director, Controller will prepare a report of anticipated cash disbursements for each month, along with projected ending grant funds on hand. The report will be submitted to the Exec Director or Treasurer for review and to request written approval for the drawdown. Such approval shall be obtained prior to requesting the drawdown. Cash draw requests will be reconciled to actual program expenditures on a quarterly basis. Proposed Completion Date: October 1, 2026.

View Audit 412036

Finding 1236504 (2025-001)

Material Weakness 2025

GULF OF ALASKA KEEPER

AK

Allowable Costs / Cost Principles Significant Deficiency

Finding 2025-001: Lack of Internal Control over Activities Allowed or Unallowed and Allowable Cost Principles – Cash Disbursements – Approvals Name of Contact: Chris Pallister, Executive Director Corrective Action: The Organization will establish a Purchase Order system. Purchases exceeding $500 in ...

Finding 2025-001: Lack of Internal Control over Activities Allowed or Unallowed and Allowable Cost Principles – Cash Disbursements – Approvals Name of Contact: Chris Pallister, Executive Director Corrective Action: The Organization will establish a Purchase Order system. Purchases exceeding $500 in a single transaction will require a PO. Purchase order approvals will be restricted to specified personnel or directors who are responsible for monitoring the budget. Approved PO’s will be recorded and matched to the respective purchases in the accounting system by the Controller. Contracts requiring recurring or variable payments will be assigned a Blanket Purchase Order. Those payments exceeding $25,000 will require written approval from the Board Treasurer. Proposed Completion Date: September 15, 2026.

View Audit 412036

Finding 1236499 (2025-006)

Material Weakness 2025

Chicago Housing Authority

IL

Procurement, Suspension & Debarment Subrecipient Monitoring HUD Housing Programs § 200.303 § 200.318 § 200.319 § 200.320

Finding 2025-006 I. Procurement, Suspension and Debarment Procurement Approval and Executed Agreement Compliance Management agrees with the finding and has outlined the following corrective actions: • Obtain Board approval for a new intergovernmental agreement for Chicago Police Department at the Se...

Finding 2025-006 I. Procurement, Suspension and Debarment Procurement Approval and Executed Agreement Compliance Management agrees with the finding and has outlined the following corrective actions: • Obtain Board approval for a new intergovernmental agreement for Chicago Police Department at the September 2026 board meeting. • Complete a full review of 2025 and 2026 procurement files by the end of Q1-2027 to ensure all required Board approvals and executed agreements are retained. • Strengthen internal workflows to prevent procurement actions from proceeding without verified approvals and executed agreements through inclusion of a new checklist which will be reflected in an updated standard operating procedures (SOP). • Provide refresher training to procurement staff on 2 CFR 200 documentation retention requirements by December 2026. Suspension and Debarment Compliance Management concurs with the findings and will implement: • Semiannual targeted training to reinforce staff responsibilities for verifying vendor eligibility and documenting compliance to begin December 2026. • Enhanced managerial monitoring through a standardized checklist to ensure required suspension/debarment checks are completed and retained before issuing purchase orders. Implemented January 2027. Responsible for Corrective Action: Tamika Carson, Director of Procurement; Sheila Johnson, Deputy Chief Procurement Anticipated Completion Date: Q1-2027

View Audit 412020

Finding 1236498 (2025-004)

Material Weakness 2025

Chicago Housing Authority

IL

HUD Housing Programs § 200.303

Finding 2025-004 N. Special Tests and Provisions: H6. Housing Assistance Payment HCV: CHA acknowledges the auditors’ interpretation regarding the HUD‑52641A Tenancy Addendum but maintains that participant signatures are not required under HUD regulations or standard program practice. The auditors’ p...

Finding 2025-004 N. Special Tests and Provisions: H6. Housing Assistance Payment HCV: CHA acknowledges the auditors’ interpretation regarding the HUD‑52641A Tenancy Addendum but maintains that participant signatures are not required under HUD regulations or standard program practice. The auditors’ position that the Tenancy Addendum must be signed by the participant in order to be executed is based on the 2025 Compliance Supplement, not on HUD regulation or normal program operations. HCV has provided sufficient evidence that all HAP contracts have been fully executed in accordance with HUD regulations. All HAP issued during the audit period was accurate based on income calculations provided by the family at program admission or during the most recent regular or interim recertification. HCV will continue to seek updated guidance from HUD regarding the execution of the HAP contract which includes the Tenancy Addendum. No further actions are warranted. Low Rent & RAD: CHA Management centralized the RAD rent‑increase process under a single Asset Manager in Q4-2025, with full control procedures implemented in Q2-2026 to ensure consistent tracking, timely processing, and stronger accountability. The Asset Manager now manages owner outreach, request review and submission, Yardi updates, management‑firm coordination, and quality‑control verification, while maintaining complete documentation of approvals and system updates. A standard operating procedure (SOP) formalizing this process will be completed by Q3-2026. The centralized process applies through 2026, with responsibilities planned to return to individual asset managers in 2027. Responsible for Corrective Action: Solonge Robinson, Director of Asset Management Anticipated Completion Date: 3Q-2026

View Audit 412020

Finding 1236497 (2025-003)

Material Weakness 2025

Chicago Housing Authority

IL

HUD Housing Programs Special Tests & Provisions § 200.303

Finding 2025-003 N. Special Tests and Provisions: N4. NSPIRE/Housing Quality Standards Inspections HCV generally agrees with the recommendation to follow its established internal controls over HQS/NSPIRE inspections as outlined in its HCV Administrative Plan. HCV Inspections Compliance team will rev...

Finding 2025-003 N. Special Tests and Provisions: N4. NSPIRE/Housing Quality Standards Inspections HCV generally agrees with the recommendation to follow its established internal controls over HQS/NSPIRE inspections as outlined in its HCV Administrative Plan. HCV Inspections Compliance team will review inspection scheduling procedures of contracted HCV inspections team to ensure HQS/NSPIRE inspections are scheduled and conducted biennially in accordance with the Inspections Guidebook and HCV Administrative Plan. Yardi and Power BI reporting will be generated and employed to aid tracking of inspections scheduling practices. Also, HCV will update guidance in its Administrative Plan to mirror HUD regulations in relation to timelines of inspections conducted. Responsible for Corrective Action: Roberto Galvez, HCV Inspections Compliance Manager Anticipated Completion Date: Q4-2026

View Audit 412020

Finding 1236496 (2025-002)

Material Weakness 2025

Chicago Housing Authority

IL

Subrecipient Monitoring HUD Housing Programs Internal Control / Segregation of Duties § 200.303

Finding 2025-002 N. Special Tests and Provisions: N16. Environmental Contaminants Testing and Remediation Low-Rent and RAD (UPCS): Management has designed a control to further strengthen work order compliance. The control includes: • As CHAs third party vendor completes its NSPIRE inspections, the P...

Finding 2025-002 N. Special Tests and Provisions: N16. Environmental Contaminants Testing and Remediation Low-Rent and RAD (UPCS): Management has designed a control to further strengthen work order compliance. The control includes: • As CHAs third party vendor completes its NSPIRE inspections, the Property and Office Management team will run a report day of inspection and/or day after to capture/identify work orders requiring 24hr completion. • CHA monitors 24-hour work orders daily and generates weekly remediation reports covering all required timeframes (24-hour, 30-day, 60-day). • Weekly reports are generated by CHA and provided to the PPMs for review and work order closure. • Work orders which remain open past due dates trigger warning letters to the respective property managers. Additionally, comments are added to the weekly reports to document reasons for outstanding compliance. Weekly reports are stored on SharePoint and accessible by management. • Property Managers are provided with warning letters for untimely closed work orders. 3 warning letters triggers a default by the PPM as enacted by the Department of Procurement and Contracts. • The above process has been enacted as of Aug 2026 and will be captured in a standard operating procedure (SOP) by Q3-2026. Responsible for Corrective Action: Anthony Myers, Director, Property Operations; Takina Clark, Property Operations; Pamela Fairley, Director RAD Anticipated Completion Date of: 3Q-2026 Low-Rent and RAD (Environmental): The Green and Healthy Homes Program, in coordination with Property Operations and Private Property Management (PPM), is implementing process improvements to strengthen environmental contaminant testing, moisture assessment, and mold remediation practices across CHA properties. Key actions include finalizing internal, partner, and vendor guidelines and SOPs—covering product specifications, guidance, and decision mapping—targeted for distribution in Q4-2026. CHA established a dedicated environmental vendor pool as of September 1, 2026, enabling standardized training and compliance monitoring for moisture assessments and remediation work. PPM staff will receive ongoing quarterly training on identifying and triaging suspected mold, implementing prevention strategies, and applying best practice remediation responses. Resident education will focus on prevention and safe housekeeping practices. Pending the release of new Illinois Department of Public Health mold and moisture regulations, CHA will conduct targeted training and certification outreach to ensure compliance once rulemaking is complete. Two PPM training sessions were completed in Q2 & Q3 2026. Completion and ongoing compliance will be validated through (a) workflow process improvement efforts, (b) distribution of updated guidelines/SOPs, (c) implementation of quality assurance audits of remediation work (sampling one out of every four relevant projects), and (d) enhanced data capture within Yardi to support screening during inspections. Relevant projects include work orders that are flagged as either mold/moisture or lead-based paint hazard. Audits will include a desktop review to determine whether property is a target property (per building year data and 24 CFR Part 35) and whether property management took appropriate moisture/mold remediation steps or lead-safe work practices. Responsible for Corrective Action: Elizabeth Poole, Director Healthy Homes Anticipated Completion Date: Q4-2026

View Audit 412020

Finding 1236495 (2025-001)

Material Weakness 2025

Chicago Housing Authority

IL

HUD Housing Programs § 200.303

Finding 2025-001 E. Eligibility, L. Reporting (Form HUD-50058 MTW), and N. Special Tests and Provisions – N1. Waiting List, N2. Reasonable Rent, N3. Utility Allowance Schedule, N6. Housing Assistance Payment HCV: HCV generally agrees with the recommendation to strengthen policies, procedures, and in...

Finding 2025-001 E. Eligibility, L. Reporting (Form HUD-50058 MTW), and N. Special Tests and Provisions – N1. Waiting List, N2. Reasonable Rent, N3. Utility Allowance Schedule, N6. Housing Assistance Payment HCV: HCV generally agrees with the recommendation to strengthen policies, procedures, and internal controls surrounding the timeliness of ensuring program eligibility. HCV notes that no ineligible households were identified during the audit period. HCV Program Compliance team will review quality control procedures of HCV program administrators to ensure processes are sound and efficient, proper controls are in place and regular recertifications are conducted and submitted to the U.S. Department of Housing and Urban Development (HUD) completely and timely. HCV will work closely with the CHA Internal Audit team to create an audit plan to ensure established strengthened procedures and internal controls are effective. Responsible for Corrective Action: Isaelena Albarran, HCV Program Compliance Manager Anticipated Completion Date: Q2-2027 Low-Rent and RAD: CHA is strengthening internal controls and oversight for Public Housing and RAD tenant file compliance through 2027. CHA has issued a request-for-proposal for a comprehensive 100% tenant file audit to address deficiencies in eligibility, reexaminations, documentation, income/rent calculations, and HUD 50058 reporting. As part of this effort, CHA Compliance will also assess enhancements to electronic document management systems to improve document completeness and support streamlined, accountable workflows. CHA will reinforce Perfect File standards, update written procedures and controls, and provide standardized training to Private Property Management firms (PPMs) and staff on core compliance requirements and common deficiencies. PPMs will remain responsible for maintaining compliant files. CHA will improve tracking of findings and corrective actions, including accountability, due dates, escalation for overdue or repeat issues, and enforcement when appropriate. CHA Compliance will monitor the 100% audit, report on progress and trends, and use results to assess control effectiveness and determine needed training, guidance, and management actions. Responsible for Corrective Action: Iwona Kowalska, Director of Compliance Anticipated Completion Date: 4Q-2027

View Audit 412020

Finding 1236485 (2025-005)

Material Weakness 2025

Chicago Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Finding 2025-005 N. Special Tests and Provisions: N4. Vacant Units HCV agrees with the auditor’s recommendation to reassess its internal control over vacant units to ensure claims are reduced or reduced in a timely manner. Project Based Voucher (PBV) Program Compliance staff will review and update w...

Finding 2025-005 N. Special Tests and Provisions: N4. Vacant Units HCV agrees with the auditor’s recommendation to reassess its internal control over vacant units to ensure claims are reduced or reduced in a timely manner. Project Based Voucher (PBV) Program Compliance staff will review and update written quality control procedures of PBV program administrators to ensure vacancy payment processes are efficient, properly controlled, and compliant with HUD requirements. PBV Program Compliance will provide updated procedures and training to all impacted teams. In addition, the HCV Program Compliance Manager will strengthen existing compliance monitoring activities to identify and address any exceptions related to vacancy payment processing. Responsible for Corrective Action: Isaelena Albarran, HCV Program Compliance Manager Anticipated Completion Date: Q4-2026

View Audit 412020

Finding 1236483 (2025-001)

Material Weakness 2025

California Invasive Plant Council

CA

Reporting Internal Control / Segregation of Duties

Finding Reference Number: 2025-001 Description of Finding: The annual SF-425 for the period ended June 30, 2025, was submitted on January 30, 2026, approximately four months after its September 30, 2025 due date. In addition, the first-quarter 2025 progress report was submitted on May 6, 2025, six d...

Finding Reference Number: 2025-001 Description of Finding: The annual SF-425 for the period ended June 30, 2025, was submitted on January 30, 2026, approximately four months after its September 30, 2025 due date. In addition, the first-quarter 2025 progress report was submitted on May 6, 2025, six days after its April 30, 2025 due date. Statement of Concurrence or Nonconcurrence: The California Invasive Plant Council agrees with the audit finding. Corrective Action: The California Invasive Plant Council Program team and Finance team will share a reminder of a report’s due date, with members of both teams invited, on their respective Outlook calendars with a pop-up reminder appearing at least 2 weeks prior to the due date of the reports. After a grant agreement is executed, a coordination meeting between the Director of Finance, Operations, and Administration (DFOA) and the Grants & Contracts Manager (GCM) will occur to identify the report due dates and address any other special grant needs. After the meeting, the GCM will send a list of the identified report due dates to the DFOA who will set the date reminder and invite members from both teams to it. The goal is to reconcile the grant expenses by both teams and to complete and review the report well in advance of the EPA (or other federal agency) due dates to ensure timely submission of required reports. Name of Contact Person: Jutta Burger, Executive Director, 510-843-3902 Ext 305 Projected Completion Date: The California Invasive Plant Council anticipates resolving this audit finding by October 2026. It will be monitored and confirmed by the Executive Director and/or the Director of Finance, Operations, and Administration, in association with the Grants & Contracts Manager and the Finance Team.

View Audit 412016

Finding 1236482 (2025-003)

Material Weakness 2025

Internews Network

CA

Subrecipient Monitoring § 200.303 § 200.329 § 200.331 § 200.333

Views of Responsible Officials: Management acknowledges the finding and agrees that certain subrecipient monitoring documentation requested during the audit was not available for review. Management believes that the underlying monitoring, oversight, and compliance procedures were performed in accord...

Views of Responsible Officials: Management acknowledges the finding and agrees that certain subrecipient monitoring documentation requested during the audit was not available for review. Management believes that the underlying monitoring, oversight, and compliance procedures were performed in accordance with organizational policies and Federal requirements during the period under audit. As with procurement activities, significant reductions in force following the termination of U.S. Government funding resulted in the rapid reassignment or discontinuation of responsibilities and limited the organization's ability to consolidate all supporting records. Documentation was maintained in multiple locations, and not all files were transitioned to a centralized repository before staff departures occurred. As a result, management was unable to provide complete supporting documentation for all items selected for testing. To address this issue, management has already revised its subrecipient management and monitoring policy. The updated policy clearly defines roles, responsibilities, record retention requirements, and documentation standards within the organization's current operating structure. The revised policy has been formally communicated and distributed across the organization. Management believes these actions will strengthen accountability, improve documentation consistency, and enhance the accessibility of subrecipient records in the future.

View Audit 412014

Finding 1236481 (2025-002)

Material Weakness 2025

Internews Network

CA

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.327

Views of Responsible Officials: Management acknowledges the finding and agrees that certain procurement files requested during the audit could not be located or produced in complete form. Management believes that procurement activities were conducted in accordance with organizational policies and ap...

Views of Responsible Officials: Management acknowledges the finding and agrees that certain procurement files requested during the audit could not be located or produced in complete form. Management believes that procurement activities were conducted in accordance with organizational policies and applicable Federal requirements at the time the transactions occurred. However, following the rapid and significant reductions in force resulting from the termination of U.S. Government funding, not all procurement responsibilities and records were fully transitioned to remaining personnel. Functions were discontinued on an accelerated timeline, resulting in procurement documentation being maintained across multiple systems and storage locations rather than within a single centralized repository. Consequently, certain supporting records could not be readily retrieved during the audit.Management has initiated a comprehensive revision of its procurement policy and related procedures. The revised policy will require centralized storage of procurement documentation and establish clearer accountability for records management. In addition, roles and responsibilities will be more clearly defined within the organization's current structure to promote consistency, continuity, and accessibility of procurement records going forward.

View Audit 412014

Finding 1236480 (2025-001)

Material Weakness 2025

Internews Network

CA

Subrecipient Monitoring Reporting § 200.303

Views of Responsible Officials: Management acknowledges the finding and the challenges encountered in providing supporting documentation for FFATA reporting activities during the audit. Management maintains that established FFATA reporting procedures were followed and that required reporting activit...

Views of Responsible Officials: Management acknowledges the finding and the challenges encountered in providing supporting documentation for FFATA reporting activities during the audit. Management maintains that established FFATA reporting procedures were followed and that required reporting activities were performed during the period under audit. Following the abrupt termination of significant U.S. Government funding, Internews implemented substantial reductions in force that affected personnel responsible for grant compliance, reporting oversight, and record retention. As a result, key staff members with primary responsibility for FFATA reporting and supporting documentation were no longer available to assist with the retrieval, explanation, or validation of records requested during the audit process. While management believes that applicable FFATA reporting requirements were met, the organization was unable to provide sufficient supporting documentation to demonstrate compliance for all items selected for testing. Management recognizes the need to strengthen record retention and knowledge-transfer procedures to ensure continuity of documentation during periods of organizational transition and staffing reductions. Management will evaluate opportunities to further centralize reporting records and strengthen controls surrounding the retention of compliance documentation.

View Audit 412014

Finding 1236341 (2025-003)

Material Weakness 2025

Community Foundation of Northern Nevada

NV

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.303

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer ...

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer of the quarterly financial reports. Corrective Action Plan: Previous reports were compiled by the Foundation’s vendors and submitted by the prior CFO. Future reports will be prepared by the Accountant and reviewed by the CFO prior to submission. Responsible Individuals: Alisha Kinnison, Accountant and Matt Lazar, CFO Anticipated Completion Date: July 2025

View Audit 412006

Finding 1236340 (2025-002)

Material Weakness 2025

Community Foundation of Northern Nevada

NV

Procurement, Suspension & Debarment

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have adequate internal controls to ensure contracts under federal awards contained all of the applicable provisions or...

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have adequate internal controls to ensure contracts under federal awards contained all of the applicable provisions or to ensure procedures were followed to verify an entity was not suspended or debarred prior to entering into a covered transaction. Corrective Action Plan: The Foundation has procedures in place to verify an entity was not suspended or debarred; however, documentation was not retained of procedures performed. The Foundation will retain evidence of steps taken to verify an entity is not suspended or debarred prior to entering into future covered transactions. Responsible Individuals: Ross Kemper, Controller, and Matt Lazar CFO Anticipated Completion Date: July 2025

View Audit 412006

Finding 1236339 (2025-001)

Material Weakness 2025

Keene Housing

NH

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency

Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: The Authority should implement a process and control to ensure that all proper documentation is being maintained for HQS inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit...

Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: The Authority should implement a process and control to ensure that all proper documentation is being maintained for HQS inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Keene Housing has implemented a process to ensure that all proper documentation is being maintained for HQS inspections. Name(s) of the contact person(s) responsible for corrective action: Ellen Wishart, Director of Voucher Program Planned completion date for corrective action plan: immediately, August 1, 2026

View Audit 412003

Finding 1236337 (2025-005)

Material Weakness 2025

Kanabec County

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

ALLOWABLE COSTS Recommendation: It is recommended the County implement procedures to ensure appropriate individuals are included in the account codes used for reporting and on the random moment studies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...

ALLOWABLE COSTS Recommendation: It is recommended the County implement procedures to ensure appropriate individuals are included in the account codes used for reporting and on the random moment studies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure appropriate individuals are included. Name of the contact person responsible for corrective action plan: Kelly Christianson, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2026

View Audit 412000

Finding 1236335 (2025-004)

Material Weakness 2025

Kanabec County

MN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

CASEFILE REVIEWS Recommendation: It is recommended the County implement procedures to ensure proper documentation in the casefiles and that it matches the information input into the eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. A...

CASEFILE REVIEWS Recommendation: It is recommended the County implement procedures to ensure proper documentation in the casefiles and that it matches the information input into the eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will retain documentation related to applicable federal requirements. Name of the contact person responsible for corrective action plan: Kelly Christianson, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2026

View Audit 412000

Finding 1236333 (2025-001)

Material Weakness 2025

County of Lehigh

PA

Eligibility

The County will ensure that when a person turns 18, funding will be terminated per the grant requirements. Responsible Official: Joshua Bridges, Director of Human Services. Contact Information : 610-782-3551. Anticipated Resolution Date: Immediately

View Audit 411991

Finding 1236332 (2025-003)

Material Weakness 2025

Big Apple Institute INC

NY

Procurement, Suspension & Debarment School Nutrition Programs

On behalf of the finding 25-03- The following changes will be implemented: Food purchases will be reconciled to planned menus, required portion sizes, actual meals served, and vendor purchase records. Shopping lists will be prepared and maintained based on menu requirements and the anticipated or ac...

On behalf of the finding 25-03- The following changes will be implemented: Food purchases will be reconciled to planned menus, required portion sizes, actual meals served, and vendor purchase records. Shopping lists will be prepared and maintained based on menu requirements and the anticipated or actual number of servings. Commodity items, substitutions, changes in quantities, and other variations between planned purchases and actual food usage will be clearly documented and explained. Management will review the reconciliation records periodically to ensure that food purchases are reasonable, properly supported, and consistent with program requirements. The enforcement of the procedure of business credit card purchases will be in effect starting October 2026.

View Audit 411985

Finding 1236329 (2025-002)

Material Weakness 2025

Special Health Resources for Texas, Inc.

TX

Subrecipient Monitoring Material Weakness Program Income

SHR will correct the identified non-Ryan White Part B (RWB) patients who were incorrectly included in the RWB program income. The corrective action consists of generating a report of all RWB patients and matching this report to a separate report listing patient receipts collected. This process will ...

SHR will correct the identified non-Ryan White Part B (RWB) patients who were incorrectly included in the RWB program income. The corrective action consists of generating a report of all RWB patients and matching this report to a separate report listing patient receipts collected. This process will occur on a monthly basis, with RW program collections being posted as community income. This process will also include reconciling the results with an independent report generated by our external collection agency. This QA procedure will ensure that patients included in the RWB program income report are appropriately classified as RWB patients and are not community clinic patients who are not eligible for inclusion in RWB program income. SHR will continue to monitor the effectiveness of these controls and will make additional adjustments as necessary to ensure that RWB program income is accurately classified, recorded, and reported in accordance with applicable program requirements.

View Audit 411958

Finding 1236328 (2025-001)

Material Weakness 2025

Special Health Resources for Texas, Inc.

TX

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Previous corrective actions included revised registration forms, pre-visit schedule preparation, post-visit audits, and staff training. While these measures improved monitoring, SHR identified the need for stronger point-of-service controls and increased operational oversight. We are revising our SF...

Previous corrective actions included revised registration forms, pre-visit schedule preparation, post-visit audits, and staff training. While these measures improved monitoring, SHR identified the need for stronger point-of-service controls and increased operational oversight. We are revising our SFS and front-office policies and procedures to clearly define documentation requirements, staff responsibilities, and management accountability. A key revision will require patients requesting or renewing SFS eligibility to provide all required documentation at the time of service. The previous process allowing additional time after the visit to submit documentation will be discontinued. Patients without required documentation will be handled according to the revised policy regarding SFS eligibility and financial responsibility. SHR is also establishing an Assistant Director of Operations (ADOO) position responsible for standardized front-office training, monitoring, and accountability across all clinic locations. The ADOO will train front-office staff and Clinic Managers on SFS eligibility requirements, point-of-service documentation, and revised policies and procedures.The ADOO will conduct routine audits of SFS eligibility records and front-office documentation. Deficiencies will be documented and addressed with the applicable Clinic Manager and staff through retraining, corrective follow-up, and accountability measures as appropriate. Corrective actions will be tracked through resolution, with recurring or significant deficiencies escalated through Operations leadership. These strengthened point-of-service requirements, revised policies, standardized training, routine auditing, and defined accountability measures will provide SHR with a consistent process for identifying and correcting deficiencies and supporting sustained SFS compliance across all clinic locations.

View Audit 411958

Finding 1236327 (2025-001)

Material Weakness 2025

Shalom Health Care Center, Inc.

IN

Special Tests & Provisions Eligibility Significant Deficiency

Significant Deficiency Over Financial Reporting – The following steps have been taken or will be taken to address Finding 2025-001: • Shalom Health Care Center, Inc. has been updated the verbiage in the Sliding Fee Discount Schedule policy and procedures so that the definition of family in the polic...

Significant Deficiency Over Financial Reporting – The following steps have been taken or will be taken to address Finding 2025-001: • Shalom Health Care Center, Inc. has been updated the verbiage in the Sliding Fee Discount Schedule policy and procedures so that the definition of family in the policy better matches the procedures that were being implemented. • Shalom Health Care Center, Inc will be reviewing the updated Sliding Fee Discount Schedule policy and procedures with all employees. • Shalom Health Care Center, Inc will also make sure there is another level of review to make sure that the sliding fee discounts are assigned accordingly based on income and household size. Management did challenge this as being a Significant Deficiency and believes that it should be listed as a note. Management believes additional consideration should be given to the nature, scope, and impact of the exceptions before concluding that the matter constitutes a significant deficiency in compliance with 42 CFR 51c.303(f). The Organization maintained a Board of Directors approve Sliding Fee and Discount Program policy which highlight the family definition and income definition, maintained and annually updated its sliding fee discount schedule in accordance with applicable federal poverty guidelines. The issue identified by the auditors did not involve the design of the discount schedule itself or the incorporation of the federal poverty guidelines. Rather, the exceptions resulted from staff members applying an interpretation of family size that differed from the definition established in the Organization's internal policy when processing individual applications. Accordingly, management believes the audit report should clearly distinguish between an error in applying the Organization's internal methodology and a violation of a federal compliance requirement. Management has requested that the auditors identify the specific provision of 42 CFR 51c.303(f) that was allegedly violated in each of the three cited cases. Management does agree that the procedures did not follow the policy and that this is more of an issue of process and controls. Management respectfully disagrees with the Finding 2025-001, particularly the classification given as a Significant Deficiency and the characterization of the exceptions as noncompliance with the federal requirement cited in the finding. Management requested the auditors to reconsider whether the circumstances support classification as a Significant Deficiency. At a minimum, management requests that the finding clearly distinguish between (1) compliance with the federal requirement and (2) the Organization's internal procedures for determining family size and calculating the sliding fee discount. Based on the limited number of exceptions, the absence of questioned costs, the lack of evidence of intentional noncompliance, and the fact that the Organization maintained and updated its sliding fee schedule in accordance with the applicable poverty guidelines, management believe that the finding should have given a lesser finding classification and a note in the audit report.)

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