Corrective Action Plans

Finding 1236651 (2025-001)

Material Weakness 2025

DC

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

AEECA/ESF PD Programs -Assistance Listing No. 19.900 Professional and Cultural Exchange Programs - Citizen Exchanges - Assistance Listing Number 19.415 Recommendation: Cultural Vistas, Inc. should strengthen controls over the calculation and review of fringe benefit charged to federal awards. Contro...

AEECA/ESF PD Programs -Assistance Listing No. 19.900 Professional and Cultural Exchange Programs - Citizen Exchanges - Assistance Listing Number 19.415 Recommendation: Cultural Vistas, Inc. should strengthen controls over the calculation and review of fringe benefit charged to federal awards. Controls should include a documented review to verify that fringe benefit cost charges are calculated using the currently approved NICRA and that charges to federal awards do not exceed the allowable rate prior to submission of reimbursement requests and federal financial reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has not applied for the fringe benefit negotiated indirect rate as offiscal year 2026. For any future fringe benefit NICRA, a Finance team member will review the charges to the federal award against the allowable rate quarterly to ensure the correct rate was applied. If the amount exceeds the allowable rate, an adjustment will be made on a quarterly basis to reduce the fringe benefit expense according to the allowable rate. Name(s) of the contact person(s) responsible for corrective action: Megan Bah Planned completion date for corrective action plan: July 14, 2026

View Audit 412177

Finding 1236606 (2025-003)

Material Weakness 2025

Bristol Bay Borough, Alaska

AK

Period of Performance Allowable Costs / Cost Principles Reporting § 200.512

Name of Contact Person: Rhys Winter, Manager Corrective Action Plan: The Borough has engaged accounting resources and staff with the appropriate time and expertise to expedite the completion of future financial reports. Completion Date: March 30, 2027

View Audit 412160

Finding 1236592 (2025-001)

Material Weakness 2025

Technology for Rural Enhancement of Communities

SD

Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Finding #2025-001: Activities Allowed or Unallowed Responsible Individual: Tiera Nikodym, Fiscal Specialist Corrective Action Plan: The Organization is aware of the finding and is working to develop a system to prevent future occurrences. This includes increased communication between the Fiscal Spec...

Finding #2025-001: Activities Allowed or Unallowed Responsible Individual: Tiera Nikodym, Fiscal Specialist Corrective Action Plan: The Organization is aware of the finding and is working to develop a system to prevent future occurrences. This includes increased communication between the Fiscal Specialist and Executive Director, to include monthly discussion of administrative costs. In addition, fiscal dashboards have been developed to monitor administrative costs, forecasting processes have been enhanced, new time studies have been conducted to improve the accuracy of cost allocations, and classifications are now reviewed monthly. The Organization is currently seeking a waiver, but as of the date of financial statement issuance, the waiver has not been obtained. Anticipated Completion Date: 2026

View Audit 412147

Finding 1236553 (2025-002)

Material Weakness 2025

City of Poughkeepsie

NY

Allowable Costs / Cost Principles

Effective January 2026, the City implemented updated procedures requiring mandatory supervisory review and approval of all employee timesheets prior to submission. Effective May 2026, the City transitioned to an electronic time clock system that provides automated timekeeping, digital audit trails, ...

Effective January 2026, the City implemented updated procedures requiring mandatory supervisory review and approval of all employee timesheets prior to submission. Effective May 2026, the City transitioned to an electronic time clock system that provides automated timekeeping, digital audit trails, and required supervisory verification, significantly reducing the risk of incomplete or unsigned records. These corrective measures have been fully implemented and are actively enforced to ensure continued compliance with HUD requirements and prevent recurrence of this issue. Mr. Joseph Donat, City Administrator, is responsible for ensuring that this corrective action is enforced.

View Audit 412103

Finding 1236519 (2025-002)

Material Weakness 2025

Summitview Child & Family Services

CA

Allowable Costs / Cost Principles § 200.302

Planned Corrective Action: Summitview will reinforce the developed system for retaining all invoices, payment records, and supporting documentation associated with federal awards.

View Audit 412064

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 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 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 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 1236303 (2025-001)

Material Weakness 2025

Grady Memorial Hospital Corporation

GA

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

Condition: An invoice totaling $34,675.10 was incorrectly included in a reimbursement request at $34,975.10, resulting in an overstatement and reimbursement of $300. The error was determined to be the result of a manual data-entry (keystroke) error when transcribing invoice information to the sponso...

Condition: An invoice totaling $34,675.10 was incorrectly included in a reimbursement request at $34,975.10, resulting in an overstatement and reimbursement of $300. The error was determined to be the result of a manual data-entry (keystroke) error when transcribing invoice information to the sponsor's reimbursement template. The underlying invoice support was accurate; however, the amount entered on the reimbursement form differed from the source documentation by $300. Corrective Action: To strengthen compliance with internal control requirements under 2 CFR 200.303, management reimbursement requests will continue to undergo a secondary review that verifies invoice amounts, supporting documentation, calculations, and reimbursement totals prior to submission. Management recognizes that despite maintaining a robust system of internal controls and multiple levels of review, no system of internal control can eliminate the possibility of isolated human error in processes that require manual data entry. Given the volume and complexity of grant activity administered by the organization, management believes this exception represents an isolated clerical error rather than a systemic control weakness. Management will continue to review sponsor invoices to ensure consistency will allowable costs incurred during the invoice period. Responsible Official: David Noble, Director, Grant Administration Implementation Date: Ongoing Expected Result: These corrective actions are designed to provide reasonable assurance that reimbursement requests are accurate, supported, and reviewed prior to submission, thereby reducing the risk of errors and strengthening compliance with Uniform Guidance requirements.

View Audit 411922

Finding 1236271 (2025-001)

Material Weakness 2025

Regional Office of Education #47

IL

Reporting Allowable Costs / Cost Principles Cash Management § 200.303

Corrective Action Plan FINDING 2025-001 – Noncompliance with Grant Requirements CONDITION: The Regional Office of Education #47 did not maintain adequate internal controls over the grant accounting and financial reporting process. While the Regional Office of Education #47 maintains controls over th...

Corrective Action Plan FINDING 2025-001 – Noncompliance with Grant Requirements CONDITION: The Regional Office of Education #47 did not maintain adequate internal controls over the grant accounting and financial reporting process. While the Regional Office of Education #47 maintains controls over the processing of expenditures, there are not sufficient controls over the general ledger and financial statement reporting process for management or employees in the normal course of performing their assigned functions to prevent, or detect and correct, discrepancies between grant expenditures reports, the general ledger, financial statements, and supplementary information. During our review of the Regional Office of Education #47’s grant expenditures, it was noted that the Regional Office of Education #47 did not have adequate controls to ensure accuracy and consistency between grant expenditures reports, general ledger, financial statements, and supplementary information. Audit procedures revealed differences between the grant expenditures reports and the Regional Office of Education #47’s financial statements and General Ledger (GL) as shown below: Total Expenditures Per Grant Reports and the Schedule of Difference Federal Grants Expenditures of Total Expenditures Over Assistance Listing Federal Awards Per Financial (Under) Number (SEFA) Statements and GL Stated ARP - McKinney Education for Homeless Children 84.425W $112,133 $124,432 $(12,299) ARP - Community Partnerships 84.425U 2,475 3,300 (825) McKinney Education for Homeless Children 84.196A 123,965 121,671 2,294 Federal Grants Net Difference $(10,830) Total Total Expenditure Expenditures Per Financial Difference State Grant Per Grant Statements Over Code Reports and GL (Under) Computer Science 2025 -3999 $43,567 $27,723 $15,844 Less Expenditures disbursed in FY26 (10,627) State Grant Net Difference $ 5,217 Management was unable to provide documentation to support and reconcile the federal and State grant differences of $(10,830) and $5,217, respectively. PLAN: The Regional Office of Education #47 will strengthen its grant reconciliation procedures by implementing a formal reconciliation process for all federal and state grant reports prior to submission and as part of the year-end closing process. Grant expenditure reports will be reconciled to the general ledger and financial statements, and the reconciliation will be documented and reviewed by a responsible official with preparer and reviewer sign-offs maintained in the grant file. While all grant funds were properly accounted for and no questioned costs were identified, these additional procedures will provide enhanced documentation and ensure consistency between grant reports, the general ledger, and the financial statements. ANTICIPATED DATE OF COMPLETION: Fiscal Year 2027 CONTACT PERSON: Mr. Chris Tennyson, Regional Superintendent for Lee, Ogle, and Whiteside Counties.

View Audit 411874

Finding 1236268 (2025-001)

Material Weakness 2025

Frida Kahlo Community Organization

IL

Allowable Costs / Cost Principles

Frida Kahlo Community Organization concurs with the finding and acknowledges the need to strengthen its procedures for documenting, approving, and monitoring the allocation of salary costs among federal awards, other grants, and organizational activities. The Organization intends to engage a qualifi...

Frida Kahlo Community Organization concurs with the finding and acknowledges the need to strengthen its procedures for documenting, approving, and monitoring the allocation of salary costs among federal awards, other grants, and organizational activities. The Organization intends to engage a qualified independent third-party consultant with experience in federal grant compliance, payroll allocation, and the Uniform Guidance. The consultant will assist management in evaluating existing payroll-allocation practices and developing and implementing a formal, documented process to support compliance with applicable federal award requirements. With the assistance of the third-party consultant, the Organization will undertake the following corrective actions: 1. Develop a written payroll-allocation policy establishing how salary and related benefit costs will be allocated among federal awards, other grants, and organizational activities based on the work performed. 2. Implement a time-and-activity documentation process that supports compensation charged to federal awards and reflects employees’ total compensated activities, including the distribution of time among applicable grants and other cost objectives. Employees will be required to document their activities at established intervals.

View Audit 411865

Finding 1236242 (2025-004)

Material Weakness 2025

Pipestone County

MN

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303 § 200.318

Finding Number: 2025-004 Finding Title: Federal Awards Internal Control Policy and Procedures 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: County management will develop and formally adopt a federal exp...

Finding Number: 2025-004 Finding Title: Federal Awards Internal Control Policy and Procedures 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: County management will develop and formally adopt a federal expenditures policy to establish procedures for administering and monitoring federal awards in accordance with Uniform Guidance requirements. The policy will address internal controls over compliance, allowable costs, reporting requirements, record retention, and other applicable federal compliance requirements. Management will also communicate the policy to appropriate personnel responsible for administering federal programs. 3. Official Responsible for Ensuring CAP: Steve Ewing, County Administrator, is the official responsible for ensuring corrective action plan. 4. Planning Completion Date for CAP: 12/31/2026 5. Plan to Monitor Completion of CAP: County management will review the policy periodically to ensure it remains current with federal requirements and will monitor compliance with the policy through the administration and oversight of federal programs.

View Audit 411842

Finding 1236224 (2025-001)

Material Weakness 2025

The Family Conservancy, INC

KS

Reporting Allowable Costs / Cost Principles

Identifying Number: 2025-001 Finding: During testing, it was identified that the annual Federal Financial Report (SF-425) was not submitted by the reporting deadline prescribed in the grant terms and conditions and Office of Head Start reporting requirements. As a result, the Agency did not comply w...

Identifying Number: 2025-001 Finding: During testing, it was identified that the annual Federal Financial Report (SF-425) was not submitted by the reporting deadline prescribed in the grant terms and conditions and Office of Head Start reporting requirements. As a result, the Agency did not comply with federal reporting requirements applicable to the program. Corrective Actions Taken or Planned The Agency concurs with the finding. Although the SF-425 was prepared and initially submitted by the deadline, it was not certified as required for submission until after the deadline due to finance staff transitions and delays in obtaining system access. To ensure compliance with federal reporting requirements and strengthen internal controls, the following corrective actions will be implemented: 1. Establish a Formal Reporting Calendar and Tracking System A centralized reporting calendar will be developed to track all federal reporting deadlines, including SF-425 submissions. The calendar will include automated reminders and will be reviewed monthly by finance leadership to ensure timely preparation and submission. 2. Implement Supervisory Review and Sign-Off Procedures A supervisory review process will be implemented for all federal reports. The VP of Finance or Controller will verify the accuracy of cumulative expenditures and ensure the SF-425 is supported by accounting records before submission. 3. Strengthen Internal Controls and Written Procedures Written procedures will be updated to include detailed steps for preparing, reviewing, and submitting the SF-425. Procedures will clearly define roles, responsibilities, timelines, and documentation requirements. 4. Staff Training on Federal Reporting Requirements Finance and grants staff will receive training on SF-425 reporting requirements, Uniform Guidance reporting standards, and Head Start financial reporting expectations. Training will include review of the finding and emphasize the importance of timely and accurate reporting. 5. Continuity Controls to Address Turnover Risk To mitigate the impact of staff turnover, responsibility for federal reporting will be assigned to both a primary and secondary staff member. Cross-training will be implemented to ensure continuity and reduce reliance on a single individual. Contact Persons Responsible for Corrective Action Vice President of Finance and Controller / Head Start Fiscal Coordinator Anticipated Completion Dates • Reporting calendar and tracking system implemented: September 30, 2026 • Written reporting procedures finalized: October 31, 2026 • Staff training completed: November 30, 2026

View Audit 411833

Finding 1236195 (2025-003)

Material Weakness 2025

Town of Centerville

IN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.302 § 200.303

FINDING 2025-003 Finding Subject: Federal Award Findings and Questioned Costs Contact Person Responsible for Corrective Action: Sarah Rice Contact Phone Number and Email Address: 765-855-5515, srice@town.centerville.in.us Views of Responsible Officials: Option 1: “We concur with the finding.”  Drin...

FINDING 2025-003 Finding Subject: Federal Award Findings and Questioned Costs Contact Person Responsible for Corrective Action: Sarah Rice Contact Phone Number and Email Address: 765-855-5515, srice@town.centerville.in.us Views of Responsible Officials: Option 1: “We concur with the finding.”  Drinking Water State Revolving Fund – Written Policies/Procedures to Determine Allowability of Costs using Federal Grant Funds- I will be getting in touch with our council president to make sure we come up with a policy on how to use federal funding with clear guidance on what costs are constituted as direct and indirect charges. Anticipated Completion Date: February 28, 2027 INDIANA

View Audit 411798

Finding 1236174 (2025-001)

Material Weakness 2025

The Contingent

OR

Allowable Costs / Cost Principles Student Financial Aid Material Weakness § 200.430

Management will reconfigure the system to require after-the-fact entry of actual hours worked and to restrict advance entry and approval, reinforce supervisory review procedures to ensure timely and accurate approval of timecards, and provide training to employees and supervisors on federal timekeep...

Management will reconfigure the system to require after-the-fact entry of actual hours worked and to restrict advance entry and approval, reinforce supervisory review procedures to ensure timely and accurate approval of timecards, and provide training to employees and supervisors on federal timekeeping requirements under 2 CFR 200.430. These actions will strengthen internal controls and ensure payroll costs charged to federal awards accurately reflect work performed going forward.

View Audit 411785

Finding 1236172 (2025-001)

Material Weakness 2025

CONVERGENT RESEARCH, INC.

MA

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

2025-001 Auditor’s Recommendation: Convergent Research, Inc. should establish written procedures and management review controls to: ● Reconcile provisional indirect and fringe rates to actual allowable costs; ● Review award-specific provisions related to indirect costs, cost sharing, and budget flex...

2025-001 Auditor’s Recommendation: Convergent Research, Inc. should establish written procedures and management review controls to: ● Reconcile provisional indirect and fringe rates to actual allowable costs; ● Review award-specific provisions related to indirect costs, cost sharing, and budget flexibility; ● Identify all allowable costs incurred during the period of performance; and ● Perform and document a final award reconciliation before submitting final expenditure reports. Corrective Action: Convergent Research has updated its grant closeout procedures to require: 1. reconciliation of provisional fringe and indirect cost rates to actual allowable costs at the time of award closeout; 2. review of award-specific provisions related to indirect costs, cost sharing, and budget flexibility; 3. identification of all allowable costs incurred during the period of performance, including any unbilled amounts, before final reporting; and 4. a documented management review and final award-level reconciliation prior to submission of the final expenditure report. This reconciliation step has been incorporated into the Finance team's standard grant-closing checklist. Responsible for Corrective Action: The assigned Finance & Accounting Manager will complete the closeout procedures for review by the Head of Finance and the grant PI. Anticipated Completion Date: Implemented August 2026 — updated grant-closeout procedures are in effect for all open federal awards. Procedures are documented in Notion under Federal Grant Accounting Policy and Procedures.

View Audit 411779

Finding 1236167 (2025-012)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services, Division of Senior and Disability Services Audit Finding Number: 2025-012 - Medicaid SPPC Participant Choice Agreements Name of the contact person responsible for co...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services, Division of Senior and Disability Services Audit Finding Number: 2025-012 - Medicaid SPPC Participant Choice Agreements Name of the contact person responsible for corrective action: Kim Toebben Anticipated completion date for corrective action: DHSS anticipates that the work described below will be completed by July 2029. Corrective action planned is as follows: The Department of Health and Senior Services (DHSS), Division of Senior and Disability (DSDS) agrees with the auditor’s findings and appreciates the opportunity to respond to the missing Participant Choice Statements in the records of 14 Home and Community Based Services (HCBS) participants. DHSS is monitoring this issue closely and taking this finding seriously. DSDS continues to work diligently to improve the percentage of forms signed and uploaded while conducting reassessments. In May 2025, DSDS implemented a new case management system that expanded reporting capabilities and strengthened DSDS’s capacity to monitor missing documentation. Additionally, DSDS continues to rely on established quality assurance practices, which include monthly random case record reviews of assessor documentation to ensure accuracy and completeness. In addition, DSDS has been working to expand partnerships with new contractors to assist with reassessment volume. The goal is to shift from a high volume of provider-based reassessors to more value-based partners. These value-based partners receive enhanced monitoring to qualify for a higher reimbursement rate. If quality standards are not met, they are no longer eligible for enhanced payment. This model is designed to build partnerships with contracted assessors who consistently produce accurate, timely, and high-quality work. These expanded partnerships are beginning to provide state staff with more time to focus on their assigned workload, ultimately improving overall documentation quality. DSDS’s goal is to continue to increase the number of these partners and their caseload capacity so that all assessors have adequate time to complete thorough, high-quality assessments with proper documentation. Existing partners have set scaling plans to increase the number of assessments they are supporting DSDS with over the next year. While DSDS is committed to resolving documentation gaps, the division is unable to immediately correct all missing Participant Choice Statements due to staffing limitations and the size of the program. With more than 70,000 participants statewide, managing active caseloads while addressing legacy documentation issues presents ongoing operational challenges. DSDS will utilize quality assurance processes, targeted training, and enhanced reporting to identify issues and implement necessary improvements and remediations at time of assessment. Missing Participant Choice Statements will be completed at each participant’s next reassessment. Moving forward, DSDS’s efforts will center on ensuring that Participant Choice Statements are consistently completed during the assessment itself rather than relying on remediation after the fact. The continued expansion of value-based partnerships is expected to significantly support this shift. As these partners assume a greater share of reassessments, DSDS anticipates improved consistency, timeliness, and documentation quality at the point of assessment. This increased capacity allows state staff to focus more on oversight and quality assurance, strengthening long-term compliance, and reducing the need for follow-up corrections.

View Audit 411772

Finding 1236163 (2025-003)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Subrecipient Monitoring Eligibility § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-003 - Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-003 - Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: 12/31/2026 Recommendation: The DSS through the MHD and the FSD strengthen internal controls to ensure redeterminations are completed as required. DSS Response: The DSS disagrees with this finding. Throughout SFY 2025, the agency was actively monitoring and strategizing to work towards completing all renewals by the deadline of December 31, 2025. While the DSS was unable to complete all renewals by the deadline of December 31, 2025, progress throughout all of SFY 2025 continued. Additionally, the DSS does not consider this within the scope of the SFY 2025 audit because federal requirements did not require all renewals to be complete until December 31, 2025, which falls in SFY 2026. DSS resumed initiating renewals starting in April 2023 under the unwinding plan submitted to CMS with the goal to complete all unwinding related renewals prior to the deadline of August 31, 2024. However, DSS encountered staffing challenges in completing all unwinding renewals by the established deadline. On August 29, 2024, CMS released guidance recognizing the challenges that many states faced impacting the ability to complete unwinding related renewals and restore routine operations within the original timelines established, extending the allowance for states to continue to use the exception under 42 CFR 435.912(e) through December 31, 2025. With the backlog of MAGI annual renewals and the changes that will be implemented from the passage of HR. 1 (the Big, Beautiful Bill), a new plan to complete redeterminations was formed based on federal flexibilities. The DSS continued to complete redeterminations for MAGI participants throughout the unwinding period; however, around April 2025 leadership began revising the procedures of eligibility staff and leveraging additional staff to ensure case actions, including annual renewals, were completed timely. The department contracted to increase temporary staff through 2026 to focus on working the backlog for MAGI annual renewals by December 31, 2026.

View Audit 411772

Finding 1236162 (2025-002)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Eligibility § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-002 - Medicaid and CHIP MEDES Death Match Name of the contact person responsible...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-002 - Medicaid and CHIP MEDES Death Match Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: 1/1/2027 Recommendation: The DSS through the MHD and the FSD resume the DHSS vital records death match in the MEDES. DSS Response: The DSS partially agrees with this finding. DSS has controls in place to identify deceased individuals in the MAGI eligibility system (MEDES). DSS administers an electronic verification match with the federal hub at application and during the annual review process to inquire about death. Currently, a death match with Department of Health and Senior Services (DHSS) vital records is functional in the Family Assistance Management Information System (FAMIS) eligibility system currently used for Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and MO HealthNet for Aged, Blind, and Disabled (MHABD) individuals. When the match is received into FAMIS from DHSS, that information is included on the eligibility file submitted to MMIS to ensure that the death date is captured in MMIS to prohibit any payments after the death of the individual. This control ensures that no improper payments are made on a beneficiary’s behalf after the date of death. DSS has processes in place to close eligibility when death information is received from family members and providers during the certification period. Additionally, in compliance with 42 CFR 435.949, DSS administers an electronic verification match with the federal hub at application and during the annual review process to inquire about death. DSS is continuing to evaluate necessary steps to reinstate the death match with DHSS vital records, but DSS does not have an anticipated completion date. Corrective action planned is as follows: The DSS is strengthening controls by updating the eligibility systems to include the quarterly match with the Social Security Administration (SSA) master death file as required by HR 1. DSS estimates that the update will be completed by January 1, 2027 as required.

View Audit 411772

Finding 1236161 (2025-001)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Subrecipient Monitoring Eligibility § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-001 – Medicaid and CHIP Eligibility System Internal Controls Name of the contact...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-001 – Medicaid and CHIP Eligibility System Internal Controls Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: 4/1/26 Recommendation: The DSS through the MHD and the FSD strengthen internal controls to timely prevent, detect, and correct improper dual enrollments in the MEDES and the FAMIS for participants of the Medicaid program and the CHIP. The DSS should review the dual enrollments for the participants identified in this finding, correct any improper enrollments in the applicable eligibility system(s), and recoup any related improper payments and claims. DSS Response: The DSS agrees with this finding. Corrective action planned is as follows: A report was developed in October 2025 to identify individuals with multiple active Medicaid Eligibility (ME) Codes that include different coverage types. The report is filtered through the FAMIS system to ensure both levels of coverage are active when the report is worked. Staff began working this report manually in Spring of 2025 and they identified higher priority tasks such as closing Adult Expansion Group (AEG) coverage for individuals who have been determined eligible for a mandatory Non-MAGI coverage type. Staff have significantly reduced the number of individuals with dual coverage as of Spring 2026. Please note that there are certain ME Codes that can run concurrently with other coverage. In order to reduce staff burden and improve efficiency, program staff will work with system staff to automate the manual processes that are done with this report to ensure dual coverage is closed in a timely manner. There is no estimated completion date at this time, but the DSS hopes to have some level of automation by December 31, 2027.

View Audit 411772

Finding 1236143 (2025-010)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-010 - CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Administrator, Bureau o...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-010 - CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Administrator, Bureau of Community Food and Nutrition Assistance (BCFNA), Division of Community and Public Health Anticipated completion date for corrective action: Not Applicable The Missouri Department of Health and Senior Services (DHSS) disagrees with this finding because the controls over meal reimbursements are in compliance with the federal U.S. Department of Agriculture (USDA) requirements and guidance. In addition, the nearly identical audit finding of fiscal year 2023 was not sustained by the federal funding agency. One hundred percent of the 43 overclaim exceptions noted by the SAO were either under the USDA’s acceptable minimum threshold of $600 or were recouped from subsequent claims in accordance with USDA and DHSS program requirements. The remaining 7 errors were underclaims. None of the error items noted by the SAO which exceeded the established USDA threshold resulted in questioned costs. The following SAO statement is factually incorrect: “Since meal reimbursements are made without any supporting documentation, the BCFNA relies on system edit checks and subrecipient monitoring procedures to prevent and detect meal reimbursement claim errors.” BCFNA is in compliance with USDA regulation as well as DHSS policies and procedures in regard to reviewing supporting documentation. In accordance with USDA regulations, sponsors are required to maintain documentation for three years in addition to the current year. However, this documentation is not required to be submitted to the state agency prior to every month’s claim reimbursement. The SAO said, “If similar errors were made on the remaining population of CACFP meal reimbursements totaling approximately $69.9 million, unallowable costs could be significant.” The SAO’s projection of a full year of ineligible sponsor claims is not supportable to determine this finding is material noncompliance. The sample of those sponsors is not representative of the population and cannot be assumed to be a claim error for the whole year, as it is based on a biased population of reviews performed by DHSS. DHSS’s risk-based monitoring approach of reviewing higher risk subrecipients more frequently would lead to higher claim amounts than a sample of the population as a whole. Each of the claims in question were recouped in subsequent months in accordance with USDA regulations and BCFNA policies and procedures, resulting in no loss of federal program funds or questioned costs. Further, all but one of the items with $2,000 or more in overclaims were due at least in part to temporary eligibility issues resulting from untimely submission of Income Eligibility Forms (IEFs). These were identified as a result of BCFNA’s well-designed monitoring processes and remedied in following months when parents or guardians provided the completed eligibility forms and should not be automatically assumed to account for a full year of overclaims.

View Audit 411772

Finding 1236114 (2025-002)

Material Weakness 2025

LEAGUE OF HUMAN DIGNITY INC

NE

Allowable Costs / Cost Principles Material Weakness

The corrective action plan for the internal control material weakness, noncompliance with Uniform Audit Guidance Subpart E-Cost Principles (2025-002), is summarized as follows: Corrective Action Planned: Management respectfully disagrees with the finding that indirect costs were double charged. The ...

The corrective action plan for the internal control material weakness, noncompliance with Uniform Audit Guidance Subpart E-Cost Principles (2025-002), is summarized as follows: Corrective Action Planned: Management respectfully disagrees with the finding that indirect costs were double charged. The Organization uses the Direct Allocation Method described in Appendix IV to 2 CPR Part 200. Under this method, joint costs are allocated directly to benefiting programs and activities using allocation bases designed to reflect the relative benefits received. General administrative and general expenses are treated as indirect costs. The Organization also elected to use the de minimis indirect cost rate permitted by 2 CPR§ 200.414(f). Management believes the costs allocated directly to the federal award and the costs recovered through application of the de minimis rate represent separate cost categories and that no individual cost was charged to the award both directly and indirectly. Management's allocation methodology and resulting charges were also reviewed and approved by the grantor, and management relied on that approval in determining that its treatment was acceptable. Although management disagrees with the finding, the Organization will review and enhance its written cost-allocation procedures to more clearly identify: • Costs charged directly to each federal award; • Joint costs allocated under the Direct Allocation Method; • General administrative costs treated as indirect costs; and • Controls designed to ensure that costs charged directly are not also recovered through another allocation or reimbursement method. Management will also retain documentation supporting the allocation bases used, the calculation and application of the de minimis rate, and relevant grantor approvals and communications. Anticipated Completion Date: Responsible: Management and Board of Directors.

View Audit 411744

Finding 1236112 (2025-002)

Material Weakness 2025

Clear Path for Veterans New England, Inc.

MA

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

2025-002 – Allowable Activities and Costs Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Management concurs with the finding. To strengthen internal controls o...

2025-002 – Allowable Activities and Costs Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Management concurs with the finding. To strengthen internal controls over payroll time distribution, the Organization will implement the following corrective actions:  Complete a comprehensive review and cleanup of employee labor allocation records, remove outdated grants, inactive labor allocations, and legacy program assignments.  Review employee labor allocations whenever an employee is hired, changes position, or changes funding sources to ensure the labor allocation reflects current program assignments.  Supervisors will be instructed to review employee timesheets for both hours worked and program allocation accuracy before approving timecards.  Periodically perform reconciliations between labor allocation reports, payroll registers, personnel assignments and the general ledger to verify that payroll documentation and accounting records remain consistent.  Monitor payroll service provider system updates and promptly address any future reporting discrepancies with the vendor. Management expects these actions to strengthen controls over payroll documentation and reduce the risk of payroll costs being supported by inaccurate time distribution records. Anticipated Completion Date April 2026

View Audit 411743

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