Corrective Action Plans

Finding 1205159 (2025-003)

Material Weakness 2025

FL

Student Financial Aid Eligibility Significant Deficiency

Recommendation: We recommend the College evaluate its procedures around packaging and awarding students to ensure loan eligibility is reassessed prior to disbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to...

Recommendation: We recommend the College evaluate its procedures around packaging and awarding students to ensure loan eligibility is reassessed prior to disbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: 􀁸 The College determined that this issue resulted from the absence of a consistent process to identify and reassess students whose transfer credits were added or revised after initial financial aid packaging, potentially affecting grade level classification and Direct Loan eligibility. 􀁸 To correct this, the College will revise its packaging procedures to require a mandatory review of Direct Loan eligibility whenever transfer credits are added or updated. The Financial Aid Office will work in coordination with the IT Department and the Registrar’s Office to develop automated reports or system alerts that flag students with transfer credit changes occurring after packaging. These reports will be reviewed regularly, and any impacted student records will be reassessed and updated as necessary prior to disbursement. 􀁸 In addition, the College will strengthen oversight by implementing monitoring controls such as requirements. These measures are intended to prevent future instances of under-awarding and to enhance internal controls within the financial aid packaging and awarding process. Name(s) of the contact person(s) responsible for corrective action: Stephanie Liebowitz, Director of Financial Aid Planned completion date for corrective action plan: April 15, 2026 – Procedures will be in place for the awards cycle of the incoming 2026-2027 class.

View Audit 396825

Finding 1205148 (2025-030)

Material Weakness 2025

State of Arkansas

AR

Eligibility Subrecipient Monitoring Reporting

Finding Number: 2025-030 ALN Number(s) and Program Title(s): 93.778 – Medical Assistance Program (Medicaid Cluster) Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. DCO will continue periodic matching and review of state employees with public assistance pr...

Finding Number: 2025-030 ALN Number(s) and Program Title(s): 93.778 – Medical Assistance Program (Medicaid Cluster) Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. DCO will continue periodic matching and review of state employees with public assistance programs administered by the agency. Appropriate disciplinary action will continue to be taken by the agency on its own employees based on the outcome of case reviews. The agency will explore the addition of systematic data matching to ensure that salaries of state employees are properly reflected in the eligibility determination and benefit calculation for public assistance benefits. For additional controls, the agency has incorporated a notice into the hiring process regarding reporting all changes in household circumstance and annual communications to all staff regarding their reporting obligations. Anticipated Completion Date: 6/30/26 Contact Person: Name: Mary Franklin Title: Director, Division of County Operations Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8377 Email Address: Mary.franklin@dhs.arkansas.gov

View Audit 396807

Finding 1205147 (2025-029)

Material Weakness 2025

State of Arkansas

AR

Subrecipient Monitoring Eligibility Significant Deficiency

Finding Number: 2025-029 ALN Number(s) and Program Title(s): 93.778 – Medical Assistance Program (Medicaid Cluster) Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. For cases that included a date of death in MMIS, most deficiencies can be attributed to cas...

Finding Number: 2025-029 ALN Number(s) and Program Title(s): 93.778 – Medical Assistance Program (Medicaid Cluster) Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. For cases that included a date of death in MMIS, most deficiencies can be attributed to case worker error which is being addressed through continued worker education and training. A small number of deficiencies can be attributed to a variety of system errors which are in the process of being corrected. Recoupments of overpayments are also being processed. For cases with no date of death in MMIS, almost half were the result of the eligibility system not receiving the date of death via the monthly match to the Arkansas Department of Health (ADH) vital records data. DHS will work with ADH to identity date of death for those cases and identify any corrective action needed to the match process. The remaining deficiencies can be attributed to a variety of system errors which are in the process of being corrected and worker errors which is being addressed through worker education and training. Recoupments will be processed through both automatic reconciliation and manual processes. Anticipated Completion Date: 6/30/2026 Contact Person: Name: Mary Franklin Title: Director, Division of County Operations Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8377 Email Address: Mary.Franklin@dhs.arkansas.gov

View Audit 396807

Finding 1205146 (2025-028)

Material Weakness 2025

State of Arkansas

AR

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility

Finding Number: 2025-028 ALN Number(s) and Program Title(s): 93.778 – Medical Assistance Program (Medicaid Cluster) Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. For juveniles with SSI Medicaid, the Social Security Administration (SSA) is responsible fo...

Finding Number: 2025-028 ALN Number(s) and Program Title(s): 93.778 – Medical Assistance Program (Medicaid Cluster) Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. For juveniles with SSI Medicaid, the Social Security Administration (SSA) is responsible for suspending Medicaid coverage. All incarcerations for cases noted in the findings involving SSI Medicaid, which make up 95% of the total questioned costs for this finding, were reported timely to SSA by the agency. All payments noted as questioned costs were capitated payments which will be recouped through an automatic reconciliation process. Anticipated Completion Date: 6/30/26 Contact Person: Name: Elizabeth Pitman Title: Director, Division of Medical Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-244-3944 Email Address: Elizabeth.Pitman@dhs.arkansas.gov

View Audit 396807

Finding 1205143 (2025-025)

Material Weakness 2025

State of Arkansas

AR

Subrecipient Monitoring Eligibility Significant Deficiency

Finding Number: 2025-025 ALN Number(s) and Program Title(s): 93.767 – Children’s Health Insurance Program Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The error was caused by an eligibility system defect that was corrected in April 2024. Anticipated Co...

Finding Number: 2025-025 ALN Number(s) and Program Title(s): 93.767 – Children’s Health Insurance Program Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The error was caused by an eligibility system defect that was corrected in April 2024. Anticipated Completion Date: Complete Contact Person: Name: Mary Franklin Title: Director, Division of County Operations Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8377 Email Address: Mary.Franklin@dhs.arkansas.gov

View Audit 396807

Finding 1205139 (2025-021)

Material Weakness 2025

State of Arkansas

AR

Matching / Level of Effort / Earmarking Subrecipient Monitoring

Finding Number: 2025-021 ALN Number(s) and Program Title(s): 93.658 – Title IV-E Foster Care Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. DCFS will update its internal controls to require monthly review of contractor financial deliverables. Anticipated...

Finding Number: 2025-021 ALN Number(s) and Program Title(s): 93.658 – Title IV-E Foster Care Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. DCFS will update its internal controls to require monthly review of contractor financial deliverables. Anticipated Completion Date: 4/30/26 Contact Person: Name: Tiffany Wright Title: Director, Division of Children and Family Services Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-396-6477 Email Address: Tiffany.Wright@dhs.arkansas.gov

View Audit 396807

Finding 1205137 (2025-019)

Material Weakness 2025

State of Arkansas

AR

Matching / Level of Effort / Earmarking Subrecipient Monitoring Reporting

Finding Number: 2025-019 ALN Number(s) and Program Title(s): 93.575 – Child Care and Development Block Grant 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster) Views of Responsible Officials and Planned Corrective Action: DESE concurs with this fin...

Finding Number: 2025-019 ALN Number(s) and Program Title(s): 93.575 – Child Care and Development Block Grant 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster) Views of Responsible Officials and Planned Corrective Action: DESE concurs with this finding. Staff turnover resulted in missing the reporting submission deadlines for the ACF-696 reports. New procedures have been put into place for cross-training and quarterly reconciliations to prevent future expenditure reporting on the ACF-696 report from being missed. Anticipated Completion Date: Completed. Contact Person: Name: Greg Rogers Title: Chief Fiscal Officer Agency: DESE Address: 4 Capitol Mall, Room 204-A City, State, Zip: Little Rock, AR 72201 Phone Number: 501-682-4475 Email Address: Greg.Rogers@ade.arkansas.gov

View Audit 396807

Finding 1205134 (2025-018)

Material Weakness 2025

State of Arkansas

AR

Reporting Matching / Level of Effort / Earmarking § 200.302

Finding Number: 2025-018 ALN Number(s) and Program Title(s): 93.575 – Child Care and Development Block Grant 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund Views of Responsible Officials and Planned Corrective Action: DESE concurs with this finding. Staff tur...

Finding Number: 2025-018 ALN Number(s) and Program Title(s): 93.575 – Child Care and Development Block Grant 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund Views of Responsible Officials and Planned Corrective Action: DESE concurs with this finding. Staff turnover resulted in missed reporting on the ACF-696 reports. New procedures have been put into place for cross-training and quarterly reconciliations to prevent future expenditure reporting on the ACF-696 report from being missed. Anticipated Completion Date: Completed. Contact Person: Name: Greg Rogers Title: Chief Fiscal Officer Agency: DESE Address: 4 Capitol Mall, Room 204-A City, State, Zip: Little Rock, AR 72201 Phone Number: 501-682-4475 Email Address: Greg.Rogers@ade.arkansas.gov

View Audit 396807

Finding 1205128 (2025-014)

Material Weakness 2025

State of Arkansas

AR

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.332

Finding Number: 2025-014 ALN Number(s) and Program Title(s): 21.029 – Coronavirus Capital Project Funds Views of Responsible Officials and Planned Corrective Action: ASBO acknowledges the auditor’s observation regarding the inclusion of required matching amounts in the executed grant agreements. The...

Finding Number: 2025-014 ALN Number(s) and Program Title(s): 21.029 – Coronavirus Capital Project Funds Views of Responsible Officials and Planned Corrective Action: ASBO acknowledges the auditor’s observation regarding the inclusion of required matching amounts in the executed grant agreements. The Capital Projects Fund (CPF) program does not require cost sharing or matching funds under federal guidance. However, the Arkansas State Broadband Office (ASBO) incorporated a minimum match expectation as part of its state-level program design and evaluation process. Proposed match commitments were submitted by applicants and evaluated during the award process. ASBO recognizes that the final required match amount was not expressly stated in the executed grant agreement. While match expectations were documented during application review and award evaluation, ASBO agrees that explicitly including the finalized match requirement in the executed agreement would provide greater clarity and reduce ambiguity. ASBO notes that no questioned costs were identified in connection with this finding. ASBO will update its grant agreement templates to ensure that any state-imposed matching requirements are explicitly incorporated into the final executed agreement. This enhancement will ensure alignment between program evaluation criteria and formal award documentation going forward. Anticipated Completion Date: June 30, 2026 Contact Person: Name: Glen Howie Title: State Broadband Director Agency: Arkansas State Broadband Office Address: 1 Commerce Way City, State, Zip: Little Rock, AR 72202 Phone Number: 501-683-6000 Email Address: broadband@arkansas.gov

View Audit 396807

Finding 1205120 (2025-006)

Material Weakness 2025

State of Arkansas

AR

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

Finding Number: 2025-006 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance on com...

Finding Number: 2025-006 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance on completion of the FNS-46 S-EBT and FNS-388 S-EBT reports. All noted reports have been revised, if necessary, reviewed, and certified. Staff have been trained on the updated procedures. Anticipated Completion Date: Complete Contact Person: Name: Renee Ikard Title: Chief Financial Officer Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8985 Email Address: Renee.Ikard@dhs.arkansas.gov

View Audit 396807

Finding 1205117 (2025-003)

Material Weakness 2025

State of Arkansas

AR

Cash Management Procurement, Suspension & Debarment Subrecipient Monitoring

Finding Number: 2025-003 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance that r...

Finding Number: 2025-003 ALN Number(s) and Program Title(s): 10.646 – Summer Electronic Benefit Transfer Program for Children Views of Responsible Officials and Planned Corrective Action: DHS concurs with this finding. The agency has updated its internal procedures to comply with FNS guidance that requires Summer EBT funds to be drawn down after expenditures are made. All funds expunged from EBT cards are in the process of being returned to FNS. Anticipated Completion Date: 3/31/2026 Contact Person: Name: Renee Ikard Title: Chief Financial Officer Agency: Department of Human Services Address: 700 Main Street City, State, Zip: Little Rock, AR 72201 Phone Number: 501-681-8985 Email Address: Renee.Ikard@dhs.arkansas.gov

View Audit 396807

Finding 1205113 (2025-001)

Material Weakness 2025

Caribbean University, Inc.

PR

Student Financial Aid Matching / Level of Effort / Earmarking

Reporting Controls and Monitoring Implementation of a fixed NSLDS reporting calendar.Monthly validation of enrollment status changes (withdrawals, drops, enrollment level changes).Accountability and OversightAssignment of dedicated personnel responsible for Enrollment Reporting.Supervisory review an...

Reporting Controls and Monitoring Implementation of a fixed NSLDS reporting calendar.Monthly validation of enrollment status changes (withdrawals, drops, enrollment level changes).Accountability and OversightAssignment of dedicated personnel responsible for Enrollment Reporting.Supervisory review and approval prior to submission of each report.Targeted Training Focused training on NSLDS compliance and federal regulations.Cross-training to reduce dependency on a single staff member Procedural Enhancements Review and update of established process between Academic Departments and the Registrar Office to unsure proper identification of students who have fulfilled graduation requirements.Implementation of reporting checklists to ensure compliance at each cycle.Systems Integration Review and validation of integration between internal systems and NSLDS/Clearinghouse to ensure data accuracy.

View Audit 396799

Finding 1205098 (2025-004)

Material Weakness 2025

Puerto Rico Safe Drinking Water Treatment Revolving Loan Fund

PR

Eligibility Cash Management Significant Deficiency

PRMP partially concurs with this finding and emphasizes that claims submitted to the federal government must accurately distinguish eligibility categories to ensure the appropriate federal matching percentage is applied. A corrective action plan has already been implemented as part of the Phase 3 ro...

PRMP partially concurs with this finding and emphasizes that claims submitted to the federal government must accurately distinguish eligibility categories to ensure the appropriate federal matching percentage is applied. A corrective action plan has already been implemented as part of the Phase 3 rollout of the MMIS project, initiated in May 2024. This phase focuses on establishing a comprehensive Financial Management solution within PRMMIS. The enhanced system capabilities support the calculation, production, and distribution of capitation and supplemental payments to carriers, including automated adjustments and reconciliations. Stabilization activities have also included the conversion and reconciliation of legacy system data to facilitate a seamless transition.

View Audit 396776

Finding 1205085 (2025-001)

Material Weakness 2025

Mount St. Mary's University

MD

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

Identifying Number: 2025-001 Finding: For sixteen out of forty students tested who had enrollment changes at the University, the student’s status effective dates at the campus level and program level were not reported to the NSLDS timely. Corrective Actions Taken or Planned: We agree with the findin...

Identifying Number: 2025-001 Finding: For sixteen out of forty students tested who had enrollment changes at the University, the student’s status effective dates at the campus level and program level were not reported to the NSLDS timely. Corrective Actions Taken or Planned: We agree with the finding. The delays in reporting were identified beginning in December 2024 with the hire of a new registrar and since that time we have caught up with reporting requirements are now timely. We have also increased our cross-training efforts in the department, training multiple individuals on NSC reporting procedures, in order to ensure that if turnover were to occur again in the future there are other individuals who can perform the required functions. Person(s) Responsible for Corrective Actions: Katie Soter, Registrar Anticipated Completion Date: Completed

View Audit 396741

Finding 1205071 (2025-002)

Material Weakness 2025

Economic and Community Development Institute, Inc.

OH

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.303

Condition: During eligibility testing of loan disbursements under the RMAP program, one of eight disbursements tested was made to a borrower located outside of the eligible area. The loan was disbursed in fiscal year 2025 for $10,000. Planned Corrective Action: The ECDI processing and loan allocatio...

Condition: During eligibility testing of loan disbursements under the RMAP program, one of eight disbursements tested was made to a borrower located outside of the eligible area. The loan was disbursed in fiscal year 2025 for $10,000. Planned Corrective Action: The ECDI processing and loan allocation teams will not exclusively leverage it’s CRM system for determining USDA eligibility based on borrower/business address. The team will use the USDA website in determining eligibility prior to allocating USDA funds to a project. Related to the specific ineligible $10,000 USDA loan, the team has communicated to its USDA partner to make them aware of this specific issue and ECDI is in the process of removing USDA funds and replacing with another source. Contact Person Responsible for Corrective Action: Brian Barrett and Sean Henderson Completion Date: In process

View Audit 396710

Finding 1205069 (2025-001)

Material Weakness 2025

Economic and Community Development Institute, Inc.

OH

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

Condition: During our testing of allocated salaries and wages, we identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. One employee in each program, 59.046 and 93.570, had an inappropr...

Condition: During our testing of allocated salaries and wages, we identified errors in how employee time was allocated to the program, and salaries and wages allocated to the program in excess of the Executive Level II Salary maximum. One employee in each program, 59.046 and 93.570, had an inappropriate wage rate applied to allocated time to the program. Additionally, for the 59.046 program only, one employee had compensation levels allocated to the program in excess of the Executive Level II Salary maximum amount in effect for the respective period. Planned Corrective Action: ECDI will put additional steps in place related to the Payroll Review process to ensure reconciliation of payroll charges to actual time records and rates. The organization will modify its calculations to ensure that pay rates are reflective of the timeframe in question (not for periods before or after). ECDI will update its calculations to include thresholds for Executive pay so they are not entered more than approved rates. The company is also exploring technology enhancements so that information from ECDI’s Payroll system flows directly into ECDI’s Accounting system to limit the chance of errors during extraction from Payroll system and uploading into Accounting system. Contact Person Responsible for Corrective Action: David Chew and Hudu Ahmed. Completion Date: In process

View Audit 396710

Finding 1204971 (2025-002)

Material Weakness 2025

County of Fresno

CA

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs

Management concurs with the finding. After the Fiscal Year 2024 monitoring finding last year, the Department developed a comprehensive certification for property owners to complete and a list of required files to be provided to the County on an annual basis. In 2025, Department staff confirmed with ...

Management concurs with the finding. After the Fiscal Year 2024 monitoring finding last year, the Department developed a comprehensive certification for property owners to complete and a list of required files to be provided to the County on an annual basis. In 2025, Department staff confirmed with the County’s HUD representative that the new monitoring documents and plan would satisfy the HUD’s monitoring requirements. Staff are providing technical assistance to the property owners, as preliminary records reviewed indicate all units are still maintained as affordable, but the owners’ provision of all documentation is still in progress. The physical inspections of the property exteriors in October 2025 indicated broadly that housing quality standards are still being maintained. The Department continues to seek out training for staff on HOME requirements and will continue efforts to update monitoring policies and procedures, as necessary, to address all current regulatory requirements. The Department’s multifamily monitoring for all projects in the HOME period of affordability for calendar years through 2024 will be completed prior to August 30, 2026. Although not due in Fiscal Year 2024-25, the Department is moving forward with monitoring for calendar year 2025, which is anticipated to be completed timely, prior to December 31, 2026. As part of the monitoring process, the Department will collect or create documents demonstrating a property’s annual or semi-annual (as relevant) compliance with HOME requirements, review for adherence to regulations, draft and issue a report of findings, and require owners of projects with deficiencies to prepare and submit a satisfactory corrective action plan. The Department will continue to follow up regularly with property owners until all corrective actions are implemented. Staff’s recommendation to facilitate ongoing, decades-long monitoring requirements include the creation of a master omnibus amendment to all existing property agreements to ensure concrete requirements for recordkeeping and monitoring are clearly outlined and accompanied by explicit deadlines. This amendment will be pursued as time permits and after lessons learned from current monitoring activities are integrated into the monitoring process. Anticipated Completion Date August 2026 Contact Information of Responsible Official Name: Augustine Ramirez Title: Division Manager, DPWP Community Development Division Phone: 559-600-4266

View Audit 396642

Finding 1204963 (2025-001)

Material Weakness 2025

City of Manteca

CA

Cash Management Reporting Matching / Level of Effort / Earmarking § 200.303

Finding #SA2025-001 Cash Management and Accuracy of Federal Financial Reports Assistance Listing Number: 20.507, 20.526 Assistance Listing Title: COVID-19 – Federal Transit Formula Grants (Urbanized Area Formula Program) – Federal Transit Cluster Name of Federal Agency: Department of Transportation ...

Finding #SA2025-001 Cash Management and Accuracy of Federal Financial Reports Assistance Listing Number: 20.507, 20.526 Assistance Listing Title: COVID-19 – Federal Transit Formula Grants (Urbanized Area Formula Program) – Federal Transit Cluster Name of Federal Agency: Department of Transportation Federal Award Identification Number: CA-2022-083-00, 2020-206, 2020-212 • Name(s) of the contact person: Melissa Munoz, Interim Assistant Finance Director • Corrective Action Plan: The City will develop procedures to ensure all grant-funded expenditures are included on drawdown request and prepared quarterly. Finance staff plan to have regular check-ins with department staff administering federal grants to obtain status updates on expenditures and drawdowns, and reconcile activities accordingly. • Anticipated Completion Date: 06/30/2026

View Audit 396634

Finding 1204948 (2025-001)

Material Weakness 2025

Universidad Interamericana De Puerto Rico, Inc.

PR

Reporting Matching / Level of Effort / Earmarking

As a corrective action, the University will implement the following: Assignment of a dedicated resource: A person will be appointed as responsible for the FEMA project to oversee the functioning of the control, ensuring the proper collection and monitoring of the information (“FEMA Coordinator”). We...

As a corrective action, the University will implement the following: Assignment of a dedicated resource: A person will be appointed as responsible for the FEMA project to oversee the functioning of the control, ensuring the proper collection and monitoring of the information (“FEMA Coordinator”). We are already coordinating with the Office of the President for the corresponding approval of the new structure. Inclusion of obligated and incurred expenditures related to the Department of Homeland Security/FEMA in the corresponding SEFA report for each year: We have instructed the Institutional Director of the Office of Accounting for External Programs to notify the FEMA Coordinator, the Associate VP of Management and Budget, the Associate VP of Accounting and Finance and the VP of Management, Finance and Systemic Services when the automated SEFA report is ready, so that the FEMA Coordinator can provide her all the information to be included for the Department of Homeland Security/FEMA. The Institutional Director will include this information and send the amended SEFA to the four persons mentioned above. Implementation timeline: We estimate that these actions will be fully operational by July 1, 2026. We are committed to closely monitoring these measures and ensuring their successful implementation, guaranteeing compliance with internal control standards.

View Audit 396572

Finding 1204946 (2025-001)

Material Weakness 2025

Chief Leschi Schools, Inc.

WA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.430

15.047 Indian Education Facilities, Operations, and Maintenance – Assistance Listing No. Recommendation: To implement a stronger system of review for ensuring that all changes in employee payroll are properly implemented and approved. Explanation of disagreement with audit finding: There is no disag...

15.047 Indian Education Facilities, Operations, and Maintenance – Assistance Listing No. Recommendation: To implement a stronger system of review for ensuring that all changes in employee payroll are properly implemented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Human Resources (HR) is working with Finance to process retroactive compensation for the full underpaid amount owed. Associated DRS contributions will also be reviewed and corrected to ensure full compliance. Moving forward, HR will implement an enhanced verification control at the beginning of each fiscal year. This includes documented confirmation of pay accuracy for a minimum of two employees per department following salary schedule implementation and prior to the first payroll. Ideally, this control will be performed jointly by HR and Finance to ensure segregation of duties and consistency. Name(s) of the contact person(s) responsible for corrective action: Beth Wilde, Director of Human Resources Planned completion date for corrective action plan: July 1, 2026

View Audit 396562

Finding 1204944 (2025-002)

Material Weakness 2025

Box Butte General Hospital

NE

Material Weakness Matching / Level of Effort / Earmarking

FINDING 2025-002 USDA LOAN COVENANTS COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and EHR system in May 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearin...

FINDING 2025-002 USDA LOAN COVENANTS COMPLIANCE Effect and recommendation The Hospital implemented a new accounting and EHR system in May 2023 and experienced significant delays in being able to bill and process claims. In addition, there was a cyberattack on the Hospital’s claims processing clearinghouse in February 2024 that took the Hospital offline from processing claims. These two events had a negative and material impact on the Hospital’s cash collections over the last two years resulting in the Hospital not having the required 90 days of cash on hand. The Hospital did receive a waiver from the USDA regarding not meeting this loan covenant for fiscal year 2025. Views of responsible officials and planned corrective actions The Hospital has made several changes to its system since the initial implementation and has contracted with a third party vendor to make improvements in its billing and collection processes. These changes are expected to result in cash collection improvements. Additionally, the Centers for Medicare and Medicaid Services (CMS) approved the State of Nebraska’s preprint and provider assessment waiver that governs Nebraska’s Medicaid Directed Payment Program (Program). CMS’ approval of the Program is for the period July 1, 2024 through December 31, 2024 and January 1, 2025 to December 31, 2025 only, with future years subject to an annual approval by CMS. These additional funds are also expected to significantly improve the Hospital’s days of cash on hand by the end of fiscal year 2026. Hospital management notified its USDA representatives and received a waiver from the 90 days of cash on hand for the period ended June 30, 2025. Anticipated completion date Ongoing

View Audit 396560

Finding 1204904 (2025-008)

Material Weakness 2025

County of Ventura

CA

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

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirements...

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: VCPH Management agrees with the recommendation for the Department to strengthen its policies and procedures to ensure all required reports are reviewed, approved and retained as evidence in the applicable grant folder. View of Responsible Officials and Corrective Action: VCPH Management will implement a requirement that all applicable reports must include documented review and approval (e.g. email approval, signed cover sheet, or workflow confirmation) before submission and retention of such approval evidence in the applicable grant folder location. Name of Responsible Persons: Maria Macias, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: April 2026

View Audit 396507

Finding 1204902 (2025-006)

Material Weakness 2025

County of Ventura

CA

Special Tests & Provisions Cash Management Material Weakness § 200.303

Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Materia...

Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Material Weakness in Internal Control over Compliance and Material Non-Compliance Department’s Management Response: Health Care Agency (HCA) management agrees and acknowledges the findings related to the application and review of sliding fee discounts under the Self-Pay Discount Program. The Department recognizes the importance of consistent application of sliding fee discount schedules and proper documentation of review processes to ensure full compliance with federal requirements. The Department is committed to maintaining strong internal controls and ensuring adherence to all applicable policies, procedures, and regulatory standards governing the Sliding Fee Discount Program. View of Responsible Officials and Corrective Action: HCA Management agrees with the finding and will implement corrective actions to strengthen internal controls and ensure consistent application of the sliding fee discount program. The following actions will be taken: • Reinforcement of Policies and Procedures: Re-educate all applicable staff on existing sliding fee discount program policies, including proper calculation and application of discounts. First re-education session was held on February 4, 2026. • Standardization of Workflow: Update and implement standardized workflows and job aids within the registration and billing processes to ensure discounts are applied accurately and consistently. Standardized workflows completed on February 2, 2026. • Enhanced Review and Oversight: Establish a formalized secondary review process for sliding fee discount determinations, including required documentation and supervisory sign-off. Supervisor sign off on sliding fee applications by April 1, 2026. • Ongoing Training: Incorporate sliding fee discount program requirements into onboarding and annual refresher training for relevant staff beginning April 1, 2026. • Audit and Monitoring: Conduct monthly internal audits of sliding fee discount applications to monitor compliance and identify any trends or gap by May 1, 2026. These corrective actions are designed to ensure compliance with federal requirements, improve consistency in application, and strengthen overall internal controls. Name of Responsible Persons: Octavius Gonzaga, Ambulatory Care CFO – Establishes sliding fee discount program policy, procedures, and fee schedules. Erika Herincx, Ambulatory Care Revenue Cycle Manager – Responsible for the oversight of the training program and ensures the listed activities in the Corrective Action Plan are executed. Implementation Date: February 4 - March 30, 2026 – Training of front-end staff and clinic management. April 1, 2026 – Implementation of supervisor sign off for each sliding fee application. April 1, 2026 – Re-Training of Medical Billing Specialists on adjustments. May 1, 2026 – Monthly sampling of encounters December 1, 2026 – Year-to-date report and internal audit

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Finding 1204900 (2025-005)

Material Weakness 2025

County of Ventura

CA

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

Program: Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii Assistance Listing No.: 14.228 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Pass-Through California Department of Housing and Community Development Award No.: 17-MITP...

Program: Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii Assistance Listing No.: 14.228 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Pass-Through California Department of Housing and Community Development Award No.: 17-MITPPS-21029, 18-DRWD-23003, 21-CDBG-HK-0010 Award Year: 2022, 2024 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: Management agrees with the recommendation to revise its procedures to include evidence documenting the individual who reviewed and approved required reports prior to submission. View of Responsible Officials and Corrective Action: a. With regards to the CDBG-CV2 and CDBG-MIT reports managed by the County Executive Office Community Development Division, procedures were revised beginning in April 2025 due to prior year findings 2024-007 and 2024-008 to incorporate documented review and approval requirements for all applicable federally required reports. These enhanced internal controls are being phased in across all relevant reporting processes, with full implementation completed by the end of June 2025. These changes are intended to ensure that evidence of review and approval is consistently retained and that reporting is accurate, complete, and compliant with federal requirements. The reports identified in the finding were completed prior to the stated corrective action. b. With regards to the VC Heal Activity reports managed by Ventura County Workforce Development (VCWD) management, the required reports were prepared by the subrecipient (Career TEAM) using the standardized HCD format and underwent multiple levels of review, the County acknowledges that documentation of the specific individual review and approval prior to submission was not consistently retained. To strengthen internal controls to ensure all required reports include documented evidence of review and approval prior to submission, VCWD management will: • Implement a standardized review and approval protocol requiring documented sign‑off by designated VCWD management prior to submission. • Require Career TEAM to use a formal certification or routing process identifying the preparer and reviewer. • Maintain centralized documentation identifying the report preparer, reviewer/approver, and date of review. • Incorporate these requirements into internal procedures and contractor guidance. • Conduct periodic internal monitoring to verify compliance. Name of Responsible Persons: a. Kimberlee Albers, Deputy Executive Officer b. VCWD staff responsible for the CDBG program Career TEAM (Subrecipient – Report Preparation) Implementation Date: a. April – June 2025 b. April 2026

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Finding 1204897 (2025-004)

Material Weakness 2025

County of Ventura

CA

Matching / Level of Effort / Earmarking Special Tests & Provisions Significant Deficiency § 200.303 § 200.326

Finding 2025-004 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...

Finding 2025-004 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC-06-0507, B-24-UC-06-0507, 95-6000807 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Department’s Management Response: The County Executive Office agrees with the recommendation to strengthen its internal controls to ensure compliance with wage rate requirements. View of Responsible Officials and Corrective Action: The County Executive Office Community Development Division will conduct a comprehensive review and update of its Federal Labor Standards Policy and Procedure (FLSPP), with completion targeted no later than July 1, 2026. The updated FLSPP will include a requirement for County staff to obtain and retain certified payroll submissions monthly for all construction activities subject to prevailing wage requirements. Although the formal policy update will not be effective until July 1, staff will begin implementing this control immediately. Name of Responsible Persons: Kimberlee Albers, Deputy Executive Officer Tracy McAulay, Housing Solutions Director Ying Vang, Management Analyst (Community Development Block Grant) Michael Skinner, Management Analyst (HOME Investment Partnerships Program) Implementation Date: April 2026

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Corrective Action Plans

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