Corrective Action Plans

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

Finding 1182512 (2025-016)

Material Weakness 2025

State of Kansas

KS

Student Financial Aid Eligibility Matching / Level of Effort / Earmarking § 200.303

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department for Children and Families (KDCF) Federal Program Name: Adoption Assistance Title IV-E Assistance Listing Number: 93.659 Award Number: 2402KSADPT, 2502KSADPT Award Period: July 1, 2024 through June...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department for Children and Families (KDCF) Federal Program Name: Adoption Assistance Title IV-E Assistance Listing Number: 93.659 Award Number: 2402KSADPT, 2502KSADPT Award Period: July 1, 2024 through June 30, 2025 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Condition: During testing of eligibility requirements, it was noted that three participants out of forty tested did not have supporting documentation in their case files for nonrecurring adoption expenses paid on their behalf. Recommendation: We recommend that KDCF strengthen internal controls to ensure that supporting documentation for nonrecurring adoption expenses is obtained, reviewed, and retained prior to payment to mitigate the risk of noncompliance in the future. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: KDCF policy requires that all case files contain documentation supporting state expenditures and all associated payments, in accordance with Policy #0430 Contents of Foster Care, Adoption and Independent Living Services Case Records. Additionally, staff must follow the procedures outlined in Policy #6924 Payment Procedures for Non-Recurring Expenses. Non-recurring expense payments are made according to the authorization provided on forms PPS 6140 or PPS 6130. A PPS 2833 Client Purchase Agreement must be completed by PPS staff, with a copy of the PPS 6130 or PPS 6140 attached to document the authorization for payment. An itemized bill should also be attached when available. While this policy is in place, this finding indicates the need to reinforce internal controls to ensure full compliance. To address the deficiency and prevent recurrence, KDCF will implement the following corrective actions: 1. Reinforcement of Documentation Requirements: Adoption program and I-VE program leadership will review the audit findings with regional adoption staff, I-VE payment specialists, Regional I-VE Administrators and Regional Foster Care Administrators. During this meeting Adoption program and I-VE program leadership will review the corrective action plan and emphasize the importance of the need for complete and accurate documentation in regard to adoption assistance. 2. Enhanced File Review Process Prior to Payment: KDCF will implement a detailed Adoption Assistance Packet Checklist. This is an internal double-check step requiring staff to verify that all required supporting documents for non-recurring adoption expenses are present before submitting or approving payment. This verification will be incorporated into the existing payment workflow to ensure consistency across regions. 3. Targeted Training and Guidance: Updated reminders and written guidance will be issued to all adoption staff outlining specific documentation requirements and the procedures for retaining them. Training will emphasize the allowable cost requirements under Title IV-E and the purpose of maintaining complete records for federal compliance and audit readiness. 4. Ongoing Monitoring: Program leadership will conduct periodic spot checks of adoption subsidy files to validate that required documents are consistently included and will address any identified gaps with staff promptly. These actions will strengthen internal controls and help ensure that documentation supporting nonrecurring adoption expenses is properly obtained and retained in all adoption case files moving forward. Name(s) of the contact person(s) responsible for corrective action: Adoption Program Manager and Kim Fay, I-VE Program Manager Planned completion date for corrective action plan: January 1, 2027

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 1182425 (2025-003)

Material Weakness 2025

Plymouth Community School Corporation

IN

School Nutrition Programs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2025-003 Finding Subject: Child Nutrition Cluster, Internal Controls Audit Findings: Material Weakness 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 Official...

FINDING 2025-003 Finding Subject: Child Nutrition Cluster, Internal Controls Audit Findings: Material Weakness 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: The Food Service Director will oversee and review the process in place to ensure accuracy of eligible students. The Food Service Director will approve the uploaded Direct Certification reports after reviewing to ensure directly certified students were properly processed. The Business Manager/Treasurer will be the final approver of all Direct Certification reports. The Food Service Director will verify that contractors and subrecipients of the federal award are not suspended, debarred or otherwise excluded. The Food Service Director will complete this task for any expense expected to exceed $25,000 by checking SAMS exclusions, collecting a certification from that vendor or adding a clause or condition to the covered transaction with that vendor. The Business Manager/Treasurer will be the second reviewer/approver for suspension and disbarment. Anticipated Completion Date: March 1, 2026 and ongoing

View Audit 393841

Finding 1182417 (2025-002)

Material Weakness 2025

Meals on Wheels of Wake County, Inc.

NC

Subrecipient Monitoring Eligibility Reporting

We concur with the recommendation. We acknowledge Meals on Wheels of Wake County was understaffed in eligibility staffing during this period. Thus, some assessments were delayed. We have since added 1.5 FTE to assist in this process. However, it should be acknowledged that we see our clients in thei...

We concur with the recommendation. We acknowledge Meals on Wheels of Wake County was understaffed in eligibility staffing during this period. Thus, some assessments were delayed. We have since added 1.5 FTE to assist in this process. However, it should be acknowledged that we see our clients in their home or at congregate sites on a routine/daily basis, therefore are completely aware of their condition and eligibility. Additionally, Title III Nutrition programs do not mean test. For Home Delivered Meals, there are criteria for being considered homebound. For congregate the only requirement is to be 60 years of age and sign up for meals. We have implemented procedures to ensure the meal recipients are evaluated and assessed in a timely manner.

View Audit 393839

Finding 1182288 (2025-002)

Material Weakness 2025

Kellogg Community College

MI

Student Financial Aid Eligibility Significant Deficiency

Condition: Out of 22 students tested for Pell eligibility we identified one student whose student aid index (formerly known as expected family contribution) was changed, however the additional award was never disbursed to the student. Planned Corrective Action: System generated ISIR’s and correction...

Condition: Out of 22 students tested for Pell eligibility we identified one student whose student aid index (formerly known as expected family contribution) was changed, however the additional award was never disbursed to the student. Planned Corrective Action: System generated ISIR’s and corrections will be reviewed for changes and then given to the Director for weekly review to ensure the updates and awards are accurate and complete Contact person responsible for corrective action: Nikki Jewell Anticipated Completion Date: June 30, 2026

View Audit 393699

Finding 1182265 (2025-003)

Material Weakness 2025

Oak Hill United School Corporation

IN

School Nutrition Programs Eligibility § 200.303

FINDING 2025-003 Finding Subject: Child Nutrition Cluster- Eligibility and Reporting Contact Person Responsible for Corrective Action: Chris Goris Contact Phone Number and Email Address: 765-395-3341, christengo@ohusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description ...

FINDING 2025-003 Finding Subject: Child Nutrition Cluster- Eligibility and Reporting Contact Person Responsible for Corrective Action: Chris Goris Contact Phone Number and Email Address: 765-395-3341, christengo@ohusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will review eligibility of students for the free and reduced meal program through the state level system that identifies Direct Certification eligibility. The district will have a secondary individual from the food service department review the eligibility determination for both financial applications and through Direct Certification following the initial review by the Food Service Director. Both the director and the secondary individual will sign off on the determined eligibility status of free/ reduced applications submitted by households and Direct Certification eligibility through the Child Nutrition Program. The secondary individual will additionally review to ensure accuracy of the eligibility determination entered in the student information system by the Food Service Director. The district will prepare monthly meal claims and submit them to the Child Nutrition Program by following the listed steps: 1. The Food Service Director will prepare the meal claim numbers from the district’s student information system. 2. The CFO, or secondary individual from the food service department, will review the reports prepared by the Food Service Director. 3. The Food Service Director will enter monthly meal counts for reimbursement into CNP.4. The CFO or secondary individual from the food service department will review the CNP entry of meal claim information before submission. 5. The Food Service Director and CFO and/ or secondary individual will sign off on the preparation and entry of the monthly meal claim reimbursement. Anticipated Completion Date: 3/31/2026

View Audit 393654

Finding 1182217 (2025-001)

Material Weakness 2025

Community Health Center of Southeast Kansas

KS

Special Tests & Provisions Subrecipient Monitoring Eligibility

Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Staff Training Quality Assurance ...

Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Staff Training Quality Assurance and Monitoring To ensure sustained compliance, the organization is implementing the following monitoring process: • Monthly random chart audits of sliding fee documentation. • Minimum sample size of 40 patient records • Audit elements will include: o Income documentation present o Household size documented o Correct FPG calculation o Correct discount level applied • Findings will be reported to senior leadership and the compliance committee. Corrective coaching is provided when deficiencies are identified. Comprehensive training is being conducted for all relevant staff including: • Patient access / front desk staff • Financial counselors • Billing staff • Site managers Training topics include: • HRSA Sliding Fee Discount Program requirements • Determining household size • Calculating FPG percentage • Acceptable income documentation • Proper EHR documentation • Self-attestation procedures

View Audit 393604

Corrective Action Plans

Filters