Corrective Action Plans

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 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 1182483 (2025-005)

Material Weakness 2025

Eastern Oregon University

OR

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 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 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 1182471 (2025-002)

Material Weakness 2025

Eastern Oregon University

OR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Recommendation: We recommend the University retain evidence that key controls over COD reporting were performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office completes COD reporting on a...

Recommendation: We recommend the University retain evidence that key controls over COD reporting were performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office completes COD reporting on a weekly basis and will maintain a documentation set for each reporting cycle in a central location using consistent naming conventions. The documentation set will include COD submission batch acceptance files and receipt acknowledgements, edit and error reports with resolution notes and dates, internal system disbursement rosters showing dates and amounts, and adjustment logs. These records will be used to support monthly federal aid reconciliations with the Business Affairs Office. Designated staff responsible for COD submission tracking will also maintain the related reconciliation support documentation. The Financial Aid Policy and Procedure Manual will be updated accordingly, and staff will be trained annually and during onboarding. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Director of Financial Aid Planned completion date for corrective action plan: March 31, 2026

View Audit 393884

Finding 1182469 (2025-001)

Material Weakness 2025

Eastern Oregon University

OR

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

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend that the University implement a key control to ensure that enrollment data, changes in status, and effective dates within NSLDS match the records of the institution and a...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend that the University implement a key control to ensure that enrollment data, changes in status, and effective dates within NSLDS match the records of the institution and are reported timely, and to store evidence of the key control having occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University reports enrollment more frequently than the required 60 days to capture status changes in a timely manner. Reporting occurs each term at the end of the second week, the Tuesday after Census, Monday of week 7, and the end of the term. The Registrar and Financial Aid Office created a process to communicate accurate last dates of academic engagement (LDAs) for unofficial withdrawals so that withdrawal dates match LDAs used in Return of Title IV (R2T4) calculations and unofficial withdrawals are reported to NSLDS through the regular NSC process. The Offices have also instituted a shared tracking and review process to regularly spot-check enrollment reports to ensure that data reported in Banner matches NSC reports and is correctly uploaded to NSLDS. Documentation of unofficial withdrawals, LDAs, error reports, and tracking of sampling outcomes with any needed corrections are maintained in the school’s files and shared between offices. The Registrar’s Office will review Banner and NSC submissions to ensure accurate and matching LDAs and status dates; the Financial Aid Office is responsible for confirming NSC submittals have successfully uploaded to NSLDS and reflect correct data that matches R2T4 and unofficial withdrawal info. Manual reporting to NSLDS will only be used for emergency updates to meet timeliness requirements, with multiple follow-up verification for NSC or roster file overwrites. Policy and Procedures Manuals will be updated accordingly, and staff in both offices will be trained annually and with onboarding. Name(s) of the contact person(s) responsible for corrective action: Emily Sharratt, Registrar; Jason Hibbert, Director of Financial Aid Planned completion date for corrective action plan: March 31, 2026

View Audit 393884

Finding 1182463 (2025-002)

Material Weakness 2025

Ruby Valley Hospital District Dba Ruby Valley Medical Center

MT

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking

The District will work to establish and review policies and procedures to ensure adequate funding is reserved for debt service during the year and at fiscal year end.

View Audit 393871

Finding 1182462 (2025-002)

Material Weakness 2025

Heritage Behavioral Health Center, Inc.

IL

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

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

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

View Audit 393858

Finding 1182455 (2025-001)

Material Weakness 2025

Eastern Carver County Schools Independent School District No. 112

MN

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.303

Material Weakness in Internal Control Over Compliance Recommendation: We recommend that the District review its procurement policies and controls to ensure there is a formally documented control to ensure all vendors are checked for suspension and debarment prior to entering into a covered transacti...

Material Weakness in Internal Control Over Compliance Recommendation: We recommend that the District review its procurement policies and controls to ensure there is a formally documented control to ensure all vendors are checked for suspension and debarment prior to entering into a covered transaction. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procedures and policies over procurement and suspension and debarment to ensure that the District performs the proper suspension and debarment procedures prior to entering into a covered transaction, either through a sam.gov check or by including self-certification language in the contract and retain documentation of this process. Name(s) of the contact person(s) responsible for corrective action: David Brecht, Executive Director of Finance and Operations. Planned completion date for corrective action plan: June 30, 2026

View Audit 393848

Finding 1182452 (2025-001)

Material Weakness 2025

Alliance Apartments Housing Development Fund Co., Inc.

NY

Cash Management HUD Housing Programs Significant Deficiency

Budget Based Rent increase has been submitted to HUD and is in queue for approval. The request includes funding for the reimbursement of the Replacement Reserve. We anticipate that this will be approved.

View Audit 393847

Finding 1182448 (2025-008)

Material Weakness 2025

Plymouth Community School Corporation

IN

Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

FINDING 2025-008 Finding Subject: COVID-19, Education Stabilization Fund - Special Test and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Amanda Bender Contact Phone Number and Email Address:...

FINDING 2025-008 Finding Subject: COVID-19, Education Stabilization Fund - Special Test and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & 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: The Business Manager/Treasurer will require wage rate information for construction contracts in excess of $2,000 that if financed by federal assistance funds. The Business Manager will ensure the wages paid on those contracts are not less than those established for the locality of the project by the Department of Labor. The Payroll Specialist/Deputy Treasurer will be the second approver of such confirmation of labor rates in these situations and circumstances. The corporation will require all vendors that are contracted through the use of federal assistance funds to provide their certified payrolls throughout the project process. These payrolls will be verified to be in compliance by the Treasurer and Deputy Treasurer and kept on file with fund paperwork. Anticipated Completion Date: March 1, 2026 and ongoing

View Audit 393841

Finding 1182445 (2025-007)

Material Weakness 2025

Plymouth Community School Corporation

IN

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

FINDING 2025-007 Finding Subject: Title I Grants to Local Educational Agencies - Earmarking Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke, Brittany Sabinas & Jill VanDriessche Contact Phone Number and Email Address: 574-936-3115,...

FINDING 2025-007 Finding Subject: Title I Grants to Local Educational Agencies - Earmarking Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke, Brittany Sabinas & Jill VanDriessche Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Business Manager/Treasurer provides to the corporation grant administrator monthly grant reports, as well as a grant tracking spreadsheet. The appropriations for each grant are entered into Komputrol, according to the budget located in the approved grant documents. The appropriations are presented to the Grant Administrator for approval. All spending from each grant is approved by the corporation grant administrator. More robust documentation will be created to ensure our earmarked funds are being expended as a requirement of this grant. With the more robust documentation, we will ensure the expenses are recorded properly by the Business Manager/Treasurer. The Accounts Payable Specialist will be a second approver of the spending as well as a signatory on the monthly grant reimbursement requests. Anticipated Completion Date: March 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 1182374 (2025-003)

Material Weakness 2025

City of Portsmouth

NH

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

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

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

View Audit 393804

Finding 1182367 (2025-002)

Material Weakness 2025

City of Portsmouth

NH

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

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

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

View Audit 393804

Finding 1182365 (2025-001)

Material Weakness 2025

City of Portsmouth

NH

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

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

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

View Audit 393804

Finding 1182363 (2025-001)

Material Weakness 2025

Wesleyan University

CT

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

Upon identification of the configuration error, the University corrected its National Student Clearinghouse (NSC) file submission settings to ensure enrollment status changes are properly processed and transmitted to NSLDS. The University has implemented a new monitoring control whereby an employee ...

Upon identification of the configuration error, the University corrected its National Student Clearinghouse (NSC) file submission settings to ensure enrollment status changes are properly processed and transmitted to NSLDS. The University has implemented a new monitoring control whereby an employee independent of the enrollment reporting function performs a review of NSLDS to verify that data submitted through NSC has been accurately and timely transmitted in accordance with required timeframes. This control is designed to provide timely detection of any future transmission failures and ensure corrective action is taken within the required reporting windows.

View Audit 393798

Finding 1182347 (2025-003)

Material Weakness 2025

Lutheran Community Services Northwest

WA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.306

Finding 2025-003 Significant deficiency in internal controls over compliance and instance of noncompliance related to matching requirements. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: Management identified that the required matching report was not submitted t...

Finding 2025-003 Significant deficiency in internal controls over compliance and instance of noncompliance related to matching requirements. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: Management identified that the required matching report was not submitted to the funder in accordance with the grant deliverable requirements. The organization has since reviewed the grant agreement to ensure full understanding of all reporting and matching obligations. Corrective actions have been implemented. A centralized grant compliance checklist has been developed to outline all required deliverables, including matching report deadlines. Matching requirements have been incorporated into the organization’s grant reporting calendar with reminder controls in place. Responsibility for tracking and submitting match documentation has been formally assigned to designated Finance personnel, with supervisory review prior to submission. These measures strengthen internal controls over grant compliance and are designed to ensure timely submission of all required matching documentation going forward. Anticipated completion date: Implemented as of December 31, 2025

View Audit 393787

Finding 1182326 (2025-003)

Material Weakness 2025

Madison-Grant United School Corporation

IN

Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

FINDING 2025-003 Finding Subject: Education Stabilization Fund – Wage Rate Requirements Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 and bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding. Descripti...

FINDING 2025-003 Finding Subject: Education Stabilization Fund – Wage Rate Requirements Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 and bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will ensure that construction contracts in excess of $2,000 financed by federal assistance funds include a provision that the contractor or subcontractor comply with Wage Rate Requirements. Anticipated Completion Date: January 1, 2026

View Audit 393770

Finding 1182251 (2025-009)

Material Weakness 2025

Griffith Public Schools

IN

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

FINDING 2025-009 Finding Subject: Title I Grants to Local Educational Agencies –Earmarking Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A2200...

FINDING 2025-009 Finding Subject: Title I Grants to Local Educational Agencies –Earmarking Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A220014, S010A230014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Matching, Level of Effort, Earmarking Significant Deficiency, Noncompliance Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, detecting, and correcting noncompliance. for Eligibility, Reporting, and Special Tests and Provisions - Assessment System Security. Contact Person Responsible for Corrective Action: Kim Holmquist Contact Phone Number and Email Address: 219-924-4250 kholmquist@griffith.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Griffith Public Schools will be developing, implementing, and documenting, a system of internal controls, including policies and procedures that provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Anticipated Completion Date: June 30, 2026

View Audit 393619

Finding 1182249 (2025-008)

Material Weakness 2025

Griffith Public Schools

IN

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

FINDING 2025-08 Finding Subject: Title I Grants to Local Educational Agencies – Internal Controls Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S0...

FINDING 2025-08 Finding Subject: Title I Grants to Local Educational Agencies – Internal Controls Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A220014, S010A230014, S010A240014, Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Summary of Finding: Significant Deficiency. The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, detecting, and correcting noncompliance for Eligibility. Contact Person Responsible for Corrective Action: Kim Holmquist Contact Phone Number and Email Address: 219-924-4250 kholmquist@griffith.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Griffith Public Schools will be developing, implementing, and documenting, a system of internal controls, including policies and procedures that provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Anticipated Completion Date: June 30, 2026

View Audit 393619

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