Corrective Action Plans

Finding 1182841 (2025-019)

Material Weakness 2025

State of Vermont

VT

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles

Reference Number: 2025-019 Prior Year Finding: 2024-020 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2401VTCCDD (10/1/2023 – 9/30/2026) 2501VTCCDD (10...

Reference Number: 2025-019 Prior Year Finding: 2024-020 Federal Agency: U.S. Department of Health and Human Services State Agency: Agency of Human Services Federal Program: CCDF Cluster Assistance Listing Number: 93.575, 93.596 Award Number and Year: 2401VTCCDD (10/1/2023 – 9/30/2026) 2501VTCCDD (10/1/2024 – 9/30/2027) Compliance Requirement: Special Tests and Provisions – Health and Safety Requirements Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: We recommend that the Agency review and enhance training monitoring procedures and controls to ensure that all child care providers complete required health and safety training. The Agency should update its training content to include all required elements and ensure that provider corrective action plans and documentation are properly maintained. Site visit documentation should clearly indicate the results of training requirement monitoring. Views of responsible officials: Management agrees with the finding. Corrective Action Plan: DCF-CDD continues their rule revision process and now has the added support of a project manager and legal counsel. The revision process has been rigorous, and the rules have undergone several drafts. The public has had another opportunity to provide feedback on the latest draft prior to the formal promulgation process. Additionally, CDD received technical assistance from our federal partners to ensure our rule revisions met all CCDF requirements and will continue to refer to this document as we move the rules towards promulgation. The proposed rules will address the findings documented in this audit related to the federal requirement that pre-service orientation includes the required eleven (11) healthy and safety topics which staff will be required to complete, “before being left alone with children, counted in staff to child ratios, or within one (1) month of starting employment, whichever comes first.” DCF-CDD submitted an RFP for a new pre-service orientation training to include all the required health and safety topics that must be covered within the first month of employment. CDD will continue to work with the apparent successful bidder to ensure these modules are available to the field in 2026. DCF-CDD licensing unit will review the results of the single audit with licensing staff and our partners at Northern Lights at CCV (NL). CDD will begin a shift in our site visit preparation process that includes NL providing the division with a complete list of staff who have and who have not completed the required number of annual training hours. CDD licensing will document deficiencies in site visit reports and will require a plan from the providers to come into compliance. Scheduled Completion Date of Corrective Action Plan: DCF-CDD anticipates the licensing rules will be submitted to ICAR on February 20, 2026. This date may need to shift dependent on legal counsel’s final review of the rules and the weeks needed to prepare the documents required at this stage in the promulgation. CDD will be provided with a promulgation timeline which we aim to have completed before the end of 2026. DCF-CDD will seek outside contractual support to develop guidance manuals and training for the field on the rule changes, which includes shifts in required pre-service orientation topics. DCF-CDD pre-service orientation modules are scheduled to be completed within six (6)-nine (9) months from when the contract has been signed between the SOV and the apparent successful bidder. DCF-CDD will implement the site visit preparation practice shift by April-May 2026. This work requires NL staff to shift job responsibilities to accommodate the ongoing training review of the staff for all providers. By January 26, 2026, CDD director of child care licensing will meet with the licensing supervisors to review the results of this audit, review the CAP, and establish a plan for supervisory oversight at it relates to licensors documenting training deficiencies when conducting site visits. By January 27, 2026, CDD director of child care licensing will meet with the licensing unit to review the results of this audit, review the CAP, discuss the shift in site visit preparation practice as we partner with NL who will be reviewing compliance with annual training hours, and discuss the expectations around how deficiencies must be documented in annual site visit reports. Contacts for Corrective Action Plan: Beth Maurer, Director of Child Care Licensing, elizabeth.maurer@vermont.gov Kelly Lyford, Licensing Supervisor, kelly.lyford@vermont.gov Janet McLaughlin, CDD Deputy Commissioner, janet.mclaughlin@vermont.gov Dawn Rouse, Director of Statewide Systems, dawn.rouse@vermont.gov Peter Moino, AHS Director of Internal Audit, peter.moino@vermont.gov

View Audit 394235

Finding 1182828 (2025-009)

Material Weakness 2025

State of Vermont

VT

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403

Reference Number: 2025-009 Prior Year Finding: 2024-009; 2023-007 and 2022-016 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: 25A55UI000119 (10/1/2024 – 12/31/2027) ...

Reference Number: 2025-009 Prior Year Finding: 2024-009; 2023-007 and 2022-016 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: 25A55UI000119 (10/1/2024 – 12/31/2027) UI370952155A50 (9/1/2021 – 5/22/2025) 23A60UB000019 (8/3/2023 – 5/22/2025) 24A60UD000052 (8/20/2024 – 8/20/2027) Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the Department review and enhance its procedures and controls regarding payment processing to ensure that, prior to charging costs to the program, they are reviewed by a supervisor who is knowledgeable of the regulations regarding allowable program costs and that documentation of the review is maintained. Views of responsible officials: Management agrees with the finding. Corrective Acton Plan: The Department has reviewed its procedures and internal controls, and we believe that they adequately require oversight and signoff of all expenditures to ensure that expenditures are adequately reviewed and signed off on. However, there is currently no double check to ensure that the accounting clerks are following these procedures. Department will be adding a secondary check to the procedure to occur at the end of each month to review expenditures for proper coding (cost center, project code and function code) as well as responsible party signoff. Scheduled Completion Date of Corrective Action Plan: May15, 2026 Contacts for Corrective Action Plan: Kristine Murphy, Director, Unemployment Insurance, kristine.murphy@vermont.gov Chad Wawrzyniak, Chief Financial Officer, chad.wawrzyniak@vermont.gov

View Audit 394235

Finding 1182826 (2025-007)

Material Weakness 2025

State of Vermont

VT

Allowable Costs / Cost Principles Period of Performance Subrecipient Monitoring § 200.303 § 200.308 § 200.309 § 200.403

Reference Number: 2025-007 Prior Year Finding: 2024-010; 2023-008: and 2022-017 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: 25A55UI000119 (10/1/2024 – 12/31/2027)...

Reference Number: 2025-007 Prior Year Finding: 2024-010; 2023-008: and 2022-017 Federal Agency: U.S. Department of Labor State Agency: Vermont Department of Labor Federal Program: Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Period: 25A55UI000119 (10/1/2024 – 12/31/2027) Compliance Requirement: Period of Performance Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend the Department review and enhance its procedures and controls to ensure that, prior to charging costs to the program, they are incurred within an award’s allowable period of performance and that payments are reviewed and approved by a supervisor who has knowledge of costs that are allowable under the program. Views of responsible officials: Management agrees with the finding. Corrective Acton Plan: The Department will review its procedures and internal controls and update as necessary to ensure that all expenditures incurred on an award fall within the allowable period of performance. Scheduled Completion Date of Corrective Action Plan: June 30, 2026 Contacts for Corrective Action Plan: Chad Wawrzyniak, Chief Financial Officer, chad.wawrzyniak@vermont.gov

View Audit 394235

Finding 1182817 (2025-007)

Material Weakness 2025

Circle of Nations School INC

ND

Allowable Costs / Cost Principles § 200.430

Allowable Costs/Activities Allowed or Unallowed Federal Financial Assistance Listing 15.042 Indian School Equalization Significant Deficiency in Internal Control over Compliance and Immaterial Instances of Noncompliance Findings Summary: During the course of the engagement, Eide Bailly LLP identifie...

Allowable Costs/Activities Allowed or Unallowed Federal Financial Assistance Listing 15.042 Indian School Equalization Significant Deficiency in Internal Control over Compliance and Immaterial Instances of Noncompliance Findings Summary: During the course of the engagement, Eide Bailly LLP identified an expenditure where payroll benefits were not paid in accordance with the employment letter. Responsible Individuals: Trevor Gourneau, Superintendent Corrective Action Plan: The School will review internal controls surrounding allowable costs and activities to exsure they are adequate to identify unallowable expenditures. Anticipated Completion Date: June 30, 2026

View Audit 394228

Finding 1182788 (2025-001)

Material Weakness 2025

Town of Longmeadow

MA

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Audit Finding Reference: 2025-001 Improve Oversight Over Period of Performance of Federal Awards Planned Corrective Action: To address the material weakness regarding the period of performance, the Longmeadow Public Schools will implement the following actions: Procedure Revision: The Longmeadow Pub...

Audit Finding Reference: 2025-001 Improve Oversight Over Period of Performance of Federal Awards Planned Corrective Action: To address the material weakness regarding the period of performance, the Longmeadow Public Schools will implement the following actions: Procedure Revision: The Longmeadow Public Schools will update internal control procedures to require that all invoices charged to federal grants explicitly state the dates of service. Staff pro-cessing invoices against Federal grant funds will be instructed to verify these dates against the au-thorized period of performance listed on the Grant Award Notification before processing payment. Staff Training: The Town will conduct mandatory training for the Special Education Department and central office administrative support staff. This training will focus on 2 CFR §200.309, specif-ically emphasizing that costs are only allowable if incurred during the approved budget period, re-gardless of when the invoice is received or paid. Name of Contact Person: Thomas Mazza, Assistant Superintendent for Finance and Operations, Longmeadow Public Schools, tmazza@longmeadow.k12.ma.us Completion Date: Prior to July 1, 2026

View Audit 394167

Finding 1182675 (2025-008)

Material Weakness 2025

School City of East Chicago

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Equipment & Real Property Management § 200.1 § 200.302 § 200.303 § 200.305 § 200.313

FINDING 2025-008 Finding Subject: COVID-19 - Education Stabilization Fund – Condition of Records Federal Agency: Department of Education Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Lela Simmons, CFO Contact Phone Number and Email Address: 219...

FINDING 2025-008 Finding Subject: COVID-19 - Education Stabilization Fund – Condition of Records Federal Agency: Department of Education Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Lela Simmons, CFO Contact Phone Number and Email Address: 219 391 4100 Ex 12365: lesimmons@ecps.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Internal controls will be put in place to ensure all COVID 19 ESSER Funds are reported accurately to the State and Federal Department of Education. Reimbursements will be attached to State Email for disbursement. Anticipated Completion Date: We anticipate having the above corrective action plan in place by October 31, 2026

View Audit 394104

Finding 1182653 (2025-003)

Material Weakness 2025

School City of East Chicago

IN

Allowable Costs / Cost Principles School Nutrition Programs Internal Control / Segregation of Duties § 200.303

FINDING 2025-003 Finding Subject: Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions - Non-Profit School Food Service Accounts Audit Findings: Material Weakness Contact Person Responsible for Corrective Action: Lela Simmons, CFO C...

FINDING 2025-003 Finding Subject: Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions - Non-Profit School Food Service Accounts Audit Findings: Material Weakness Contact Person Responsible for Corrective Action: Lela Simmons, CFO Contact Phone Number and Email Address: 219 391 4100 Ex 12365: lesimmons@ecps.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Food Service director responsibilities are to oversee all functions of the Food Management Company. Food Service Director will be required to draft internal controls and detail instruction for the school corporation to ensure all documentation procedures match the FSMC invoice. The school corporation will not pay any unallowable cost by state regulation and rules. All state reporting documents and invoice will continue to be reviewed and signed off by the district CFO. A copy of all documents will be held in the food director office Anticipated Completion Date: We anticipate having the above corrective action plan in place by October 31, 2026

View Audit 394104

Finding 1182627 (2025-001)

Material Weakness 2025

Cottonwood-Oak Creek Elementary School District No.6

AZ

Allowable Costs / Cost Principles School Nutrition Programs Significant Deficiency

Finding Number: 2025‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Business Manager, Food Service Director, and Business Office Staff Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The foll...

Finding Number: 2025‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Business Manager, Food Service Director, and Business Office Staff Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The following corrections will be implemented. 1. Review and update procedures for calculating indirect costs in accordance with USDA Memo SP 60‐2016 and 2 CFR Part 200. 2. Ensure use of the ADE‐approved unrestricted indirect cost rate annually. 3. Implement a standardized calculation worksheet to document allowable indirect cost limits. 4. Require review and approval of indirect cost calculations by the Business Manager prior to posting. 5. Provide training to business office staff on federal cost principles and Child Nutrition requirements. 6. Perform periodic internal reviews to ensure compliance.

View Audit 394062

Finding 1182624 (2025-003)

Material Weakness 2025

Ascension Health Alliance D/b/a Ascension

MO

Allowable Costs / Cost Principles

Finding 2025-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles, and Reporting Federal Grantor: U.S. Department of Homeland Security – Federal Emergency Management Agency (FEMA) Assistance Listing Number: 97.036, COVID-19 Disaster Grants - Public Assistance (Presidentially Dec...

Finding 2025-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles, and Reporting Federal Grantor: U.S. Department of Homeland Security – Federal Emergency Management Agency (FEMA) Assistance Listing Number: 97.036, COVID-19 Disaster Grants - Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management & Homeland Security Division Ascension Entity: Ascension Providence Rochester Hospital- Michigan Pass-Through Award Number: DR4494 - PW811 Pass-Through Award Period: 07/01/2021 - 6/30/2022 Views of responsible officials: Ascension acknowledges the inability to locate relevant documentation pertaining to the COVID classification for a specific patient with services during the COVID-19 public health emergency. Although the documentation was not located in this instance, patient care was appropriately provided. However, Ascension will sample test patient level encounter records at Ascension Providence Rochester Hospital prior to future revenue recognition to ensure appropriate documentation Responsible Official: Rob Madsen, Director of Accounting and Reporting, Grants & Research Anticipated completion date: June 30, 2026

View Audit 394059

Finding 1182621 (2025-001)

Material Weakness 2025

Ascension Health Alliance D/b/a Ascension

MO

Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2025-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing Number: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Entity: Stat...

Finding 2025-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing Number: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Entity: State of Tennessee Department of Health Ascension Ministry Market: Saint Thomas Medical Partners dba Ascension Medical Group (Ascension, Tennessee) Pass-Through Award Number: Not applicable Pass-Through Award Period: 11/1/2022-6/30/2026 Views of responsible officials: Ascension Grants & Research Department will reinforce the importance of timely approval of Time & Effort reports with appropriate personnel at Saint Thomas Medical Partners. Responsible Official: Rob Madsen, Director of Accounting and Reporting, Grants & Research Anticipated completion date: May 1, 2026

View Audit 394059

Finding 1182593 (2025-002)

Material Weakness 2025

Charles County Public Schools

MD

Allowable Costs / Cost Principles Period of Performance § 200.309 § 200.403

Special Education Cluster – Assistance Listing No. 84.173 Recommendation: We recommend that the Board strengthen internal controls over federal grant expenditure by implementing procedures to ensure costs are incurred within the approved period of performance prior to being charged to federal awards...

Special Education Cluster – Assistance Listing No. 84.173 Recommendation: We recommend that the Board strengthen internal controls over federal grant expenditure by implementing procedures to ensure costs are incurred within the approved period of performance prior to being charged to federal awards. This should include enhanced supervisory review, system controls where feasible, and training for staff responsible for grant accounting and compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To address this issue, the Board will implement the following corrective actions: 1. Enhanced Review Procedures: All payroll journal entries to reclassify expenditures charged to federal grants will be reviewed by Lead Staff Accountant and/or Budget Manager to verify that the time worked along with the transaction accounting date falls within the approved grant period of performance prior to posting. 2. System and Process Improvements: The Board will explore report customizations regarding payroll transactions to provide more visibility of the actual days worked regardless of the transaction accounting date. This system improvement will help prevent payroll journal entry reclassifications from being charged to grants outside of the approved period of performance. These procedures will strengthen internal controls over federal grant expenditures and help ensure compliance with federal regulations. Name(s) of the contact person(s) responsible for corrective action: Sherri Fisher-Davis Planned completion date for corrective action plan: March 2026

View Audit 394040

Finding 1182591 (2025-003)

Material Weakness 2025

The Center for Women & Families Inc.

KY

Allowable Costs / Cost Principles Cash Management Reporting

Recommendation: The Center for Women and Families, Inc. should implement processes and procedures and provide staff training in order to properly record time spent on program related grants and that time records should be maintained in manner to provide the requested support for any billings in a ti...

Recommendation: The Center for Women and Families, Inc. should implement processes and procedures and provide staff training in order to properly record time spent on program related grants and that time records should be maintained in manner to provide the requested support for any billings in a timely manner. Action Taken: The Center for Women and Families, Inc. has hired a new Vice President of Finance to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling all report documentation to maintained in a manner to smoothly support the reports being filed. Staff has also been trained on the proper procedures in documenting their time on time detail reports.

View Audit 394037

Finding 1182579 (2025-005)

Material Weakness 2025

City of South Portland, Maine

ME

Allowable Costs / Cost Principles Cash Management Reporting

Management response/corrective action plan: Management will ensure the amount discussed with the auditors is returned per instructions. Additionally, management will reconcile grant funds and will develop a periodic fund reconciliation process to ensure all credits and adjustments are considered whe...

Management response/corrective action plan: Management will ensure the amount discussed with the auditors is returned per instructions. Additionally, management will reconcile grant funds and will develop a periodic fund reconciliation process to ensure all credits and adjustments are considered when preparing reimbursement requests.

View Audit 394031

Finding 1182576 (2025-003)

Material Weakness 2025

Manchester School District

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

The District has historically managed our Title I grant as supplemental funding and has a methodology for allocating local funds to schools without regard to whether they receive Title I funds. During fiscal year 2025, the district developed procedures to document our process, however the methodolog...

The District has historically managed our Title I grant as supplemental funding and has a methodology for allocating local funds to schools without regard to whether they receive Title I funds. During fiscal year 2025, the district developed procedures to document our process, however the methodology was not included. The District will update the written procedure with the methodology to be in compliance with the Title I Supplement, Not Supplant requirement.

View Audit 394029

Finding 1182567 (2025-001)

Material Weakness 2025

Port Jervis City School District

NY

Allowable Costs / Cost Principles

The District will implement a system of internal controls to ensure that all certifications are completed by employees working in the federal award programs and in a timely manner. Additionally, the District will ensure that time being charged to the grant agrees to actual time spent working in the ...

The District will implement a system of internal controls to ensure that all certifications are completed by employees working in the federal award programs and in a timely manner. Additionally, the District will ensure that time being charged to the grant agrees to actual time spent working in the grant for each employee by sharing this information with building Principals to ensure that the information is accurate and they obtain the employee signature as soon as possible.

View Audit 394022

Finding 1182555 (2025-003)

Material Weakness 2025

Northwestern School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2025-003 Finding Subject: Child Nutrition Cluster- Internal Controls Contact Person Responsible for Corrective Action: Camden Parkhurst Contact Phone Number and Email Address: 765.457.8101, camden.parkhurst@nwsc.k12.in.us Views of Responsible Officials: We concur with the finding. Descriptio...

FINDING 2025-003 Finding Subject: Child Nutrition Cluster- Internal Controls Contact Person Responsible for Corrective Action: Camden Parkhurst Contact Phone Number and Email Address: 765.457.8101, camden.parkhurst@nwsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Activities Allowed or Unallowed, Allowable Cost/Cost Principals E-Funds has been automatically debited from our account since its inception. The auto debt was falling at a time each month that caused us to miss adding to our Allowance of Claims. We will correct the time that this is added to our statements so that it will make the Allowance of Claims for each month. Eligibility This was a one time issue when we were switching our software to Meal Magic. This was only related to one direct certification cluster to start the 23-24 school year. We have multiple people from our food service department prepare and sign off on direct certifications on a monthly basis to ensure we are accurate and complaint. Anticipated Completion Date: Immediate. INDIANA STATE

View Audit 394000

Finding 1182544 (2025-002)

Material Weakness 2025

Career Academy of South Bend, INC

IN

Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties

Recommendation: The school should strengthen its documentation retention and record management procedures to ensure that all transactions included in audit populations—regardless of fiscal year—are readily available and adequately supported. Management should also implement controls to verify that s...

Recommendation: The school should strengthen its documentation retention and record management procedures to ensure that all transactions included in audit populations—regardless of fiscal year—are readily available and adequately supported. Management should also implement controls to verify that supporting documentation is complete and accessible prior to submission for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has contracted with an outside firm to assist with developing the required Internal Controls and Processes with an estimated completion date of December 31, 2026. Name(s) of the contact person(s) responsible for corrective action: Mary Hunt, CFO. Planned completion date for corrective action plan: December of 2026.

View Audit 393976

Finding 1182538 (2025-004)

Material Weakness 2025

Navigator Schools

CA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.430

Management concurs with Finding 2025 - 4 and acknowledges that controls over the review and approval of timecards for federally funded staff were not consistently applied. In response, we will reinforce timekeeping expectations, clarify roles, and ensure that policies and procedures are aligned with...

Management concurs with Finding 2025 - 4 and acknowledges that controls over the review and approval of timecards for federally funded staff were not consistently applied. In response, we will reinforce timekeeping expectations, clarify roles, and ensure that policies and procedures are aligned with 2 CFR § 200.430. We will conduct targeted training for supervisors to reinforce expectations. Central office monitoring will now include quarterly internal audit reviews and follow-up, creating a continuous feedback loop that supports compliance. These enhancements reflect management’s commitment to ensuring that payroll charges to federal programs are accurate, well supported, and reliably documented going forward.

View Audit 393962

Finding 1182529 (2025-101)

Material Weakness 2025

Lead Charter Schools

AZ

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Eligibility § 200.430

CFDA NUMBER 84.010A – Title I Grants to Local Educational Agencies US Department of Education – 2025 Passed Through Arizona State Department of Education Project Number: 25FT1TTI-510414-01A Finding: Unallowable Personnel Costs Charged to Federal Grant Description of Finding During the fiscal year, t...

CFDA NUMBER 84.010A – Title I Grants to Local Educational Agencies US Department of Education – 2025 Passed Through Arizona State Department of Education Project Number: 25FT1TTI-510414-01A Finding: Unallowable Personnel Costs Charged to Federal Grant Description of Finding During the fiscal year, the school received reimbursement through a federal grant for services performed by an Instructional Assistant. It was subsequently identified that for a portion of this period the employee was temporarily reassigned to perform substitute teacher duties. Substitute teaching services are not an allowable activity under the federal grant for this position. As a result, a portion of payroll costs were inadvertently charged to the federal program. Corrective Action Taken The school conducted a review of payroll records and staff assignments to determine the time period during which the Instructional Assistant performed substitute duties. The payroll costs associated with that period have been identified and were removed from the federal grant and reclassified to an appropriate non-federal funding source. If applicable, the school will reimburse the federal program for any disallowed costs. Documentation supporting the adjustment and calculations will be maintained for audit and monitoring purposes. Steps to Prevent Recurrence To prevent similar issues in the future and ensure compliance with federal grant requirements, the following procedures will be implemented: School administration will notify the HR and finance office whenever federally funded staff are reassigned to duties outside the scope of the grant. The Payroll and HR administrators will review payroll allocations and staff assignments prior to submitting federal reimbursement requests.Time and effort documentation will be maintained for federally funded personnel to ensure that activities performed align with allowable grant requirements. Administrative and finance staff will be reminded of federal grant compliance expectations related to allowable personnel costs and documentation. Monitoring Process The payroll administrator will conduct periodic internal reviews of payroll allocations and federal reimbursement requests to confirm that personnel costs charged to federal programs align with documented duties and allowable activities. Any discrepancies identified will be corrected prior to submitting reimbursement requests. Responsible Parties School Administration and Payroll Administrator Implementation Date These procedures are effective immediately and will apply to all future federal grant reimbursement requests

View Audit 393954

Finding 1182528 (2025-101)

Material Weakness 2025

Leading Edge Academy Maricopa

AZ

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Eligibility § 200.430

CFDA NUMBER 84.010A – Title I Grants to Local Educational Agencies US Department of Education – 2025 Passed Through Arizona State Department of Education Project Number: 25FT1TTI-510397-01A Finding: Unallowable Personnel Costs Charged to Federal Grant Description of Finding During the fiscal year, t...

CFDA NUMBER 84.010A – Title I Grants to Local Educational Agencies US Department of Education – 2025 Passed Through Arizona State Department of Education Project Number: 25FT1TTI-510397-01A Finding: Unallowable Personnel Costs Charged to Federal Grant Description of Finding During the fiscal year, the school received reimbursement through a federal grant for services performed by an Instructional Assistant. It was subsequently identified that for a portion of this period the employee was temporarily reassigned to perform substitute teacher duties. Substitute teaching services are not an allowable activity under the federal grant for this position. As a result, a portion of payroll costs were inadvertently charged to the federal program. Corrective Action Taken The school conducted a review of payroll records and staff assignments to determine the time period during which the Instructional Assistant performed substitute duties. The payroll costs associated with that period have been identified and were removed from the federal grant and reclassified to an appropriate non-federal funding source. If applicable, the school will reimburse the federal program for any disallowed costs. Documentation supporting the adjustment and calculations will be maintained for audit and monitoring purposes. Steps to Prevent Recurrence To prevent similar issues in the future and ensure compliance with federal grant requirements, the following procedures will be implemented: School administration will notify the HR and finance office whenever federally funded staff are reassigned to duties outside the scope of the grant. The Payroll and HR administrators will review payroll allocations and staff assignments prior to submitting federal reimbursement requests. Time and effort documentation will be maintained for federally funded personnel to ensure that activities performed align with allowable grant requirements. Administrative and finance staff will be reminded of federal grant compliance expectations related to allowable personnel costs and documentation. Monitoring Process The payroll administrator will conduct periodic internal reviews of payroll allocations and federal reimbursement requests to confirm that personnel costs charged to federal programs align with documented duties and allowable activities. Any discrepancies identified will be corrected prior to submitting reimbursement requests. Responsible Parties School Administration and Payroll Administrator Implementation Date These procedures are effective immediately and will apply to all future federal grant reimbursement requests

View Audit 393953

Finding 1182524 (2025-001)

Material Weakness 2025

Hannibal-Lagrange University

MO

Student Financial Aid Allowable Costs / Cost Principles Eligibility

Finding Number: 2025-001 Considering Subsidized Loans First Planned Corrective Action: The financial aid office concurs with this finding. We have received guidance from our annual audit partners and will install updated processes to ensure that consideration of subsidized loans is prioritized durin...

Finding Number: 2025-001 Considering Subsidized Loans First Planned Corrective Action: The financial aid office concurs with this finding. We have received guidance from our annual audit partners and will install updated processes to ensure that consideration of subsidized loans is prioritized during the awarding process. Person Responsible for Corrective Action Plan: Brice Baumgardner, Vice President of Enrollment Management Anticipated Date of Completion: 4/1/2026

View Audit 393940

Finding 1182505 (2025-012)

Material Weakness 2025

State of Kansas

KS

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

Federal Agency: U.S. Department of Labor State Department/Agency: Kansas Department of Labor Federal Program Name: Unemployment Insurance (UI) Assistance Listing Number: 17.225 Award Number: Various Award Period: July 1, 2024 to June 30, 2025 Compliance Requirement: Activities Allowed or Unallowed &...

Federal Agency: U.S. Department of Labor State Department/Agency: Kansas Department of Labor Federal Program Name: Unemployment Insurance (UI) Assistance Listing Number: 17.225 Award Number: Various Award Period: July 1, 2024 to June 30, 2025 Compliance Requirement: Activities Allowed or Unallowed & Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: During test work of Activities Allowed or Unallowed & Allowable Costs/Cost Principles, one transaction was identified that lacked evidence that the transaction was reviewed. Recommendation: We recommend that the Department strengthen its review and monitoring procedures over federal expenditures to ensure that all transactions are appropriately reviewed for compliance with applicable federal program requirements. Management should implement controls to ensure transactions are adequately supported, reviewed in a timely manner, and documented, including supervisory review of expenditures charged to federal programs. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Management held a training session and reiterated the importance of proper approvals to pay invoices. Staff were reminded of the process of preparing invoices for payment. Additionally, the approval of vouchers procedures were updated to include checking to make sure proper approval was received for invoices prior to payment to provide a double check for the process. Name(s) of the contact person(s) responsible for corrective action: Dawn Palmberg, CFO Planned completion date for corrective action plan: Corrective action and retraining was implemented 12/16/2025.

View Audit 393917

Finding 1182500 (2025-008)

Material Weakness 2025

State of Kansas

KS

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment (KDHE) Federal Program Name: Medicaid Cluster Assistance Listing Numbers: 93.775, 93.777, 93.778 Award Period: July 1, 2024 through June 30, 2025 Award Number: Various Co...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment (KDHE) Federal Program Name: Medicaid Cluster Assistance Listing Numbers: 93.775, 93.777, 93.778 Award Period: July 1, 2024 through June 30, 2025 Award Number: Various Compliance Requirement: Special Tests and Provisions – Provider Health and Safety Standards Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: Kansas Department of Health and Environment (Department) was unable to provide supporting documentation that it had performed recertification surveys within the required timeframe which is used to meet the provider health and safety standards. Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. We recommend the Department ensure appropriate measures are in place to verify providers are meeting the prescribed health and safety and maintain all records of these verifications. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: In response to the findings, the SSA will initiate a comprehensive review of all surveys remaining open status within ACO to determine the scope and underlying causes of incomplete administrative closure. A structured tracking tool will be developed to reconcile each survey and verify that required documentation, compliance dates, and certification actions were properly entered. The SSA will engage CMS Regional Office for guidance and coordination on appropriate closure actions and implement enhanced quality assurance controls, including routine reconciliation and verification prior to finalizing surveys. This will hopefully prevent recurrence. The SSA is also in the process of upgrading its information technology software systems to accommodate these processes. The SSA will generate a report of all surveys remaining in open status in ACO and prioritize reviews of initial certification or recertifications surveys and enforcement-related cases. Each survey will be reconciled to confirm required actions. Each survey will be reconciled to confirm required actions were completed, including issuing of the CMS 2567, if applicable, acceptance of the plans of corrections, entry of revisit and compliance dates, and completion of certification actions. To help prevent recurrence, the SSA will implement routine ACO reconciliation and establish a Quality Assurance (QA) verification step prior to finalizing surveys. Name(s) of the contact person(s) responsible for corrective action: Jerry Smith, LSCSW, Bureau Director Marilyn St Peter, RN, Deputy Director Bureau of Facilities and Licensing Catherine Lenz BS RN, Deputy Bureau Director Planned completion date for corrective action plan: October 1, 2026

View Audit 393917

Finding 1182476 (2025-003)

Material Weakness 2025

Eastern Oregon University

OR

Allowable Costs / Cost Principles Eligibility Significant Deficiency § 200.303

Recommendation: We recommend the University enhance its procedures for reviewing professional judgement decisions to ensure that evidence of review is documented and retained Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to ...

Recommendation: We recommend the University enhance its procedures for reviewing professional judgement decisions to ensure that evidence of review is documented and retained Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will review its procedures and document retention practices to ensure that key controls related to professional judgment determinations are documented and evidenced for audit purposes. The University will evaluate existing processes and supporting records and will implement any needed improvements to strengthen documentation and audit support. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Director of Financial Aid Planned completion date for corrective action plan: Completed

View Audit 393884

Finding 1182464 (2025-001)

Material Weakness 2025

Frank B. Peers Senior Housing Ml-93

IL

Allowable Costs / Cost Principles HUD Housing Programs Reporting

Views of Responsible Officials and Planned Corrective Action Management agrees with the finding and is committed to strengthening our internal controls. We will review and enhance our invoice coding and approval procedures to ensure expenses are properly allocated to the correct property and to prev...

Views of Responsible Officials and Planned Corrective Action Management agrees with the finding and is committed to strengthening our internal controls. We will review and enhance our invoice coding and approval procedures to ensure expenses are properly allocated to the correct property and to prevent similar issues from occurring in the future. We believe the improvements underway will further support accurate financial reporting and continued compliance with HUD requirements.

View Audit 393876

Corrective Action Plans

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