Corrective Action Plans

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 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 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 1182519 (2025-001)

Material Weakness 2025

Kewanee Community Unit School District No. 229

IL

Internal Control / Segregation of Duties Cash Management Reporting § 200.303

Condition - The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan - A second person person (business manager) compares the meal counts in the claim to: the Skywa...

Condition - The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan - A second person person (business manager) compares the meal counts in the claim to: the Skyward daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimursement rates. The reviewer will then sign and date a reconciliation sheet before submission. Anticipated Date of Completion: December 7, 2025; Name of Contact Person - Dan Nolan, Business Manager; Management Response - The corrective action plan was discussed with the employee responsible for filing the claim, the business manager, and the superintendent. After discussion, the plan was approved by the superintendent.

View Audit 393927

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 1182511 (2025-015)

Material Weakness 2025

State of Kansas

KS

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019 – 7/31/2027) & NU51CK000384 (8/1/2024 – 7/31/2029) Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: The Kansas Department of Health and Environment (Department) submits quarterly workplan milestone progress reports; however, the reports provided are cumulative in nature and prior quarterly versions are not retained. As a result, auditors were unable to review progress and supporting information for each individual quarter, as only the most recent cumulative report was available. We were also unable to verify the dates that the quarterly performance reports were submitted. The Department prepares and submits quarterly workplan milestone progress reports and annual performance reports; however, documented evidence of supervisory or management review and approval of these reports prior to submission was not consistently maintained. As a result, the Department was unable to provide documentation demonstrating that the reports were reviewed for accuracy, completeness, or compliance with reporting requirements. Recommendation: We recommend that the Department implement procedures to retain copies of each quarterly workplan milestone progress report at the time of submission. Maintaining discrete quarterly reports will improve documentation, support compliance with program requirements, and allow for effective monitoring and audit review of progress throughout the reporting period. In addition, we recommend that the Department implement formal procedures to document the review and approval of the quarterly and annual performance reports prior to submission. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The ELC program director will download quarterly workplan milestone updates to capture quarterly progress. These will initially be signed as approved electronically by the program staff and the ELC director. A more permanent solution will be a software solution that will allow the upload of the quarterly milestone update files prior to submission to ELC CAMP, with review and approval queues. The same procedure will also be used for annual performance measures. A standard operating procedure will be created to ensure formal documentation of this process. Name(s) of the contact person(s) responsible for corrective action: Sheri Tubach Planned completion date for corrective action plan: March 1, 2026, for the interim plan and August 1, 2026, for the permanent solution

View Audit 393917

Finding 1182509 (2025-014)

Material Weakness 2025

State of Kansas

KS

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 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: Various Compliance Requirement: Reporting Type of Finding: Significant Deficiency in In...

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: Various Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Condition: During the audit period, the Department did not submit the ETA 9050, ETA 9052, and ETA 9055 reports accurately. Testing identified discrepancies between the data reported to the U.S. Department of Labor and the supporting underlying records, including variances within validation samples used to support reported figures. As a result, the reported information did not fully and accurately reflect program activity for the audit period. Recommendation: We recommend that the Department continue efforts to strengthen controls over the preparation and review of ETA reports, including completing data reconciliation procedures related to the new system implementation. This should include validating migrated data, resolving discrepancies identified within validation samples, and implementing review procedures to ensure reported information is accurate, complete, and supported prior to submission to the U.S. Department of Labor. Views of responsible officials: The Department does not disagree with the audit finding. Management acknowledges the reporting discrepancies identified and has been actively addressing these issues through quarterly SQSP corrective action reporting to USDOL. Action taken in response to finding: The Department has: • Prioritized system correction and data validation tickets. • Expanded use of the Data Validation program to identify root causes. Enhanced review procedures for ETA reports prior to submission. The Department acknowledges the finding and has already implemented corrective measures through its established oversight and reporting framework. The identified reporting discrepancies have been incorporated into the State Quality Service Plan (SQSP) Corrective Action Plans (CAPs) and are reported quarterly to the U.S. Department of Labor (USDOL). To address the root causes associated with the new system implementation and data migration, the Department is taking the following actions: • Leveraging the Data Validation (DV) program to identify and analyze underlying data integrity issues affecting ETA 9050, 9052, and 9055 reports. • Conducting ongoing validation of TUBA-generated reports to ensure accuracy, completeness, and consistency with source data. • Strengthening SQL programming logic and report queries to address discrepancies identified during validation testing. • Submitting and prioritizing system enhancement and defect-resolution tickets to address identified programming and data issues. These efforts are monitored through quarterly SQSP reporting to USDOL, and progress is reviewed regularly by program leadership to ensure timely resolution of identified issues. Name(s) of the contact person(s) responsible for corrective action: Nicole Struckhoff, Deputy UI Director of Tax and Administration Planned completion date for corrective action plan: December 31, 2026 While substantial remediation efforts are expected to be completed by the end of 2026, enhanced data reconciliation and quarterly validation procedures will remain ongoing to ensure continued accuracy, completeness, and reliability of ETA report submissions.

View Audit 393917

Finding 1182507 (2025-013)

Material Weakness 2025

State of Kansas

KS

Internal Control / Segregation of Duties Subrecipient Monitoring Matching / Level of Effort / Earmarking § 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: Reporting Type of Finding: Signif...

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: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: During our testing of ETA – 191, Financial Status of UCFE/UCX one of the two reports tested lacked documentation that the report was reviewed prior to submission. Recommendation: We recommend that the Department formalize its review procedures by maintaining documented evidence of reviews for key reports related to federal programs. Management should establish clear documentation standards, such as reviewer sign‑off, date of review, and evidence of follow‑up on identified issues, to demonstrate that oversight controls are consistently performed. Views of responsible officials: There is no disagreement with the finding. Action taken in response to finding: The Department will require that reviewed ETA-191 reports be saved with documented evidence of review, including date stamp and typed reviewer name, prior to submission. Updated documentation procedures are being implemented to ensure consistent retention of review evidence. To address this finding, the Department will implement enhanced documentation controls for ETA reports, including: • Establishing a standardized review checklist for ETA-191. • Requiring documented reviewer sign-off prior to submission, including typed name and date of review. • Ensuring all reviewed and finalized versions of reports are saved with date stamps to evidence completion of the review process. • Incorporating verification of documented review into supervisory oversight procedures. These measures will formalize existing practices and ensure sufficient audit trail documentation is maintained to demonstrate compliance with internal control requirements. Name(s) of the contact person(s) responsible for corrective action: Nicole Struckhoff, Deputy UI Director of Tax and Administration Planned completion date for corrective action plan: June 30, 2026 (End of 2nd Quarter 2026)

View Audit 393917

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 1182503 (2025-011)

Material Weakness 2025

State of Kansas

KS

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, and 2501KSTANF Period: October 1, 202...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, and 2501KSTANF Period: October 1, 2023 – September 30, 2025 Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The entity did not have a documented control in place to evidence an independent review of the ACF‑199 TANF Data Report for accuracy and completeness prior to submission to the federal awarding agency. The report was generated from system data and submitted without documented supervisory review or approval before transmission. Recommendation: We recommend that management design and implement a documented review and approval control over the ACF‑199 TANF Data Report prior to submission to the federal awarding agency. The control should include evidence of review to verify the accuracy and completeness of the report, such as documented supervisory sign‑off, electronic approval, or retention of review documentation. Implementing a consistent pre‑submission review process will strengthen internal controls over federal reporting and provide reasonable assurance of compliance with reporting requirements. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: DCF will design and implement a documented review and approval control over the ACF-199 TANF Data Report prior to submission to the Administration for Children and Families (ACF). DCF will include in the documented process the manner in which DCF will verify the accuracy and completeness of the report prior to submission to ACF. DCF will also include in the documented process the manner in which DCF will ensure the process is followed consistently and thoroughly. Name(s) of the contact person(s) responsible for corrective action: Carla Whiteside-Hicks, Economic and Employment Services Director and Melissa Vo, Program Integrity Assistant Director Planned completion date for corrective action plan: June 30, 2026

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 1182493 (2025-005)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.1 § 200.303

Federal Agency: Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019 – 7/...

Federal Agency: Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019 – 7/31/2027) & NU51CK000384 (8/1/2024 – 7/31/2029) Compliance Requirement: Reporting - Federal Funding Accounting and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: During the audit period, the entity did not submit required FFATA reports for certain first‑tier subawards subject to FFATA reporting requirements. As a result, required information was not reported in SAM.gov by the last day of the month following the month in which the subaward obligation occurred. Recommendation: We recommend that management implement policies and procedures to ensure compliance with FFATA reporting requirements. This should include identifying all federal awards and subawards subject to FFATA, establishing a process to track reporting deadlines, and providing training to personnel responsible for grant administration to ensure FFATA reports are submitted timely and accurately in SAM.gov. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Currently, all sub awardee payments are being processed by KDHE; however, moving forward, the fiscal analyst will work with the program to make sure that they have the needed information if another state agency is going to be processing the payments on KDHE’s behalf. Moving forward, the fiscal analyst will contact the program to get amounts for any subrecipient agreements/awards, which KDHE will not be the agency processing the payments for, so that any required FFATA reporting can be submitted. Name(s) of the contact person(s) responsible for corrective action: Shelley Russell, Fiscal Management Public Services Executive IV and Danette Cox, Fiscal Analyst Planned completion date for corrective action plan: Immediately. New processes will be used if another state agency will be processing the payments on KDHE’s behalf.

View Audit 393917

Finding 1182487 (2025-002)

Material Weakness 2025

Homestead Homes of Greensboro INC

NC

HUD Housing Programs Internal Control / Segregation of Duties

2. Finding 2025-002: a. Comments on the findings and Recommendation: At the time of the Audit, we agree with the findings. b. Action (s) Taken or planned on the finding: Work orders had fallen behind due to staff changes, and unit turns. Regional Asset Manager has advised the staff that this cannot ...

2. Finding 2025-002: a. Comments on the findings and Recommendation: At the time of the Audit, we agree with the findings. b. Action (s) Taken or planned on the finding: Work orders had fallen behind due to staff changes, and unit turns. Regional Asset Manager has advised the staff that this cannot continue, and all work orders must be completed within less than (30) days from date of receipt. Since completion of Audit, maintenance has been working to get all work orders completed and caught up and to make sure they will continue to be completed in a timely manner. Regional Asset Manager will also check to make sure this is being accomplished at each quarterly site visit.

View Audit 393911

Finding 1182486 (2025-001)

Material Weakness 2025

Homestead Homes of Greensboro INC

NC

HUD Housing Programs Internal Control / Segregation of Duties

1. Finding 2025-001: a. Comments on the findings and Recommendation: At the time of the audit, we agree with the findings. b. Action (s)Taken or planned on the finding: The preventative maintenance and painting schedules were started to be maintained by management as of May 2025. Regional Asset Mana...

1. Finding 2025-001: a. Comments on the findings and Recommendation: At the time of the audit, we agree with the findings. b. Action (s)Taken or planned on the finding: The preventative maintenance and painting schedules were started to be maintained by management as of May 2025. Regional Asset Manager has advised staff of the importance of these tasks and schedules to be maintained and carried out on a routine basis. Moving forward they will be maintained properly and kept current throughout the year. Regional Asset Manager will continue to check these schedules at each quarterly site visit.

View Audit 393911

Corrective Action Plans

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