Corrective Action Plans

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

Finding 1182462 (2025-002)

Material Weakness 2025

Heritage Behavioral Health Center, Inc.

IL

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

Finding 2025-002: Noncompliance with OMB Compliance Supplement; Period of Performance (H) for Assistance Listing Number (ALN) 93.958 Block Grants for Community Mental Health Services Criteria: The Code of Federal Regulations (CFR) Sections 200.308, 200.309, and 200.403(h) states “a non-Federal entit...

Finding 2025-002: Noncompliance with OMB Compliance Supplement; Period of Performance (H) for Assistance Listing Number (ALN) 93.958 Block Grants for Community Mental Health Services Criteria: The Code of Federal Regulations (CFR) Sections 200.308, 200.309, and 200.403(h) states “a non-Federal entity may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the Federal awarding agency or pass-through entity made the Federal award that were authorized by the Federal awarding agency or pass-through entities.” Costs incurred before or after the period of performance are unallowable unless explicitly approved. Condition: During our testing of expenditures charged to ALN 93.958, we identified 2 transactions out of a total sample of 15 totaling $192 that were incurred outside of the award’s period of performance. Corrective Action Plan: To ensure compliance and accurate reporting, we established internal control protocols for the formal review of service dates, verifying that all expenditures correspond to the appropriate period of performance. The Controller's signature on formal, documented month end checklists will serve as confirmation that all year-end invoices have been checked for appropriate period distribution. Responsible Person for Corrective Action Plan: Addy Hiles (Controller) Implementation Date for Corrective Action Plan: September 2025

View Audit 393858

Finding 1182443 (2025-006)

Material Weakness 2025

Plymouth Community School Corporation

IN

Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.328 § 200.329 § 200.400

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Jill VanDriessche Contact Phone Num...

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Jill VanDriessche Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. We believe this finding to be the result of an isolated incident that was reported to SBOA and Title. Description of Corrective Action Plan: The Business Manager/Treasurer provides to the corporation grant administrator monthly grant reports, as well as a grant tracking spreadsheet. The appropriations for each grant are entered into Komputrol, according to the budget located in the approved grant documents. The appropriations are presented to the Grant Administrator for approval. All spending from each grant is approved by the corporation grant administrator. Any wages paid via the corporation payroll that is charged to grant funds is approved by the business manager/treasurer and the corporation grant administrator. The Payroll Specialist/Deputy Treasurer completes the payroll and sends the distribution account records to the Business Manager/Treasurer and Grant Administrator. Any payroll claims for payment via grant funds is required to have three signatures for approval. We believe the system of internal control in place has been strong and in compliance since March 2025. Anticipated Completion Date: March 1, 2025 and ongoing

View Audit 393841

Finding 1182433 (2025-004)

Material Weakness 2025

Plymouth Community School Corporation

IN

Allowable Costs / Cost Principles School Nutrition Programs Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.400

FINDING 2025-004 Finding Subject: Child Nutrition Cluster, Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Amy Kraszyk Contact Phone Number and Email Address: 574-9...

FINDING 2025-004 Finding Subject: Child Nutrition Cluster, Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Amy Kraszyk Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Since January 2025, the internal controls that resulted in this finding have been corrected. The finding stated that “The lack of internal controls and noncompliance over Allowable Activities and Allowable Costs/Cost Principles is an isolated incident.” The Food Service Director and the Business Manager/Treasurer meet monthly to review the school lunch accounts and to concur with the month end balances. The Deputy Treasurer approves all monthly fund transfers completed by the Business Manager. Anticipated Completion Date: January 1, 2025 and ongoing

View Audit 393841

Finding 1182413 (2025-001)

Material Weakness 2025

Loma Linda University

CA

Allowable Costs / Cost Principles Cash Management Reporting

Finding 2025-001 – Internal control deficiency and noncompliance over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting related to broadband services expenditures Connecting Minority Communities Pilot Program During testing over the Activities Allowed or Unallowed, Allo...

Finding 2025-001 – Internal control deficiency and noncompliance over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting related to broadband services expenditures Connecting Minority Communities Pilot Program During testing over the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting compliance requirement, management did not have effective internal controls in place over the compliance requirements related to the award. Management submitted and received reimbursement from the grantor for broadband services expenditures without making full payment during the period under audit. In addition, management included the broadband services expenditures in the federal financial report for federal cash 10b – cash disbursements and federal expenditures and unobligated balance 10e – federal share of expenditures line items; however, as full payment was not made, these line items should exclude the broadband services expenditures. Management Response and Action Plan: Management has made full pre-payment for broadband services before the project period end date of January 14, 2026 to be in compliance and will implement a review of future prepaid expenditures, if applicable to any grants. Management has reviewed the reporting requirements of the Federal Financial Report and will implement a review to ensure that cash disbursements are accurately reported in future reports. Any discrepancies between sponsor communications and award agreements will be reviewed by management for correct interpretation and financial presentation. Responsible Person: Cindy Dickson, Executive Director/AOR- Research Innovation & Industry Relations Target Date: January 2026

View Audit 393822

Finding 1182392 (2025-004)

Material Weakness 2025

The Inner Voice, Inc.

IL

Allowable Costs / Cost Principles § 200.303 § 200.426 § 200.430

FINDING 2025-004 – Payroll Allocations Audit Finding Description: Audit procedures over expenditures revealed the following: For one (1) of forty (40) expenditure transactions tested, The Inner Voice, Inc. did not adequately track or review time and effort documentation for accuracy. For this select...

FINDING 2025-004 – Payroll Allocations Audit Finding Description: Audit procedures over expenditures revealed the following: For one (1) of forty (40) expenditure transactions tested, The Inner Voice, Inc. did not adequately track or review time and effort documentation for accuracy. For this selection, the time study used to allocate salary did not agree with the actual hours reported and paid. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Corrective Action Plan: Management will enhance policies and procedures related to time and effort reporting by strengthening review and approval processes for payroll allocations and providing additional staff training. These actions will improve consistency and reinforce internal controls over federal awards. Name of Contact Person Responsible for Corrective Action: Khurram Navaid, CFO/ Monika Mader, Exec. Manager Planned Completion Date: January 01, 2026

View Audit 393811

Finding 1182374 (2025-003)

Material Weakness 2025

City of Portsmouth

NH

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

2025-003 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are obligated and/or incurred within the period of performance. Explanation of disagreement with audit fin...

2025-003 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are obligated and/or incurred within the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City acknowledges the finding related to documentation supporting the period of performance for expenditures reported under the SLFRF revenue loss category. Because the City applied the standard allowance for revenue loss and did not track specific expenditures to the grant at the transaction level, some expenditures initially provided for testing were outside the period of performance, although sufficient eligible expenditures existed within the allowable period. To address this issue, the Finance Department will implement procedures to maintain supporting schedules identifying government service expenditures incurred within the applicable period of performance that support amounts reported under the revenue loss category. Finance will also implement a review process to verify that expenditures identified for compliance or audit testing meet applicable period of performance and obligation requirements. These procedures will strengthen documentation and ensure expenditures supporting SLFRF revenue loss are clearly identified and supported for compliance purposes. Name(s) of the contact person(s) responsible for corrective action: Michael Tucker, Deputy Finance Director Planned completion date for corrective action plan: Implemented immediately and effective for all current and future federal awards.

View Audit 393804

Finding 1182367 (2025-002)

Material Weakness 2025

City of Portsmouth

NH

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

2025-002 Special Education Cluster - Assistance Listing Number 84.027, 84.173 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are incurred within the period of performance included in the grant award. Explanation of disagreement with audit finding:...

2025-002 Special Education Cluster - Assistance Listing Number 84.027, 84.173 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are incurred within the period of performance included in the grant award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will implement procedures to ensure that expenditures charged to federal awards are incurred within the approved period of performance in accordance with 2 CFR §§ 200.308, 200.309, and 200.403. The School Department will enhance its grant monitoring procedures by maintaining a tracking schedule of grant periods of performance and reviewing invoices and payment requests for compliance with grant award dates prior to processing. School Department Finance staff will also provide guidance to departments administering grants to ensure expenditures are incurred and submitted within the allowable grant period. These procedures will strengthen internal controls and reduce the risk of expenditures being charged outside the approved period of performance. Name(s) of the contact person(s) responsible for corrective action: Brian Cisneros, Business Administrator Planned completion date for corrective action plan: Implemented immediately and effective for all current and future federal awards.

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Finding 1182365 (2025-001)

Material Weakness 2025

City of Portsmouth

NH

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.430

2025-001 Special Education Cluster - Assistance Listing Number 84.027, 84.173 Recommendation: We recommend procedures be strengthened to ensure that time and effort certifications are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audi...

2025-001 Special Education Cluster - Assistance Listing Number 84.027, 84.173 Recommendation: We recommend procedures be strengthened to ensure that time and effort certifications are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will implement procedures to ensure time and effort certifications are completed in a timely manner for all payroll costs charged to federal awards in accordance with 2 CFR 200.430. The School Department will establish a standardized process requiring employees and supervisors to complete and approve certifications within a defined timeframe following the applicable payroll period. The School Department will maintain a tracking mechanism to monitor completion and will perform periodic reviews to ensure certifications are submitted timely and accurately to reflect the employee’s total activity. Departments will be notified of any missing or late certifications and required to submit documentation promptly. These procedures will strengthen internal controls and ensure compliance with federal documentation requirements. Name(s) of the contact person(s) responsible for corrective action: Brian Cisneros, Business Administrator Planned completion date for corrective action plan: Implemented immediately and effective for all current and future federal awards.

View Audit 393804

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