Corrective Action Plans

During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted one instance where HHHRC ...

During our audit, we selected a sample of 60 clients receiving assistance under the Ryan White HIV/AIDS Program Part B (RWB) program to ascertain whether those clients met program eligibility requirements and whether costs charged to the RWB program were allowable. We noted one instance where HHHRC determined that the client met the eligibility requirements and incurred certain costs which were charged to the RWB program. However, we found that the client exceeded the income threshold to be considered low-income, as defined by the state. Accordingly, this client was not eligible to participate in the RWB program and any costs charged to the RWB program were unallowable.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Criteria

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification ...

Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration’s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements. To be eligible, clients must have a medical diagnosis of HIV/AIDS and be (a) a low-income individual, (b) a resident of the state, and (c) uninsured or underinsured, as defined by the state. Eligibility determination is required before participation in the RWB program during the in-take process. Re-assessments are performed at least once every 12 months thereafter.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client...

Per HHHRC’s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client attesting to no income or very low income.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Additionally, costs associated with clients determined to be ineligible to receive assistance under the RWB program are unallowable.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Cause

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

HHHRC did not adhere to established policies and procedures requiring that the client meet all eligibility requirements during the in-take and re-assessment process before costs are charged to the RWB program.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Effect

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

HHHRC did not comply with the RWB program allowable cost requirements for the one instance noted above.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Identification of Known Questioned Costs

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

$185 of unallowed costs were erroneously billed to the RWB program.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Identification of a Repeat Finding

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

This finding was reported as a federal award finding in the immediate previous audit as Finding No. 2024-001.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Recommendation

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

We again recommend that HHHRC adhere to established policies and procedures requiring that only allowable costs associated with clients determined to be eligible to receive benefits be charged to the RWB program.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

In addition, we recommend that HHHRC follow up with the State to determine the appropriate action for any costs erroneously billed to the RWB program.

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action

View Audit 393958

Finding 1182536 (2025-001)

Material Weakness 2025

Hawaii Health & Harm Reduction Center

HI

Eligibility Internal Control / Segregation of Duties

HHHRC is committed to continuing to improve its adherence with established policies and procedures to verify eligibility documentation for recipients of Ryan White Part B Program funds. HHHRC will review these findings with all relevant staff and provide a refresher training on appropriate documenta...

HHHRC is committed to continuing to improve its adherence with established policies and procedures to verify eligibility documentation for recipients of Ryan White Part B Program funds. HHHRC will review these findings with all relevant staff and provide a refresher training on appropriate documentation of eligibility (with a focus on income determination and reference dates as described in the condition section) by the end of March 2026. HHHRC will review its current internal controls process which currently includes review from the HIV Program Manager and random quality assurance checks from the Quality Program Coordinator. The HIV Director and/or the Deputy Director of Community Programs will be responsible for reviewing, updating, and implementing any changes to HHHRC internal auditing to ensure program compliance. HHHRC understands that this is a repeat finding and continue to prioritize both staff training and refinement of our internal review process to ensure compliance.

View Audit 393958

Finding 1182535 (2025-004)

Material Weakness 2025

Durham County

NC

Procurement, Suspension & Debarment Eligibility Material Weakness

Finding 2025-004 Material Weakness – Eligibility Name of Contact Person(s): Lashonda Bacote and Latonya Chambers Management agrees with the findings. Recommendation: We recommend that the County abide by the State policies in terms of the frequency and amount of case reviews each month. We also reco...

Finding 2025-004 Material Weakness – Eligibility Name of Contact Person(s): Lashonda Bacote and Latonya Chambers Management agrees with the findings. Recommendation: We recommend that the County abide by the State policies in terms of the frequency and amount of case reviews each month. We also recommend that policies and procedures are documented surrounding second party reviews and be reinforced to ensure that reviews are completed and followed up as necessary. Corrective Action: The Work First program has now implemented requirements that align with policy by ensuring a minimum review of 25% second party reviews are met monthly for all Work First cases. All reviews are documented in the Quality Control (QC) tool. The Assistant Director for QAT, will monitor monthly to ensure we meet the requirements. In addition, this tool is accessible to The Assistant Director for Work First, who will also monitor monthly and ensure that all benchmarks are met. 1. Review Process: • QAT Supervisor and Staff Development Specialist (SDS): 25% of all applications completed in the month, 25% of all recertifications completed in the month, and 25% of all employment services cases completed in the month. • Additionally, the Work First Cash Supervisor, Lead Worker, and Employment Supervisor will do monthly reviews to guarantee that we are above the 25%threshold. • During vacancies, Work First staff listed above will have increased cases to review. The QAT Supervisor will identify other staff to assist. The QAT Staff Development Specialist will train other SDS staff on WF policies and procedures by April 1, 2026. 2. Policy/Training: • Candice Leathers, Program Manager for QAT, reviewed the policy for the 25%threshold requirement for WF cases and reviewed the DSS ADMINISTRATIVE LETTER NO. ECONOMIC AND FAMILY SERVICES 7-2018 EFS_WF_AL-7-2018 Policy & Procedures with WF QAT Staff on both 09/04/25 and 10/9/2025.Implementation Date: Effective immediately and on-going.

View Audit 393956

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 1182522 (2025-003)

Material Weakness 2025

Special School District No. 6

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Eligibility § 200.318

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER (ALN 10.553, 10.555, AND 10.559) 2025-003 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Findi...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER (ALN 10.553, 10.555, AND 10.559) 2025-003 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster federal programs. During our audit, we noted the District did not have sufficient controls in place within its child nutrition cluster federal programs to ensure compliance with federal requirements related to assuring that the District was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District will review its policies and procedures relating to suspension and debarment for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to assure that district personnel are following the requirements of the Uniform Guidance related to suspension and debarment, including maintaining appropriate documentation. Official Responsible – Ra Chhoth, Finance and Operations Executive Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plans to Monitor – The District’s Finance and Operations Executive Director, Ra Chhoth will assure appropriate internal controls and procedures are in place to ensure compliance with suspension and debarment requirements.

View Audit 393929

Corrective Action Plans

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