Corrective Action Plans

Finding 1182512 (2025-016)

Material Weakness 2025

State of Kansas

KS

Questioned Costs Student Financial Aid Eligibility § 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 Questioned Costs Subrecipient Monitoring § 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 Questioned Costs Reporting § 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 Questioned Costs Subrecipient Monitoring § 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 Questioned Costs 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

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 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 Questioned Costs § 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

Questioned Costs 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

Questioned Costs 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

Finding 1182483 (2025-005)

Material Weakness 2025

Eastern Oregon University

OR

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Recommendation: We recommend the University implement procedures to ensure evidence of the key control review over payments to program participants 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 implement procedures to ensure evidence of the key control review over payments to program participants is documented and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Eastern Oregon University implemented a standardized internal review and documentation process for new scholarship and other program participant payment requests. The process now requires documentation showing that award criteria were reviewed and met, a secondary review was completed, the payment or disbursement amount was verified for accuracy before release, and post-disbursement reconciliation was performed. To support this process, the University created a form to document each step of the review and retain evidence of completion. The responsible department has also been instructed on the documentation expectations and records retention requirements so that evidence of these control activities is maintained and available for future audit review. This corrective action has been implemented for all new requests going forward. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Financial Aid Director Planned completion date for corrective action plan: Completed.

View Audit 393884

Finding 1182481 (2025-004)

Material Weakness 2025

Eastern Oregon University

OR

Questioned Costs Student Financial Aid Subrecipient Monitoring

Recommendation: We recommend the University review the GLBA Safeguards Rule and implement appropriate processes and controls to ensure compliance with all applicable provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response ...

Recommendation: We recommend the University review the GLBA Safeguards Rule and implement appropriate processes and controls to ensure compliance with all applicable provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT Department, in conjunction with Human Resources and individual directors and department heads, will institute an annual system inventory of data classification and owner, ensuring job roles and position descriptions are mapped to access profiles. The CIO will review the current classification process for assigning role-based access and the related IT ticketing process for access to ensure existence of documented approvals for provisioning and role changes through a defined access request and approval workflow. IT will also work with HR to establish onboarding/position change/separation controls and timelines triggered by HR provisioning with same-day termination (within 24-hours) upon termination and role change reviews with transfers. IT will also enforce multi-factor authentication (MFA) administrative access where feasible. The relevant Policy and Procedure Manuals will be updated to define access privileges and approval processes, and staff will be trained annually and with onboarding. Name(s) of the contact person(s) responsible for corrective action: Russ Fagan, Chief Information Officer Planned completion date for corrective action plan: March 31, 2026

View Audit 393884

Finding 1182476 (2025-003)

Material Weakness 2025

Eastern Oregon University

OR

Questioned Costs Allowable Costs / Cost Principles Eligibility § 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

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

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 1182451 (2025-001)

Material Weakness 2025

New Hampton Community School District

IA

Internal Control / Segregation of Duties

Management is cognizant of this limitaiton and will implement additional procedures where possible.

View Audit 393846

Finding 1182441 (2025-005)

Material Weakness 2025

Plymouth Community School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Special Tests & Provisions § 200.302 § 200.303

FINDING 2025-005 Finding Subject: Child Nutrition Cluster, Special Tests and Provisions, School Food Accounts Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke, Brittany Sabinas, Amanda Bender Contact Phone Number and Email Address: ...

FINDING 2025-005 Finding Subject: Child Nutrition Cluster, Special Tests and Provisions, School Food Accounts Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke, Brittany Sabinas, Amanda Bender 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 Special Tests and Principles, School Food Accounts is an isolated incident.” The Business Manager/Treasurer receives deposit emails from the Indiana State Comptroller. The Business Manager codes the deposit for the Accounts Payable Specialist to receipt. The Business Manager completes a monthly bank reconciliation that is reviewed by the Deputy Treasurer and Accounts Payable Specialist as part of the month end process. Anticipated Completion Date: January, 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 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 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 1182407 (2025-004)

Material Weakness 2025

Washington County

OR

Questioned Costs Reporting Internal Control / Segregation of Duties

AL 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Finding: Documentation supporting the expenditures included in the Project and Expenditure Report was not retained after the report was submitted. Auditor Recommendation: The County should develop and implement policies and proced...

AL 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Finding: Documentation supporting the expenditures included in the Project and Expenditure Report was not retained after the report was submitted. Auditor Recommendation: The County should develop and implement policies and procedures to ensure that all ARPA/SLFRF program report support is retained. Corrective Actions Taken or Planned: The County agrees and concurs. In addition to the grants coordinator position a new grant accountant will be starting in the spring of 2026 to improve grant oversight and administration. The board adopted a Grants Policy on 1/20/2026. Point of Contact for corrective actions: Sarah Keane, Deputy CFO sarah_keane@washingtoncountyor.gov

View Audit 393821

Finding 1182374 (2025-003)

Material Weakness 2025

City of Portsmouth

NH

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 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

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 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.

View Audit 393804

Finding 1182361 (2025-002)

Material Weakness 2025

Town of Montgomery, Vermont

VT

Material Weakness Reporting Internal Control / Segregation of Duties

2025-002 Material Weakness in Internal Control over financial Reporting – Lacks Ability to Prepare Financial Statements Recommendation: We recommend that management assess the time requirements of the Treasurer position and the capabilities of accounting employees and either (a) develop a training p...

2025-002 Material Weakness in Internal Control over financial Reporting – Lacks Ability to Prepare Financial Statements Recommendation: We recommend that management assess the time requirements of the Treasurer position and the capabilities of accounting employees and either (a) develop a training program to ensure that they obtain the skills and knowledge necessary to prepare financial statements in accordance with GAAP or (b) hire accounting personnel with the requisite knowledge and skill to do so. . Action Taken: We have assessed the time requirements of the Treasurer position given the changes to the growing amount of funding sources the town now has and The Town has hired support for the Treasurer. In addition, courses were taken in Audit, Single Audit and Grants Training, Fiscal Year End Considerations and Preparations and Put the Fun in Fund Balance. Person Responsible: Erin Walsh, Treasurer Anticipated Completion Date: 12/31/25

View Audit 393795

Finding 1182360 (2025-001)

Material Weakness 2025

Town of Montgomery, Vermont

VT

Material Weakness Reporting Internal Control / Segregation of Duties

2025-001 Material Weakness in Internal Control over financial Reporting – Material Adjusting Journal Entries Recommendation: Management has discussed the reporting differences and is now familiar with the proper and timely accounting for these transactions Action Taken: The Town feels that this is a...

2025-001 Material Weakness in Internal Control over financial Reporting – Material Adjusting Journal Entries Recommendation: Management has discussed the reporting differences and is now familiar with the proper and timely accounting for these transactions Action Taken: The Town feels that this is an isolated instances due to the increased funding sources during the year. These instances are due to non-routine events over the course of the year. The town feels as though this will not be an issue in the future as it has now developed an understanding of the implications of material adjustments and has increased documentation standards and processes to reduce future occurrences. Person Responsible: Erin Walsh, Treasurer Anticipated Completion Date: 12/31/25

View Audit 393795

Finding 1182353 (2025-001)

Material Weakness 2025

Fayette County

IA

Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN March 19, 2026 To: U.S. Department of Transportation Fayette County respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Hacker, Nelson & Co., CPAs 123 W. Water Street Decorah, IA 52...

CORRECTIVE ACTION PLAN March 19, 2026 To: U.S. Department of Transportation Fayette County respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Hacker, Nelson & Co., CPAs 123 W. Water Street Decorah, IA 52101 Audit period: Year ended June 30, 2025. The finding from the June 30, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Transportation: Federal Assistance Listing Number 20.205: Highway Planning and Construction Internal control deficiency: See Finding 2025-001 Recommendation: The County should review the operating procedures of the County offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff, including elected officials. While we do recognize that the County is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Board be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional procedures where possible. Anticipated Date of Completion: June 30, 2026.

View Audit 393790

Corrective Action Plans

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