Corrective Action Plans

Finding 1182722 (2025-005)

Material Weakness 2025

State of Mississippi Institutions of Higher Learning

MS

Questioned Costs Subrecipient Monitoring Cash Management § 200.305

Finding Reference: 2025-005 - Cash Management (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director - Student Financial Services & Scholarships (Letherio.h.zeigler@jsums.edu) Corrective Action Planned: During the 2024-2025 award year, there was a change in leadership within the financ...

Finding Reference: 2025-005 - Cash Management (JSU) Responsible Official: Mr. Letherio Zeigler, Executive Director - Student Financial Services & Scholarships (Letherio.h.zeigler@jsums.edu) Corrective Action Planned: During the 2024-2025 award year, there was a change in leadership within the financial aid department near the end of 2024 that disrupted the normal process of reconciliation of funds to be disbursed which caused the delayed drawdowns that were outside the scope of compliance regarding allocation of funds towards student accounts. The Executive has developed a timely process of reconciliation that is in line with federal regulations to ensure that funds will drawdown timely as well as the institution has gone voluntarily to a system with COD in which drawdowns will not occur until COD receives approved response files for Federal Pell grant and Student Loans to ensure there is no delay in drawdowns. Estimated Completion Date: August 1, 2026 Finding Reference: 2025-005 - Cash Management (USM) Responsible Official: Erica Kennedy, Associate Vice President for Research (Erica.kennedy@usm.edu) Corrective Action Planned: USM acknowledges the finding related to cash management timing requirements under 2 CFR §200.305(b). To address the root cause and ensure ongoing compliance, USM will implement the following corrective actions: 1.Maintain standard monthly draw schedule. a.USM has returned to the standard monthly draw schedule, which aligns with the institutional accounting close timeline and supports accurate, reconciled requests. b.This schedule is now designated as the required default for all TRIO drawdowns, and deviations will not be permitted except in documented emergency situations approved at the VP level. 2.Reinforce internal controls linked to monthly draws. a.Existing internal controls, including pre-draw reconciliation, multi-level review, and validation of current/month expenditures, remain in place and are explicitly tied to the monthly schedule. b.Any proposed changes to the draw frequency must undergo formal written approval, including documentation explaining the reason for change and a review of associated compliance risks. 3.Monitoring a.For the next two quarters, the AVPR will conduct spot checks to confirm continued adherence to the monthly schedule and compliance with standard reconciliation procedures. Estimated Completion Date: Corrective actions are completed. The standard monthly draw process was reinstated and fully implemented, effective April 2025.

View Audit 394137

Finding 1182689 (2025-001)

Material Weakness 2025

West Central Illinois Area Agency on Aging

IL

Matching / Level of Effort / Earmarking Subrecipient Monitoring

West Central Illinois Area Agency on Aging will strengthen its budgeting and monitoring process to ensure required minimum spending levels are met. Beginning in FY2026, staff will verify earmarked requirements during budget preparation and review expenses quarterly to confirm compliance. Responsibil...

West Central Illinois Area Agency on Aging will strengthen its budgeting and monitoring process to ensure required minimum spending levels are met. Beginning in FY2026, staff will verify earmarked requirements during budget preparation and review expenses quarterly to confirm compliance. Responsibility for monitoring has been assigned to fiscal leadership, with review and oversight by Director, Assistant Director, as well as Program Manager. The Agency believes this was an isolated incident and expects these steps to prevent recurrence in accordance with requirements from the Illinois Department on Aging.

View Audit 394128

Finding 1182677 (2025-002)

Material Weakness 2025

Uc Healthcare System

OH

Cash Management Reporting Matching / Level of Effort / Earmarking

Corrective Action Plan Federal Award Findings and Questioned Costs For the Fiscal Year Ended June 30, 2025 Finding 2025-002 – C. Cash Management, G. Matching, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services Federal Program:...

Corrective Action Plan Federal Award Findings and Questioned Costs For the Fiscal Year Ended June 30, 2025 Finding 2025-002 – C. Cash Management, G. Matching, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.493, Congressional Directives Award Period: July 1, 2024 through June 30, 2025 Summary of finding: UC Health did not appropriately design and execute internal controls to verify they were eligible for the full balance of the cash draw down made during the year under audit, which ultimately resulted in an inappropriate expenditure balance reported on the original schedule of expenditures of federal awards (SEFA). Planned corrective action: Management agrees with this finding. Federal awards for capital projects are infrequent for UC Health. However, management acknowledges the importance of adhering to the terms of the award. Responsibilities to validate and confirm the accuracy of amounts billed for each federal award will transition to the Finance staff. The Finance staff will request and review the federal award agreement and related documents and highlight the terms and conditions needed to timely and accurately request cash draws and report on the cost incurred related to the award. Request for cash draws will be validated by the Vice President and Controller to review the support, ensure the requirements are met for the expenditures, and confirm the terms are being met prior to submission. Anticipated completion date: April 1, 2026 Responsible contact person: Michael Wiedeman, Vice President and Controller

View Audit 394112

Finding 1182675 (2025-008)

Material Weakness 2025

School City of East Chicago

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Equipment & Real Property Management § 200.1 § 200.302 § 200.303 § 200.305 § 200.313

FINDING 2025-008 Finding Subject: COVID-19 - Education Stabilization Fund – Condition of Records Federal Agency: Department of Education Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Lela Simmons, CFO Contact Phone Number and Email Address: 219...

FINDING 2025-008 Finding Subject: COVID-19 - Education Stabilization Fund – Condition of Records Federal Agency: Department of Education Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Lela Simmons, CFO Contact Phone Number and Email Address: 219 391 4100 Ex 12365: lesimmons@ecps.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Internal controls will be put in place to ensure all COVID 19 ESSER Funds are reported accurately to the State and Federal Department of Education. Reimbursements will be attached to State Email for disbursement. Anticipated Completion Date: We anticipate having the above corrective action plan in place by October 31, 2026

View Audit 394104

Finding 1182667 (2025-006)

Material Weakness 2025

School City of East Chicago

IN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Lela Simmons, CFO Contact Phone Number...

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Lela Simmons, CFO Contact Phone Number and Email Address: 219 391 4100 Ex 12365: lesimmons@ecps.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The district will implement strengthen internal controls to ensure of that exit conference for each student withdrawal will be held and all documentation will be files. All documents will be scanned to student software. All students will be properly document to the state and local entities. Anticipated Completion Date: We anticipate having the above corrective action plan in place by October 31, 2026

View Audit 394104

Finding 1182647 (2025-002)

Material Weakness 2025

Tri-County Community Action Partnership, Inc.

MN

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency § 200.303

Head Start - AL #93.6000 Recommendation: The Organization should ensure all new board members receive training within 180 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will ensure that all new and existi...

Head Start - AL #93.6000 Recommendation: The Organization should ensure all new board members receive training within 180 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will ensure that all new and existing board members receive necessary training within 180 days of being seated and on an annual basis. Name(s) of the contact person(s) responsible for corrective action: Rita Zilka, Fiscal Director Planned completion date for corrective action plan: September 30, 2026

View Audit 394089

Finding 1182639 (2025-003)

Material Weakness 2025

Northeastern Oklahoma Agricultural An Mechanical College

OK

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

Student Financial Assistance Cluster– Assistance Listing No. 84.063, 84.007, 84.033, 84.268 Recommendation: We recommend the College review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported accurately and timely. Explanation of disagreement with aud...

Student Financial Assistance Cluster– Assistance Listing No. 84.063, 84.007, 84.033, 84.268 Recommendation: We recommend the College review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: NEO will perform an internal audit of enrollment reports sent to the National Student Clearinghouse (NSC) monthly to ensure NSC is submitting records on behalf of NEO in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Amy Ishmael Planned completion date for corrective action plan: April 1, 2026 If the U.S. Department of Education has questions regarding this plan, please call Amy Ishmael at 918- 540-6212.

View Audit 394070

Finding 1182638 (2025-002)

Material Weakness 2025

Northeastern Oklahoma Agricultural An Mechanical College

OK

Questioned Costs Student Financial Aid Significant Deficiency § 200.303

Student Financial Assistance Cluster– Assistance Listing No. 84.063, 84.007, 84.033, 84.268 Recommendation: We recommend that the College review policies and procedures related to R2T4 calculations to ensure calculations are performed correctly and timely. We also recommend the College implement for...

Student Financial Assistance Cluster– Assistance Listing No. 84.063, 84.007, 84.033, 84.268 Recommendation: We recommend that the College review policies and procedures related to R2T4 calculations to ensure calculations are performed correctly and timely. We also recommend the College implement formal review procedures to document the Return of Title IV calculations are being performed to minimize the likelihood that errors may go undetected and not be corrected in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: NEO will check the scheduled break days before the beginning of each semester to make sure the correct number of days is entered into SOATBRK. Documentation will be retained to confirm that a check was performed. NEO performed the recalculations and is working with FSA to make corrections. Name(s) of the contact person(s) responsible for corrective action: David Fisher and Ashley Mayfield Planned completion date for corrective action plan: March 14, 2026.

View Audit 394070

Finding 1182637 (2025-001)

Material Weakness 2025

Northeastern Oklahoma Agricultural An Mechanical College

OK

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

SIGNIFICANT DEFICIENCY 2025-001 Student Financial Assistance Cluster– Assistance Listing No. 84.063, 84.007, 84.033, 84.268 Recommendation: We recommend the College review reporting processes to ensure all students that require exit counseling receive it in a timely manner. Explanation of disagreeme...

SIGNIFICANT DEFICIENCY 2025-001 Student Financial Assistance Cluster– Assistance Listing No. 84.063, 84.007, 84.033, 84.268 Recommendation: We recommend the College review reporting processes to ensure all students that require exit counseling receive it in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: NEO will develop a separate report in addition to the RRREXIT report to identify students that need to be notified of their responsibility to complete exit counseling. Name(s) of the contact person(s) responsible for corrective action: David Fisher Planned completion date for corrective action plan: March 15, 2026.

View Audit 394070

Finding 1182619 (2025-008)

Material Weakness 2025

Rush County Schools

IN

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

FINDING 2025-008 Finding Subject: COVID-19 Education Stabilization Fund – Special Tests and Provisions – Wage Rate Requirements Summary of Finding: One of the construction contracts tested for compliance that was to be paid from federal grant funds did not have the required prevailing wage rate caus...

FINDING 2025-008 Finding Subject: COVID-19 Education Stabilization Fund – Special Tests and Provisions – Wage Rate Requirements Summary of Finding: One of the construction contracts tested for compliance that was to be paid from federal grant funds did not have the required prevailing wage rate cause nor were certified weekly payrolls for construction services performed under the contract provided upon request. Contact Person Responsible for Corrective Action: Julie Cramer Contact Phone Number and Email Address: 765-932-4186, cramerj@rushville.k12.in.us Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: The School Corporation management will establish a system of internal controls involving the Corporation Treasurer and Superintendent and include the wage requirement clause in contracts for construction that are paid with federal grant funds. The School Corporation will also request certified payrolls that will go along with these specific types of contracts. Anticipated Completion Date: March 31, 2026

View Audit 394041

Finding 1182613 (2025-006)

Material Weakness 2025

Rush County Schools

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.77 § 200.78

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation to ensure compliance with requirements related to the grant agr...

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Eligibility Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirement. Contact Person Responsible for Corrective Action: Julie Cramer Contact Phone Number and Email Address: 765-932-4186, cramerj@rushville.k12.in.us Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: The Technology Director or assigned State Reporter will supply the Title I Director and Food Services Director with rosters reports from our SIS system prior to the certification of the October 1 count each year. Applications on file will be reviewed for accuracy and updates to our SIS will be made checking for accuracy. These reports will be retained for audit purposes and used by the Grant Coordinator to determine that enrollment numbers in the Title I application have been populated correctly. The Title I Director and Food Services Director will both sign off on this document. Anticipated Completion Date: September 2026

View Audit 394041

Finding 1182611 (2025-005)

Material Weakness 2025

Rush County Schools

IN

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

FINDING 2025-005 Finding Subject: Title I Grants to Local Educational Agencies - Internal Controls over Compliance – Assessment System Security Summary of finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation to ensure co...

FINDING 2025-005 Finding Subject: Title I Grants to Local Educational Agencies - Internal Controls over Compliance – Assessment System Security Summary of finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Special Tests and Provisions – Assessment System Security compliance requirement. Contact Person Responsible for Corrective Action: Julie Cramer Contact Phone Number and Email Address: 765-932-4186, cramerj@rushville.k12.in.us Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: The Corporation’s Testing Coordinator will reiterate to our STCs in our buildings to make sure new hires are given the Test Security and Integrity sheets and follow our internal monitoring protocols to ensure that the appropriate people are trained by initialing the staff sign-in sheets verifying that the attendance information was reviewed for accuracy. These reminders for the STCs will come at least twice a year: Once in the fall before all testing begins and again in the spring before the summative tests begin. Anticipated Completion Date: March 3, 2026

View Audit 394041

Finding 1182592 (2025-001)

Material Weakness 2025

Charles County Public Schools

MD

Questioned Costs Procurement, Suspension & Debarment Significant Deficiency § 200.317 § 200.327

Special Education Cluster – Assistance Listing No. 84.027 Recommendation: We recommend the Board revise its procurement policies to fully align with Uniform Guidance requirements and strengthen internal controls to ensure procurement transactions charged to federal awards are reviewed for compliance...

Special Education Cluster – Assistance Listing No. 84.027 Recommendation: We recommend the Board revise its procurement policies to fully align with Uniform Guidance requirements and strengthen internal controls to ensure procurement transactions charged to federal awards are reviewed for compliance prior to payment. This should include updated policy guidance, staff training, and documented supervisory review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Action Plan: CCPS Purchasing Department will make the following changes to our current purchasing policy manual to comply with the Audit recommendation above: Noncompetitive bidding (written justification and purchase desc. Docs require) $ 0 - 5K threshold. Informal bidding (3) price quotes required for $5k - $25,000 purchase threshold with no exceptions for MOI. Formal Bidding required at 25K or greater (ITB, RFP, RFQ’s etc) Require purchase justification for all purchases regardless of dollar threshold Require authorized signature approval based on our current dollar threshold for all purchases Name(s) of the contact person(s) responsible for corrective action: Nelson E. Sample, CPPO, Procurement Manager Planned completion date for corrective action plan: No later than June 30,2026

View Audit 394040

Finding 1182565 (2025-003)

Material Weakness 2025

MUNICIPALITY OF BELMONT, WEST VIRGINIA

WV

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.317 § 200.318 § 200.327

City Clerk will be putting the Grant award Policies and Procedures in place

View Audit 394015

Finding 1182562 (2025-001)

Material Weakness 2025

Illinois Central College District 514

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The College acknowledges that a submission error occurred in Spring 2023, resulting in several students not being included in the routine semester enrollment submissions to the National Student Clearinghouse (NSC). Beginning in Spring 2024, our Institutional Research department initiated a comprehen...

The College acknowledges that a submission error occurred in Spring 2023, resulting in several students not being included in the routine semester enrollment submissions to the National Student Clearinghouse (NSC). Beginning in Spring 2024, our Institutional Research department initiated a comprehensive process to resubmit corrected enrollment files to the NSC, covering Spring 2023, Summer 2023, and Fall 2023. In collaboration with NSC, we followed their established process to rectify the error, which required reloading each submission one at a time in succession from the original submission with the error. This process caused delays in our subsequent submissions until the corrections were fully completed. To prevent recurrence, we have implemented enhanced checks and controls prior to each submission to review the file and file size to ensure the correct number of students are submitted to NSC. Additionally, all submissions post-Spring 2023 have been reviewed, and we have confirmed that this was an isolated incident. Due to the timing of when the College was notified by NSC, this item carried forward into audit year 2025.

View Audit 394014

Finding 1182545 (2025-003)

Material Weakness 2025

Career Academy of South Bend, INC

IN

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

Recommendation: We recommend that the School implement procedures and controls to ensure the required reports are accurate and completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Explanation of disagreement with audit finding: There is n...

Recommendation: We recommend that the School implement procedures and controls to ensure the required reports are accurate and completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has contracted with an outside firm to assist with developing the required Internal Controls and Processes with an estimated completion date of December 31, 2026. Name(s) of the contact person(s) responsible for corrective action: Mary Hunt, CFO. Planned completion date for corrective action plan: December of 2026.

View Audit 393976

Finding 1182524 (2025-001)

Material Weakness 2025

Hannibal-Lagrange University

MO

Questioned Costs Student Financial Aid Allowable Costs / Cost Principles

Finding Number: 2025-001 Considering Subsidized Loans First Planned Corrective Action: The financial aid office concurs with this finding. We have received guidance from our annual audit partners and will install updated processes to ensure that consideration of subsidized loans is prioritized durin...

Finding Number: 2025-001 Considering Subsidized Loans First Planned Corrective Action: The financial aid office concurs with this finding. We have received guidance from our annual audit partners and will install updated processes to ensure that consideration of subsidized loans is prioritized during the awarding process. Person Responsible for Corrective Action Plan: Brice Baumgardner, Vice President of Enrollment Management Anticipated Date of Completion: 4/1/2026

View Audit 393940

Finding 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 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 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 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

Corrective Action Plans

Filters