Corrective Action Plans

Finding 1204944 (2025-002)

Material Weakness 2025

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 1204942 (2025-002)

Material Weakness 2025

City of Covina

CA

Procurement, Suspension & Debarment Reporting Material Weakness

2025-002 Reporting Recommendation: We recommend the City review and update internal controls to ensure that the City submits accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Based on t...

2025-002 Reporting Recommendation: We recommend the City review and update internal controls to ensure that the City submits accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Based on the City’s review, the omission of this specific requirement from the bid documentation and subsequent reporting process appears to have been inadvertent and the result of the circumstances described above, rather than the result of intentional noncompliance. The City has since reviewed its procedures and is implementing additional internal review measures to help ensure that all applicable grant requirements are incorporated into future procurement and reporting processes. Name(s) of the contact person(s) responsible for corrective action: Alana Mantilla, Michael Lee, and Rafael Fajardo Planned completion date for corrective action plan: June 2026

View Audit 396544

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

View Audit 396507

Finding 1204877 (2025-002)

Material Weakness 2025

Catholic Charities of the Diocese of Albany, INC

NY

Cash Management Material Weakness

The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete tim...

The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete timely vouchers will occur. This new process will enable the fiscal employees responsible for vouchering to complete their functions in a timely manner.

View Audit 396496

Finding 1204645 (2025-004)

Material Weakness 2025

Tyrrell County Board of Education

NC

Subrecipient Monitoring Cash Management Material Weakness

Name of Contact Person: Kristy Christenberry, Interim Chief Finance Officer Corrective Action Plan: The Board of Education will implement controls and procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. Proposed Completion Date:...

Name of Contact Person: Kristy Christenberry, Interim Chief Finance Officer Corrective Action Plan: The Board of Education will implement controls and procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. Proposed Completion Date: Immediately

View Audit 396410

Finding 1204622 (2025-004)

Material Weakness 2025

Oklahoma State University

OK

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Material Weakness § 200.303 § 200.403 § 200.413 § 200.414

Research and Development – Assistance Listing No. 11.000 Research and Development – Assistance Listing No. 11.617 Research and Development – Assistance Listing No. 12.000 Research and Development – Assistance Listing No. 20.000 Research and Development – Assistance Listing No. 20.109 Research and De...

Research and Development – Assistance Listing No. 11.000 Research and Development – Assistance Listing No. 11.617 Research and Development – Assistance Listing No. 12.000 Research and Development – Assistance Listing No. 20.000 Research and Development – Assistance Listing No. 20.109 Research and Development – Assistance Listing No. 43.000 Research and Development – Assistance Listing No. 43.001 Research and Development – Assistance Listing No. 43.002 Research and Development – Assistance Listing No. 43.008 Research and Development – Assistance Listing No. 43.012 Research and Development – Assistance Listing No. 47.083 Research and Development – Assistance Listing No. 81.000 Economic Development Cluster - Assistance Listing No. 11.307 Recommendation: We recommend OSU should notify the applicable sponsors and federal agencies regarding the calculated questioned costs and make any necessary repayments or adjustments. Further, OSU should develop and document a process to ensure the PES rates are developed and billed in accordance with OSU Policy, applicable federal regulations, and the requirements of OSU’s Federal Agreements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: OSU will notify the applicable sponsors and federal agencies to resolve the questioned costs. OSU will also develop a process to ensure the correct PES rates are calculated and billed. Name(s) of the contact person(s) responsible for corrective action: Chris Kuwitzky, Senior Vice President for Administration & Finance and Chief Financial/Administrative Officer and Kenneth Sewell, Vice President for Research Planned completion date for corrective action plan: September 30, 2026

View Audit 396375

Finding 1203006 (2025-001)

Material Weakness 2025

Lake Michigan College

MI

Student Financial Aid Material Weakness Reporting

Finding Number: 2025-001 Condition: The College did not update the student enrollment information for any of the students graduating in Fall of 2024. Planned Corrective Action: Lake Michigan College understands the significance of accurately reporting student enrollment statuses and will implement e...

Finding Number: 2025-001 Condition: The College did not update the student enrollment information for any of the students graduating in Fall of 2024. Planned Corrective Action: Lake Michigan College understands the significance of accurately reporting student enrollment statuses and will implement enhanced oversight controls. This includes the creation of a log that now documents file “receipts” from the National Student Clearinghouse. These report receipts are then reconciled to file submissions to ensure all files were received. Additionally, we have implemented a more overarching review that ensures all files are adequately processed by the National Clearinghouse. It is important to note the institution has corrected the files noted in the audit finding and all student records have now been updated to reflect accurate graduation and enrollment statuses. Contact person responsible for corrective action: Carrie Beukelman, Registrar Anticipated Completion Date: 03/01/2026

View Audit 396272

Finding 1202948 (2025-001)

Material Weakness 2025

MacCormac College Dba Generations College

IL

Student Financial Aid Material Weakness Internal Control / Segregation of Duties

Finding 2025-001 Student Financial Aid Cluster, Assistance Listing # 84.007, 84.033, 84.063, 84.268 Condition: The College could not timely retrieve all student records and show documentation of reviews and approvals related to student records. Corrective Action Plan: Objective: To ensure the timely...

Finding 2025-001 Student Financial Aid Cluster, Assistance Listing # 84.007, 84.033, 84.063, 84.268 Condition: The College could not timely retrieve all student records and show documentation of reviews and approvals related to student records. Corrective Action Plan: Objective: To ensure the timely retrieval of all student records and the proper documentation of reviews and approvals to meet regulatory requirements and to improve accountability in the Student Financial Aid Cluster. Corrective Actions: Management agrees with this finding. The College admits that before Spring 2025, formal documentation for review and approval of financial aid processes, including Return of Title IV (R2T4) calculations, was not consistently kept. Although controls were performed in most cases, the lack of documented evidence for students selected prior to the internal processing improvements prevented demonstrating control effectiveness, which is required under the Uniform Grant Guidance. Corrective actions implemented as follows: 1. Formal SOP Implementation Developed and implemented standardized SOPs for: 1. Financial Aid packaging and disbursement 2. Return of Title IV (R2T4) calculations 3. Review and approval workflows 2. Documentation & Audit Trail Controls 1. Introduced mandatory review/approval checklists for all financial aid transactions 2. Implemented centralized digital storage of supporting documentation 3. Segregation of Duties & Oversight 1. Established defined roles for: Preparer, Reviewer, Final approver. 4. Ongoing Monitoring 1. Monthly internal compliance reviews 2. Quarterly audit-readiness assessments led by senior leadership Timeline: Process corrections implemented in Spring 2025; Full compliance expected by June 30, 2026 Person(s) Responsible for Corrective Action Plan: Anahi Huerta, Director of Financial Aid, Phone: 312-922-1884

View Audit 396203

Finding 1202931 (2025-001)

Material Weakness 2025

County of Solano

CA

Eligibility Material Weakness

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Health Care Services Award No. and Year: 2305CA5MAP, 2505CA5MAP,1946001347 A7, 2024/2025 Compliance Requirement: Eligibility...

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Health Care Services Award No. and Year: 2305CA5MAP, 2505CA5MAP,1946001347 A7, 2024/2025 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County agrees that eligibility determinations and redeterminations including obtaining documentation and verifications should be performed annually to determine if individuals are eligible in accordance with the compliance requirements of the program. Medicaid Cluster – In-Home Supportive Services (IHSS) There are overdue redeterminations in our system due to the increasing need for IHSS services in Solano County and prioritization of the CDSS IHSS July 1, 2025 compliance mandate for 100% timely redeterminations for Community First Choice Option (CFCO) IHSS clients to prevent fiscal penalties. While we have reached 99% compliance for the IHSS CFCO clients, this has resulted in delays evaluating non-CFCO IHSS clients. In addition, we experienced uncovered caseloads related to Social Worker job transition or leave, more fair hearings and the growing complexity of our client population requiring more case management and re-evaluations throughout the year. We continue to review our IHSS workflow to develop efficiencies to maximize client service delivery. We monitor the performance of our IHSS Social Workers with a standard expectation of monthly client eligibility determinations and redeterminations. This performance management plan has contributed to successfully meeting several of our state compliance markers. Lastly, we continue to participate in State level discussions related to advocacy and increased IHSS administrative funding to support the growing number of IHSS clients. Medicaid Cluster – Medical Assistance The Employment and Eligibility division continues to monitor the performance of eligibility staff and build efficiencies into processes to increase processing timeliness. We recently developed a Customer Reporting Status dashboard that monitors all incomplete redeterminations and periodic reports for timeliness, which will be an effective tool for staff to monitor redetermination processing in order to meet our mandated compliance timelines. In addition, we are in the process of transitioning to a new business model for eligibility staff that perform annual redeterminations. We anticipate that this updated model will streamline workflows and enable staff to complete redeterminations with greater efficiency and timeliness. Responsible Individual(s): Dr. Cameron Kaiser, Chief Deputy Director, Health Officer Gwendolyn Gill, Health Services Administrator Alicia Jones, Deputy Director Health and Social Services Employment and Eligibility Programs Daniel Horel, Employment and Eligibility Administrator Anticipated Completion Date: July 1, 2026

View Audit 396191

Finding 1202924 (2025-005)

Material Weakness 2025

One City Schools, Inc.

WI

Material Weakness Period of Performance Matching / Level of Effort / Earmarking § 200.303

2025-005 US Department of Education Material Weakness in Internal Control over Compliance and Other Matter Period of Performance Auditor's Recommendation: We recommend that the Organization maintain effective internal controls over period of performance requirements Corrective Action: One City under...

2025-005 US Department of Education Material Weakness in Internal Control over Compliance and Other Matter Period of Performance Auditor's Recommendation: We recommend that the Organization maintain effective internal controls over period of performance requirements Corrective Action: One City understand the requirements for expenditure of grant funds in the proper period and will work more closely with the funders to ensure that documentation exists when a no cost extension is needed. The new Chief Financial Officer will monitor compliance with the policy and ensure proper documentation exists in the grant management system. Responsible for Corrective Action: Scott R Haumersen CPA, CGMA Shaumersen@onecityschools.org 608-575-4950 Anticipated Completion Date: June 30th, 2026

View Audit 396186

Finding 1202923 (2025-004)

Material Weakness 2025

One City Schools, Inc.

WI

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303

2025--004 US Department of Education Material Weakness in Internal Control over Compliance and Other Matter Cash Management Auditor's Recommendation: One City Schools, Inc. should implement appropriate internal controls for reviewing funding claims prior to submission. Corrective Action: One City ad...

2025--004 US Department of Education Material Weakness in Internal Control over Compliance and Other Matter Cash Management Auditor's Recommendation: One City Schools, Inc. should implement appropriate internal controls for reviewing funding claims prior to submission. Corrective Action: One City adopted a new grants management process which requires that all submitted claims are reviewed and signed by two responsible officials. Evidence of approvals will be maintained in the electronic grant files. In addition, One City has developed a training tool so that all staff who have grant claiming authority must participate in the training. The new Chief Financial Officer will monitor compliance with the policy and ensure proper documentation exists. Responsible for Corrective Action: Scott R Haumersen CPA, CGMA Shaumersen@onecityschools.org 608-575-4950 Anticipated Completion Date: June 30th, 2026

View Audit 396186

Finding 1202921 (2025-002)

Material Weakness 2025

One City Schools, Inc.

WI

Procurement, Suspension & Debarment Material Weakness Matching / Level of Effort / Earmarking § 200.317 § 200.327

2025-002 US Department of Education Material Weakness in Internal Control over Compliance Material Noncompliance Procurement Auditor's Recommendation: We recommend that the Organization maintain effective internal controls over procurement requirements. Corrective Action: One City adopted a new proc...

2025-002 US Department of Education Material Weakness in Internal Control over Compliance Material Noncompliance Procurement Auditor's Recommendation: We recommend that the Organization maintain effective internal controls over procurement requirements. Corrective Action: One City adopted a new procurement policy and while it was implemented, documentation that the procedures were performed were lacking. In addition, One City has developed a training tool so that all staff who have purchasing authority must participate in the training. The new Chief Financial Officer will monitor compliance with the policy and ensure proper documentation exists Responsible for Corrective Action: Scott R Haumersen CPA, CGMA Shaumersen@onecityschools.org 608-575-4950 Anticipated Completion Date: June 30th, 2026

View Audit 396186

Finding 1202741 (2025-040)

Material Weakness 2025

Liberty County District School Board

FL

Special Tests & Provisions Eligibility Material Weakness

Finding Number: 2025-040 Planned Corrective Action: Risk-Based Screenings – Death Master File (DMF): The Agency continues to make incremental improvements in its use of the SSA DMF during provider enrollment and re-enrollment. To achieve further progress and resolve this finding, the Agency is evalu...

Finding Number: 2025-040 Planned Corrective Action: Risk-Based Screenings – Death Master File (DMF): The Agency continues to make incremental improvements in its use of the SSA DMF during provider enrollment and re-enrollment. To achieve further progress and resolve this finding, the Agency is evaluating additional opportunities and taking steps to leverage the Enterprise Data Warehouse and other Medicaid infrastructure tools during these processes. The Agency will also explore the use of these tools to support realtime checks related to Risk-Based Screenings – NPPES and to enhance the review and resolution of LEIE and SAM matches. Anticipated Completion Date: June 2027 Responsible Contact Person: Nancy Massey

View Audit 396183

Finding 1202697 (2025-039)

Material Weakness 2025

Liberty County District School Board

FL

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking

Finding Number: 2025-039 Planned Corrective Action: To proactively address these issues, FAHCA has taken several steps to improve efficiency and survey scheduling accuracy. The Quality Assurance and Performance Improvement Protocol, revised in 2024, has enhanced tracking measures to better identify ...

Finding Number: 2025-039 Planned Corrective Action: To proactively address these issues, FAHCA has taken several steps to improve efficiency and survey scheduling accuracy. The Quality Assurance and Performance Improvement Protocol, revised in 2024, has enhanced tracking measures to better identify and prioritize surveys requiring scheduling. Both management and schedulers participated in targeted training sessions held in August 2024 and December 2024. In addition, Monthly Scheduler calls are conducted to provide ongoing guidance and support to field offices regarding scheduling needs and best practices. Furthermore, scheduling workload updates are reviewed every two weeks during Bureau Call Meetings with schedulers and managers to ensure continual monitoring of survey scheduling needs and progress. This improvement reflects the commitment of staff and leadership to proactively respond to challenges and implement strategies that advance the agency’s overall performance. Anticipated Completion Date: September 15, 2026 Responsible Contact Person: Mary Maloney

View Audit 396183

Finding 1202653 (2025-038)

Material Weakness 2025

Liberty County District School Board

FL

Eligibility Reporting Material Weakness

Finding Number: 2025-038 Planned Corrective Action: FDCF will evaluate its manual closure process and if necessary, make adjustments to ensure appropriate action is taken when a manual review is required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Tera Bivens, Directo...

Finding Number: 2025-038 Planned Corrective Action: FDCF will evaluate its manual closure process and if necessary, make adjustments to ensure appropriate action is taken when a manual review is required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Tera Bivens, Director of Programs & Policy Julie Reed, Chief of Policy

View Audit 396183

Finding 1202373 (2025-035)

Material Weakness 2025

Liberty County District School Board

FL

Subrecipient Monitoring Reporting Material Weakness

Finding Number: 2025-035 Planned Corrective Action: FAHCA management will enhance reporting controls to ensure that all applicable CHIP subaward action information is timely reported in accordance with FFATA. Anticipated Completion Date: Completed Responsible Contact Person: Kimberly Jordan

View Audit 396183

Finding 1202192 (2025-027)

Material Weakness 2025

Liberty County District School Board

FL

Special Tests & Provisions Eligibility HUD Housing Programs

Finding Number: 2025-027 Planned Corrective Action: FDCF continues the phased approach of modernizing its eligibility (ACCESS) system. The modernization of the FLORIDA legacy eligibility system started development in State Fiscal Year 2025-2026 and includes the operational analysis of the state’s da...

Finding Number: 2025-027 Planned Corrective Action: FDCF continues the phased approach of modernizing its eligibility (ACCESS) system. The modernization of the FLORIDA legacy eligibility system started development in State Fiscal Year 2025-2026 and includes the operational analysis of the state’s data exchange processes. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Chris Presnell, Director of Data and Information Technology

View Audit 396183

Finding 1201937 (2025-010)

Material Weakness 2025

Liberty County District School Board

FL

Special Tests & Provisions Eligibility Material Weakness

Finding Number: 2025-010 Planned Corrective Action: FCOM worked with its Employ Florida vendor and deployed a fix for the connectivity issue between Reconnect and Employ Florida in January 2025. A follow up meeting in April of 2025 where the issue was discussed did not reveal that the issue persiste...

Finding Number: 2025-010 Planned Corrective Action: FCOM worked with its Employ Florida vendor and deployed a fix for the connectivity issue between Reconnect and Employ Florida in January 2025. A follow up meeting in April of 2025 where the issue was discussed did not reveal that the issue persisted. In February 2026, the Auditor General notified FCOM that the fiscal year 2024/2025 audit revealed that the connectivity issue raised previously may still persist. FCOM is currently conducting an evaluation of the Auditor General’s sample and its larger datasets to isolate the variables causing these inconsistencies to determine if the issue has been resolved or if there is potentially a new connectivity issue to be resolved. The updated resolution will be completed by December 31, 2026. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Roosevelt Petithomme/Wendy Castle

View Audit 396183

Finding 1201604 (2025-002)

Material Weakness 2025

Circle the City

AZ

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Item: 2025-002 Assistance Listing Number: 93.224 Programs: Health Center Program Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: N/A Contract Number: 24H80CS28365; H8JCS54690; 21H8HCS44987 Award Year: June 1, 2024 to May 31, 2025; December 1, 2024 to November 30, 20...

Item: 2025-002 Assistance Listing Number: 93.224 Programs: Health Center Program Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: N/A Contract Number: 24H80CS28365; H8JCS54690; 21H8HCS44987 Award Year: June 1, 2024 to May 31, 2025; December 1, 2024 to November 30, 2025; September 1, 2023 to August 31, 2025 Compliance Requirement: Special Tests and Provisions Criteria: Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: For five claims tested, the discount for eligible patients was inaccurately calculated and billed. Name of Contact Person: Michele Grebisz, CFO Phone Number: (602)776-0776 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: Management agrees with the finding and will implement additional controls to ensure sliding fee discounts applied are reviewed and approved before patients are billed. Management will ensure this additional process includes clearly documenting the review and approval.

View Audit 396169

Finding 1201564 (2025-003)

Material Weakness 2025

The Kennedy Collective, Inc. and Affiliates

CT

Procurement, Suspension & Debarment Material Weakness § 200.318 § 200.326

Coronavirus State and Local Fiscal Recovery Funds 21.027 Recommendation: CLA recommends that management compose a procurement policy with the criteria as set out in 2 CFR sections 200.318 and 200.326. and review the conflict of interest policy and make necessary changes to comply with the criteria a...

Coronavirus State and Local Fiscal Recovery Funds 21.027 Recommendation: CLA recommends that management compose a procurement policy with the criteria as set out in 2 CFR sections 200.318 and 200.326. and review the conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR section 200.318. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management will compose a procurement policy in line with compliance requirements and review and edit the conflict of interest policy to be in compliance. Name of the contact person responsible for corrective action: Maria Giaimo, CFO Planned completion date for corrective action plan: June 30, 2026

View Audit 396125

Finding 1201487 (2025-010)

Material Weakness 2025

William Peace Universirty

NC

Student Financial Aid Internal Control / Segregation of Duties Material Weakness § 200.303

Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. ...

Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. Additionally, ongoing training should be provided to financial aid staff on the importance of internal controls and compliance with Title IV regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review its staffing and the need for separation of duties as part of an effective internal control system and take appropriate actions.. Name(s) of the contact person(s) responsible for corrective action: Vice President for Enrollment Management Damon Wade, Director of Financial Aid Deniesha Newby, and Controller Will Gibbons Planned completion date for corrective action plan: June 30, 2026

View Audit 396041

Finding 1201464 (2025-003)

Material Weakness 2025

Hertford County

NC

Eligibility Internal Control / Segregation of Duties Material Weakness

Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Name of contact person: Corrective Action: The County acknowledges the material weakness identified in the Medicaid eligibility determination process and agrees with the audit finding. To address the deficiencies noted, the Cou...

Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Name of contact person: Corrective Action: The County acknowledges the material weakness identified in the Medicaid eligibility determination process and agrees with the audit finding. To address the deficiencies noted, the County will strengthen internal controls related to eligibility determinations by implementing a comprehensive, county-wide corrective action strategy focused on staff competency, supervisory oversight, and process standardization. First, the County will enhance training for all staff involved in Medicaid eligibility determinations. This training will reinforce program requirements and applicable State Medicaid manuals, with specific emphasis on income and resource verification, household composition, timely requests for information, redetermination timeframes, and proper handling of SSI terminations. Refresher trainings will be conducted regularly, and training materials will be updated to reflect current policy and procedural changes. Second, the County will formalize and strengthen its internal case review and quality assurance processes. Supervisory reviews will be conducted routinely to ensure eligibility determinations are accurate, complete, and compliant with federal and state guidelines. Identified errors will be documented, corrected timely, and used as coaching opportunities to prevent recurrence. Management will monitor trends in errors to assess effectiveness of corrective actions and adjust oversight efforts as needed. Anetre Vaughan, Adult Medicaid Supervisor and Jacqueline Boyd, Family and Children's Medicaid Supervisor Section III - Federal Award Findings and Question Costs BUILD YOUR FUTURE ON OUR FOUNDATION 115 Justice Drive  Suite 1  Winton, North Carolina 27986 Office 252.358.7805  Facsimile 252.358.0198  www.HerfordCountyNC.gov 116

View Audit 396031

Finding 1201438 (2025-003)

Material Weakness 2025

County of Orange, California

CA

Subrecipient Monitoring Material Weakness Reporting

Program: Community Development Block Grant Federal Financial Assistance Listing Number: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: B-24-UC-06-0504 and 2025; B-20-UW-06-0504 and 2021 Compliance Requirements: Reporting Type of Finding: Material Weaknes...

Program: Community Development Block Grant Federal Financial Assistance Listing Number: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: B-24-UC-06-0504 and 2025; B-20-UW-06-0504 and 2021 Compliance Requirements: Reporting Type of Finding: Material Weakness in Internal Control over Compliance and Material Instance of Noncompliance Criteria: CFR Appendix A to Part 170I(a)(2), Reporting Requirements, states the recipient must report each subaward to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was issued. Condition: During our testing of the County’s compliance with reporting requirements, we noted the County did not submit the required subaward data to FSRS. Cause: The department was unaware of this compliance requirement. Effect: Reports were not submitted to FSRS in accordance with the reporting requirements per Appendix A to Part 170I(a)(2). Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling : We identified that the FFATA reporting was not completed as required by 2 CFR Part 170 for the following instances: (Refer to Chart/Table to Finding 2025-003) Repeat Finding from Prior Years: No. Recommendation: We recommend that the County adhere to their policies and procedures in accordance with 2 CFR Appendix A to Part 170I(a)(2). Management Response and Corrective Action Plan: 1. Person Responsible: Francisco Padilla, Community Development Analyst 2. Corrective action plan: Concur. We will adhere to our policies and procedures to ensure reports are submitted to FSRS in accordance with 2 CFR Appendix A to Part 170I(a)(2). 3. Anticipated Implementation date: April 30, 2026

View Audit 395982

Finding 1201321 (2025-002)

Material Weakness 2025

University of San Diego

CA

Eligibility Student Financial Aid Material Weakness

Corrective Action Plan – Management concurs with this finding. During the student system set-up for academic year 2024-25, the appropriate screen was not properly updated with the new ISIR codes to set the tracking requirements to be posted for ISIR C Flags. Because the appropriate tracking document...

Corrective Action Plan – Management concurs with this finding. During the student system set-up for academic year 2024-25, the appropriate screen was not properly updated with the new ISIR codes to set the tracking requirements to be posted for ISIR C Flags. Because the appropriate tracking documents were not posted, the system allowed the students to pass through packaging and disbursement. The Law School Financial Aid Office will implement a structured verification process as part of the student system setup for each academic year. Every step of the setup will be documented. To ensure accuracy, one staff member will complete the setup, and a separate staff member will independently review and verify the configuration. Management believes these enhancements will be sufficient to prevent future errors. Completion date: November 2025 Persons responsible: Vonda Garcia, Director of Law School Financial Aid

View Audit 395955

Finding 1201302 (2025-009)

Material Weakness 2025

State of Hawaii, Department of Accounting and General Services

HI

Special Tests & Provisions Material Weakness

Finding No. 2025-009 ALN No. 17.225 Program Title: Unemployment Insurance Grant Award No.: 25-A55-UI-000105 Condition Based on our analysis of the claims processing data, the State is not in compliance with the BAM State Operations Guidance Part 602, as the minimum number of cases for paid claims wa...

Finding No. 2025-009 ALN No. 17.225 Program Title: Unemployment Insurance Grant Award No.: 25-A55-UI-000105 Condition Based on our analysis of the claims processing data, the State is not in compliance with the BAM State Operations Guidance Part 602, as the minimum number of cases for paid claims was not met. Corrective Action Plan Concur. 1. The BAM unit continues to have vacancies and remain understaffed. 2. The unit is in the process of filling a vacancy with an experienced adjudicator. Once the position is filled, the new staff member will be trained in BAM methodology. At this time, the BAM supervisor continues to help the unit toward achieving its BAM requirements. 3. The unit anticipates increasing the number of cases for paid claims beginning June 2026. Person Responsible Sheryl-Lynn Ozaki, UI Quality Control Supervisor Anticipated Date of Completion June 2027 In response to the finding State of Hawaii – Single Audit 2025 finding, the DLIR offers the following: The auditor’s recommendation for the DLIR to develop new policies and procedures to handle the increase in unemployment claims fails to recognize the true source of the deficiency. The shortcoming is a direct result of staffing shortages. A key requirement of the BAM program is for the unit to be staffed with a sufficient number of knowledgeable and skilled investigators to ensure prompt and in-depth investigations. The investigator should be knowledgeable about and trained in the application of federal and state unemployment insurance laws, regulations/rules, and official policies; able to interpret and apply laws and official policies to each claimant's situation; proficient in fact-finding and determination procedures, including the process of interviewing interested parties and providing the opportunity for fair hearings and rebuttals; use independent judgment to develop and analyze evidentiary facts, assess credibility, weigh the evidence obtained, and decide when information is sufficient to issue legally binding decisions; determine appropriate administrative actions required; authorized to change computerized records as needed to pay or stop payment of benefits; prepare timely written decisions to deny or allow benefits which clearly communicate the facts, conclusions and reasoning used to support the decisions; be knowledgeable of the methods to effectively deal with claimants/customers, employers, or others who are under stress, experiencing negative emotions, etc. including handling and controlling conflict; knowledgeable about and skilled in the navigation of the state’s benefit, employment service, and tax systems; and knowledgeable about and compliant with BAM methodology and coding instructions. Regardless of new policies and procedures, the shortcoming is a direct result of the lack of available skilled investigators with the required skills to conduct prompt and in-depth investigations in the BAM program.

View Audit 395953

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