Corrective Action Plans

Finding 1225543 (2025-003)

Material Weakness 2025

OH

Reporting Subrecipient Monitoring Significant Deficiency § 200.300

Finding 2025-003: Completeness of Schedule of Federal Awards (SEFA) Condition: Lutheran Metropolitan Ministry omitted federal expenditures related to Assistance Listing Number (ALN) 14.218 from the Schedule of Expenditures of Federal Awards (SEFA). During the audit, it was noted that management requ...

Finding 2025-003: Completeness of Schedule of Federal Awards (SEFA) Condition: Lutheran Metropolitan Ministry omitted federal expenditures related to Assistance Listing Number (ALN) 14.218 from the Schedule of Expenditures of Federal Awards (SEFA). During the audit, it was noted that management requested and received reimbursement for expenditures incurred under the program; however, the related federal expenditures were not included in the SEFA presented for audit. Corrective Action: LMM will enhance its SEFA preparation and review procedures to ensure all federal awards and related expenditures are identified and evaluated for inclusion in the SEFA. Management will reconcile expenditures included on reimbursement requests and grant activity schedules to the SEFA and document its review prior to issuance. Helen Weeber, Director of Accounting and Finance, will be responsible for implementing and maintaining these procedures and ensuring the completeness and accuracy of the SEFA. Estimated completion date is December 31, 2026.

View Audit 408423

Finding 1225539 (2025-001)

Material Weakness 2025

Liberty Georgian Arms Housing Development Fund Company, Inc.

NY

Reporting § 200.512

Finding #2025-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Georgian Arms Apartments agrees with the au...

Finding #2025-001 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Georgian Arms Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Dawn Olmstead, VP – Director of Asset Management, at (315) 337-1401.

View Audit 408420

Finding 1225520 (2025-001)

Material Weakness 2025

Town of Mullins Board of Public Works

SC

Reporting

City officials agree with this finding and have contacted the Treasury Department to assist in updating the most recent filed report, but per the Treasury Department this report is not able to be updated. City has confirmed with the Treasury Department that they will be able to make changes to the r...

City officials agree with this finding and have contacted the Treasury Department to assist in updating the most recent filed report, but per the Treasury Department this report is not able to be updated. City has confirmed with the Treasury Department that they will be able to make changes to the report in the next annual reporting period and the City will plan to make the needed changes to ARPA expenditures to more accurately refelct actual expenditures.

View Audit 408411

Finding 1225519 (2025-007)

Material Weakness 2025

County of Orangeburg

SC

Reporting Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action: We concur with the finding. The County is in the process of implementing controls and procedures to ensure reporting are being performed in order to be compliant with requirements under the Uniform Guidance and the ReConnect Program.

View Audit 408402

Finding 1225518 (2025-006)

Material Weakness 2025

County of Orangeburg

SC

Reporting Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action: We concur with the finding. The County is in the process of implementing controls and procedures to ensure reporting are being performed in order to be compliant with requirements under the Uniform Guidance and the SLFRF Program.

View Audit 408402

Finding 1225512 (2025-003)

Material Weakness 2025

Montgomery County, Il

IL

Reporting

Condition: The expenditures on the County’s P&E reports could not be reconciled to the County’s general ledger expenditure accounts. Plan: The County should have obtained, from Bellwether, reconciliations between the P&E reporting and the general ledger expenditure reporting. Name of Contact Person:...

Condition: The expenditures on the County’s P&E reports could not be reconciled to the County’s general ledger expenditure accounts. Plan: The County should have obtained, from Bellwether, reconciliations between the P&E reporting and the general ledger expenditure reporting. Name of Contact Person: Nikki Lohman, Treasurer Management Response: The final grant report was filed in April 2026 through the period March 31, 2026. All grant funds were expended through this report filing period. The 3rd party, Bellwether, is no longer needed and the American Rescue Plan Fund is now overseen by the County Treasurer as no grant funds are no longer contained in it. Anticipated Date of Completion: March 2026, anticipated date of ARPA funds being fully expensed.

View Audit 408395

Finding 1225510 (2025-001)

Material Weakness 2025

Su Casa Community Housing Association

CA

Subrecipient Monitoring HUD Housing Programs Reporting

Finding 2025-001 – Improper approval of invoices Recommendation: We recommend that management should enhance invoice review and approval procedures to ensure that expenses are recorded in the period in which the related services are performed, in accordance with U.S. GAAP and HUD requirements. Appro...

Finding 2025-001 – Improper approval of invoices Recommendation: We recommend that management should enhance invoice review and approval procedures to ensure that expenses are recorded in the period in which the related services are performed, in accordance with U.S. GAAP and HUD requirements. Approval of invoices should require verification of service dates and services performed prior to recording the expense in the general ledger. Cutoff procedures should be formalized at year-end to identify and accrue expenses for services received but not yet invoiced or approved. Supervisory reviews of expense coding and timing should be performed to confirm compliance with both financial reporting and HUD. View of Responsible Officials and Planned Corrective Action: The previous management company has been replaced with a new management company. The new management company provides complete transparency and reports directly to the Board. Existing invoice review, approval and monitoring procedures are now being consistently followed and enforced to ensure that expenses are properly reviewed and recorded in the appropriate accounting period. In addition, purchasing and payment transactions are subject to multiple levels of approval and oversight to help ensure compliance with established policies, proper authorization of expenditures and accurate financial reporting. Management response: Management agrees with the recommendation. Action Taken: The previous management company has been replaced with a new management company. The new management company provides complete transparency and reports directly to the Board. Existing invoice review, approval, and monitoring procedures are now being consistently followed and enforced to ensure that expenses are properly reviewed, approved, and recorded in the appropriate accounting period. In addition, purchasing and payment transactions are subject to multiple levels of approval and oversight to help ensure compliance with established policies, proper authorization of expenditures, and accurate financial reporting.

View Audit 408391

Finding 1225502 (2025-002)

Material Weakness 2025

Lima City School District

OH

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.430 § 200.431

Lima City Schools will prepare and complete the time and effort certifications each school year. Procedures have been put in place to verify that all employees charging salaries and benefits to federal grants will have completed semi-annual certifications, signed and verified.

View Audit 408371

Finding 1225399 (2025-002)

Material Weakness 2025

H.O.P.E. HELPING OURSELVES PREVENT EMERGENCIES

AK

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies...

Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies and procedures for the review and approval of journal entries, adjustments to expenditures, and account reconciliations, to ensure expenditures reported to granting agencies are complete, accurate, allowable, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment -Once we were made aware of this finding through the audit, we began thinking of the most efficient way to document the Board’s knowledge and approvals of journal entries, including adjustments to expenditures and account reconciliations. Root Cause -HOPE is currently revising all policies and procedures. This was HOPE’s first federal single audit, so once we heard of the finding we prioritized revisions of fiscal policies and procedures to address the finding. Action Taken- The first board meeting after learning of this finding will be held on July 27th, 2026. Beginning with that meeting, the Board’s approval of the statement of activity detail, consisting of all charges and journal entries entered into HOPE’s accounting system since the date of the last Board meeting, will be approved via motion and seconded and noted as such in the Board meeting minutes. Most journal entries made during the month are currently entered into the system by HOPE’s CPA. The remaining journal entries are entered by HOPE’s Executive Director. To ensure that the Board is aware of the adjustments made in the system, all journal entries made since the last Board meeting will be approved via a motion and a second as a separate agenda item to ensure that the Board is reviewing these items particularly. All approvals will be noted in the Board meeting minutes. The list of journal entries viewed during the meeting will be initialed by a Board member and kept on file as documentation of internal controls.

View Audit 408352

Finding 1225393 (2025-001)

Material Weakness 2025

NORTHERN ELECTRIC COOPERATIVE, INC.

SD

Reporting Material Weakness

Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of South Dakota Office of Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Association does not have an internal control system designed to provide...

Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of South Dakota Office of Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Association does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule and accompanying notes to the schedule. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the schedule of federal expenditures of federal awards and the accompanying notes to the schedule. We requested that our auditors, Eide Bailly, LLP, prepare the schedule and accompanying notes. We have designated a member of management to review the drafted schedule and accompanying notes to the schedule. Responsible Individuals: Char Hager, CEO Anticipated Completion Date: Ongoing

View Audit 408347

Finding 1225391 (2025-002)

Material Weakness 2025

Harrington Family Health Center

ME

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.512

Finding: 2025-002 Condition Found: The FAC filing for the fiscal year ended March 31, 2025, was submitted late. Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Board of Directors Planned Corrective Action: Management agrees with the finding. Due to the timin...

Finding: 2025-002 Condition Found: The FAC filing for the fiscal year ended March 31, 2025, was submitted late. Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Board of Directors Planned Corrective Action: Management agrees with the finding. Due to the timing of prior year audit completion and associated late filing, the Organization did not have sufficient time within the current audit period to fully implement and demonstrate the effectiveness of corrective actions related to audit timeliness. As a result, this finding has reoccurred. The Organization has strengthened oversight by formalizing a compliance calendar, assigning clear ownership of Single Audit and Federal Audit Clearinghouse deadlines, and incorporating milestone tracking into finance operations and executive oversight processes. In addition, continued fractional CFO support provides enhanced accountability and monitoring of financial reporting timelines. These actions build upon prior year corrective efforts and are designed to ensure timely and compliant filings going forward. Anticipated Completion Date: FY2026 filing cycle.

View Audit 408346

Finding 1225388 (2025-002)

Material Weakness 2025

Clermont County

OH

Subrecipient Monitoring Reporting § 200.414 § 200.502 § 200.510

DJFS will begin to use project numbers to allow for an additional check of all amounts reported. DJFS is also going to provide federal grant information to the Auditor’s office as soon as they complete their final report in order to give the Auditor’s office adequate time to review the information w...

DJFS will begin to use project numbers to allow for an additional check of all amounts reported. DJFS is also going to provide federal grant information to the Auditor’s office as soon as they complete their final report in order to give the Auditor’s office adequate time to review the information with MUNIS and will afford the Auditor’s office more time to compile the SEFA and have a secondary review to avoid any computational or clerical errors.

View Audit 408340

Finding 1225358 (2025-001)

Material Weakness 2025

American Bird Conservancy

VA

Questioned Costs Reporting Significant Deficiency § 200.328

SF-425 Reporting Planned Corrective Action: American Bird Conservancy will prepare, review and maintain documented comparison of general ledger details to the SF-425 reports prepared. Person Responsible for Corrective Action Plan: Angela Modrick, Vice President of Finance Anticipated Date of Complet...

SF-425 Reporting Planned Corrective Action: American Bird Conservancy will prepare, review and maintain documented comparison of general ledger details to the SF-425 reports prepared. Person Responsible for Corrective Action Plan: Angela Modrick, Vice President of Finance Anticipated Date of Completion: Implemented

View Audit 408337

Finding 1225302 (2025-001)

Material Weakness 2025

Gallaudet University

DC

Questioned Costs Reporting Significant Deficiency

FINDING 2025-001 Internal Control over Compliance and Compliance with Reporting (Significant Deficiency and Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will strengthen its procedures for collecting, maintaining, retaining, and reviewi...

FINDING 2025-001 Internal Control over Compliance and Compliance with Reporting (Significant Deficiency and Noncompliance) Responsive to finding: We agree with the finding. Corrective Action Plan: Gallaudet University will strengthen its procedures for collecting, maintaining, retaining, and reviewing supporting documentation for performance metrics reported to the U.S. Department of Education. Going forward, every reported metric will be supported by source documentation that is retained, readily accessible, and available for review upon request. The University will implement the following corrective actions: • Develop and document procedures identifying the source documentation required to support each reported performance metric. • Establish a centralized electronic repository for performance-metric documentation. Staff submitting a metric write-up will be required to submit the associated raw data file with it, so the source documentation is captured at the point of submission rather than reconstructed later. • Implement a review process requiring verification of supporting documentation prior to submission of reports. • Provide training to personnel responsible for collecting, compiling, and reporting performance metrics regarding documentation and record-retention requirements. • Periodically review supporting documentation to ensure compliance with Department of Education reporting requirements and federal record-retention standards. Together, these actions will address the documentation gap identified in the finding and establish a sustainable process to support future reporting cycles. Individual(s) Responsible for Corrective Action Plan: Caroline Kobek Pezzarossi, Dean of Curriculum, Outreach, Resources and Effectiveness Khadijat Rashid, Provost Estimated Completion Date: September 30, 2026

View Audit 408332

Finding 1225270 (2025-005)

Material Weakness 2025

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

Federal Award Finding 2025-005 - Material Weakness, Material Non-Compliance - Special Tests and Provisions, Surplus Cash and Distributions to Owners or Affiliates Finding: During the fiscal year ended December 31, 2025, project management did not prepare or document a surplus cash calculation in acc...

Federal Award Finding 2025-005 - Material Weakness, Material Non-Compliance - Special Tests and Provisions, Surplus Cash and Distributions to Owners or Affiliates Finding: During the fiscal year ended December 31, 2025, project management did not prepare or document a surplus cash calculation in accordance with HUD requirements, nor did management implement controls to review, approve, or retain documentation supporting the required calculation. Recommendation: Management should establish and implement formal policies and procedures to ensure that surplus cash is independently calculated in accordance with HUD requirements and the applicable HUD Regulatory Agreement. Such procedures should include preparation of a documented surplus cash calculation at each required reporting period using HUD-prescribed criteria; Independent review and approval of the surplus cash calculation by appropriate management personnel or, where applicable, the court-appointed receiver; and retention of supporting documentation sufficient to demonstrate compliance with HUD restrictions on the use and distribution of project funds. Management should coordinate with the court-appointed receiver and HUD to ensure that surplus cash determinations are performed consistently and in compliance with program requirements going forward. Action Taken: Management acknowledges the finding related to the absence of an independently prepared and documented surplus cash calculation. During the fiscal year ended December 31, 2025, the Organization operated in an environment of financial distress, limited staffing resources, and evolving oversight responsibilities, which contributed to informal and undocumented procedures related to surplus cash determinations. As disclosed in the financial statements, the Organization became subject to a court-appointed receivership. Following the appointment of the receiver, responsibility for financial oversight, including compliance with HUD cash flow and surplus cash requirements, has transitioned to the receiver in coordination with HUD. The receiver and management are evaluating HUD requirements related to surplus cash calculation. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: Not started

View Audit 408309

Finding 1225261 (2025-001)

Material Weakness 2025

Transcen, Inc.

MD

Subrecipient Monitoring Reporting

Finding (2025-001): TransCen did not consistently ensure that FFATA reporting requirements for applicable federal subawards were completed accurately and/or within required timeframes. Corrective Action: TransCen has established procedures to support FFATA compliance. Corrective actions focus on rei...

Finding (2025-001): TransCen did not consistently ensure that FFATA reporting requirements for applicable federal subawards were completed accurately and/or within required timeframes. Corrective Action: TransCen has established procedures to support FFATA compliance. Corrective actions focus on reinforcing consistent application of these procedures and strengthening oversight. • Responsibility & Oversight: Grants and Contracts Manager will serve as FFATA Compliance Coordinator. Accounting will perform a secondary review to confirm timely and accurate reporting. • Standardized Procedures: Existing procedures will be formalized to include identification of reportable subawards, required data elements, and reporting deadlines. • Checklist & Tracking: A FFATA checklist will be used during subaward issuance, and a centralized tracking log will monitor reporting status, due dates, and completion. • Training: Staff involved in grants administration will receive targeted FFATA training and periodic refreshers. • Ongoing Monitoring: Management will perform quarterly reviews of subawards to ensure compliance and address any exceptions in a timely manner. Implementation Timeline: Effective immediately, fully implemented by August 1, 2026 Responsible Official: Ann Deschamps, Mid Atlantic ADA Director Management Oversight: Laura Owens, President

View Audit 408304

Finding 1225247 (2025-001)

Material Weakness 2025

Rebuilding Together, Inc.

DC

Reporting Matching / Level of Effort / Earmarking § 200.328

Management has implemented enhanced procedures to strengthen the tracking, reconciliation, and reporting of recipient share (matching) contributions associated with federal awards under ALN 14.265, Rural Capacity Building for Community Development and Affordable Housing Grants. Actions include: 1. U...

Management has implemented enhanced procedures to strengthen the tracking, reconciliation, and reporting of recipient share (matching) contributions associated with federal awards under ALN 14.265, Rural Capacity Building for Community Development and Affordable Housing Grants. Actions include: 1. Updating the internal matching contribution tracking system to improve documentation and cumulative tracking of recipient share contributions by grant and reporting period. 2. Establishing a formal reconciliation process between supporting documentation, grant records, and amounts reported on the SF-425 to ensure both federal expenditures and applicable recipient share amounts are accurately reflected. 3. Implementing a pre-submission review checklist and control requiring verification that recipient share (matching) information has been evaluated, reconciled, and included on the SF-425, when applicable, prior to submission to the awarding agency. 4. Requiring supervisory review and approval of the completed SF-425 to confirm completeness, accuracy, and compliance with reporting requirements under 2 CFR §200.328 before certification and filing. 5. Updating internal grant reporting procedures and providing additional guidance to staff responsible for federal financial reporting regarding SF-425 reporting requirements and recipient share reporting expectations. Management will evaluate the SF-425 reports submitted during the audit period to determine whether amendments are necessary. If required, amended SF-425 reports will be submitted to accurately reflect recipient share (matching) contributions. Anticipated Completion Date: The enhanced controls were implemented during 2026 and will be operational for the preparation, review, and certification of the SF-425 for the reporting period ending June 30, 2026, and all future reporting periods. For the reports submitted before June 30, 2026, management will confirm with HUD by July 20 if they would like an amended report. If HUD request one, the amended report will be submitted by August 15. Responsible Contact: Lakia Goodman, Controller (preparation and reconciliation of recipient share reporting) Chris Perry Authorized SF-425 Signer/Certifying Official (final review and certification)

View Audit 408287

Finding 1225243 (2025-001)

Material Weakness 2025

Chinatown Manpower Project, INC

NY

Questioned Costs Reporting

CMP will take the following actions to ensure timely submission in future years: •Submit the 2026 DCF within five (5) business days of receiving the final audit report. •Coordinate earlier with the external audit firm to establish mutually agreed-upon deadlines for key audit deliverables. •Implement...

CMP will take the following actions to ensure timely submission in future years: •Submit the 2026 DCF within five (5) business days of receiving the final audit report. •Coordinate earlier with the external audit firm to establish mutually agreed-upon deadlines for key audit deliverables. •Implement an internal calendar to track critical reporting dates and milestones, beginning with the FY2026 audit cycle. •Assign a dedicated staff member to monitor audit progress and communicate regularly with the audit team to avoid last-minute delays.

View Audit 408285

Finding 1225241 (2025-001)

Material Weakness 2025

Dreamkey Partners, Inc.

NC

Reporting Subrecipient Monitoring § 200.328

Finding 2025-001 Corrective Action Plan: Management acknowledges the reporting lapse identified and notes that all required semi-annual reports have since been submitted as of the report date. The delay appears to have been an isolated oversight rather than a systemic breakdown in compliance. To enh...

Finding 2025-001 Corrective Action Plan: Management acknowledges the reporting lapse identified and notes that all required semi-annual reports have since been submitted as of the report date. The delay appears to have been an isolated oversight rather than a systemic breakdown in compliance. To enhance controls over grant reporting and prevent recurrence, the Organization has implemented the following corrective actions: Established a formal grant reporting calendar that includes all required reporting deadlines for each federal award. Assigned clear responsibility for report preparation and submission to specific personnel within the finance function. Implemented a secondary review process whereby management monitors upcoming deadlines and confirms timely submission of reports. Incorporated periodic compliance check-ins to ensure adherence to grant reporting requirements throughout the year. Management believes these measures strengthen oversight and will ensure timely preparation and submission of all required reports going forward. Anticipated Completion Date: December 31, 2026

View Audit 408281

Finding 1225227 (2025-002)

Material Weakness 2025

City of Springdale, Ar

AR

Reporting § 200.328

City of Springdale, Arkansas Corrective Action Plan Contact Name: Cody Loerts Contact Phone Number: 479-750-8114 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2025 Finding #2025-002 – Statement of Condition: The City did not submit the required annual Federal Financial Report (SF-425) to...

City of Springdale, Arkansas Corrective Action Plan Contact Name: Cody Loerts Contact Phone Number: 479-750-8114 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2025 Finding #2025-002 – Statement of Condition: The City did not submit the required annual Federal Financial Report (SF-425) to the FAA for the period under audit. Response: The City concurs with the finding. Management will implement additional controls related to reporting. The completion date for the above-mentioned corrective action was December 2026.

View Audit 408256

Finding 1225080 (2025-001)

Material Weakness 2025

Laramie Child Development Corporation

WY

Reporting

Finding #2025-001: Financial Statement Preparation and Schedule of Expenditures of Federal Awards (SEFA) Responsible Individual: Debbie Sullivan, Fiscal Coordinator and Jennifer Brook, Chief Financial Officer Corrective Action Plan: It is more cost effective for the Organization to hire Ketel Thorst...

Finding #2025-001: Financial Statement Preparation and Schedule of Expenditures of Federal Awards (SEFA) Responsible Individual: Debbie Sullivan, Fiscal Coordinator and Jennifer Brook, Chief Financial Officer Corrective Action Plan: It is more cost effective for the Organization to hire Ketel Thorstenson, LLP, a public accounting firm, to prepare the full disclosure financial statements as a part of the annual audit process. Management of the Organization has reviewed the financial statements and schedule of expenditures of federal awards prepared by Ketel Thorstenson, LLP. The financial statements and SEFA have been compared and reconciled to the internal records maintained by the Organization. Management and the board of directors has been given adequate opportunity to ask questions regarding the financial statements and note disclosures and have received sufficient responses from the auditors prior to final publication of the audited financial statements and SEFA. Management is satisfied that appropriate actions have been taken to allow them to take responsibility for the financial statements. Anticipated Completion Date: Ongoing

View Audit 408239

Finding 1225070 (2025-002)

Material Weakness 2025

Mount Vernon Community School District

IA

Cash Management Reporting Internal Control / Segregation of Duties

1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Administration will add additional internal controls where the benefit exceeds the cost. 3. Official Responsible for Ensuring CAP: Michael Marshall, Board Se...

1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Administration will add additional internal controls where the benefit exceeds the cost. 3. Official Responsible for Ensuring CAP: Michael Marshall, Board Secretary/Treasurer, is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP: The planned completion date for the CAP is June 30, 2026. 5. Plan to Monitor Completion of CAP: The School Board will be monitoring this CAP.

View Audit 408200

Finding 1225061 (2025-066)

Material Weakness 2025

State of Rhode Island

RI

Eligibility Reporting Questioned Costs

2025-066a: In order to address repeat income deficiencies from SWICA, Medicaid added The Work Number (TWN) as a new data source in August 2025. Since then, RI Bridges has been modified to first verify earned income against TWN. With this enhancement, Medicaid has seen an improvement in how earned in...

2025-066a: In order to address repeat income deficiencies from SWICA, Medicaid added The Work Number (TWN) as a new data source in August 2025. Since then, RI Bridges has been modified to first verify earned income against TWN. With this enhancement, Medicaid has seen an improvement in how earned income is verified during the post-eligibility verification (PEV) and annual renewal processes. Medicaid has determined the individuals flagged as being enrolled under the expansion pathway beyond their 65th birthday are the result of exceptions to the mass update eligibility process. Medicaid is working with our system vendor to develop a solution that will bypass this exception and terminate expansion eligibility for those turning 65 years old. RI Bridges appropriately identified the individual in question as requiring verification of citizenship status. However, as noted in the expansion age-out response, the mass update eligibility process exceptioned out, leaving the verification as unresolved and requiring manual review. Medicaid is working with our system vendor to develop a solution that will bypass this exception and terminate eligibility. Effective December 2025, the RI Bridges system receives quarterly matches from the SSA Death Master File (DMF). The DMF is automatically sent to the State as part of the quarterly PARIS data matching process. The State has deployed temporary system measures to process the file and automatically terminate Medicaid eligibility for individuals flagged as deceased on the DMF. As per section 71104 of the Working Families Tax Cut (WFTC) legislation, signed by the President on 7/4/25, the State will be deploying a long-term system enhancement to, “at least a quarterly basis, check the DMF to identify if enrolled individuals are deceased. If an individual is identified as deceased on the DMF, then the state must treat this information as factual, disenroll the individual, and discontinue any payments for items or services furnished after the death of the individual.” This enhancement is scheduled for the March 2027 release. In July 2024, federal partners operating the PARIS interstate match informed the State of a hold on PARIS interstate matching files. PARIS lifted the hold in October 2024. In November 2024, the State identified several defects in the PARIS results and suppressed requests for verification. A temporary system enhancement was logged to address the deficiencies and ensure the process was only requesting residency verification from individuals believed to be receiving Medicaid in another State. Long-term enhancements to the PARIS interstate match process are scheduled for late 2027. 2025-066b: Medicaid will continue to work with the Department of Human Services and HealthSource RI to improve reconciliation and quality assurance monitoring of eligibility and operational processes. Including, but not limited to automated quality control checks on batch processes, manual eligibility reviews of quarterly/annual activities, creating specialized reports, improving task logic, and identifying areas of repeat non-compliance to ensure appropriate controls are in place. 2025-066c: Upon notification from the systems team, Medicaid Finance will return any identified ineligible costs to the federal grantor. Anticipated Completion Dates: 2025-066a: Q4 2026 (exception scenarios) and Q4 2027 (PARIS) 2025-066b: Q4 2026 2025-066c: Ongoing Contact Persons: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov

View Audit 408197

Finding 1225059 (2025-064)

Material Weakness 2025

State of Rhode Island

RI

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s T...

A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s TPL data is not good enough to reject encounter claims from the MCO’s. EOHHS continues to work on improving the TPL process specifically cleaning up the TPL data in the MMIS and eligibility system today. Future system enhancements include a direct TPL vendor and new TPL module which should improve TPL accuracy. Anticipated Completion Date: July 31, 2028 Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov

View Audit 408197

Finding 1225058 (2025-063)

Material Weakness 2025

State of Rhode Island

RI

Reporting

2025-063a: On 5/14/2026 an IES system enhancement was deployed targeting the CHIP population. The change implemented allows the system to expedite automatic eligibility determinations on CHIP/MAGI cases when TPL is entered into the eligibility system. This will ensure that when TPL is added for a CH...

2025-063a: On 5/14/2026 an IES system enhancement was deployed targeting the CHIP population. The change implemented allows the system to expedite automatic eligibility determinations on CHIP/MAGI cases when TPL is entered into the eligibility system. This will ensure that when TPL is added for a CHIP member, the eligibility system will redetermine that eligibility automatically saving months of the member being in the incorrect category. EOHHS will work with Deloitte to continue to monitor the impacts of this change. OAG also noted there are cases where “eligibility terminated within RIBridges not populated within the MMIS”. As of today, there are only 62 cases for ALL of Medicaid categories where eligibility is closed in RIBridges and open in the MMIS. This count is very low when compared to each year since Bridges go-live in 2016. 2025-063b: EOHHS acknowledges that staff turnover and a lack of sufficient staff on the financial reporting team contributed to SFY 2025 reporting variances. Medicaid finance will continue to implement necessary changes to ensure accurate reporting. Changes implemented during SFY 2026 to reduce variances and assist with reconciliation work include: • Additional staffing o In process of hiring 3.0 additional FTEs directly to this team, increasing staff from 3.0 FTEs to 6.0 FTEs. o Temporarily transferred 2.0 FTEs from sister agencies to the Medicaid program to assist in federal reconciliations for SFY 2025 expenditures. o Temporary staff support has allowed existing staff to cross train team members on core functions to allow supervisors to focus on quarterly reporting challenges and improvements. • Contract support and review o Contracted with vendor that supported other Medicaid programs to review EOHHS’ CMS-64 quarterly reporting process and internal files to identify efficiencies and areas to automate to reduce the likelihood of human error. The vendor is also assisting with SFY 2025 reconciliation work. • Additional supervisory review and cross training o Prior to the start of each CMS-64, the team supervisor creates a work schedule with double-checks built into the processes which require numerous manual adjustments. The work is documented and reviewed to ensure timely submission of an accurate CMS-64. Three additional team members have also been trained in reconciling non-provider cycle expenditures each quarter. • Coordination of Medicaid Administrative Claiming draw downs and reporting o Beginning in SFY 2026, Q3, the Medicaid finance team now coordinates all administration claiming drawdowns to eliminate variances between drawn downs and reported expenditures. The coordination entails:  Switching the administrative draw down from bi-weekly to once a quarter.  Sending the proposed drawdowns to administrative claiming agencies.  Drawing down only what agencies verified should be drawn.  Sharing with sister agencies all draw down backup and final amounts.  Holding office hours each quarter before each draw down and federal reporting submission to address questions and concerns.  Reviewing and checking that each submitted administrative claiming quarterly report ties to the amount draw in that quarter. If there are variances, Medicaid finance works with the sister agencies to identify and correct the variance. 2025-063c: During SFY 2026 Medicaid Finance implemented changes to the administrative claiming and reporting process to help reconcile expenditures prior to the submission of the CMS-64 quarterly report. • Medicaid finance held training on February 4th detailing the historical draw down and reconciliation process and why it has not been effective. The training detailed possible changes to solicit agency input. • Beginning in SFY 2026, Q3, the Medicaid finance team now coordinates all administration claiming drawdowns to eliminate variances between drawn downs and reported expenditures. The coordination entails: o Switching the administrative draw down from bi-weekly to once a quarter. o Sending the proposed drawdowns to administrative claiming agencies. o Drawing down only what agencies verified should be drawn. o Sharing with sister agencies all draw down backup and final amounts. o Holding office hours each quarter before each draw down and federal reporting submission to address questions and concerns. o Reviewing and checking that each submitted administrative claiming quarterly report ties to the amount draw in that quarter. If there are variances, Medicaid finance works with the sister agencies to identify and correct the variance. • Contracted with vendor that supported other Medicaid programs to review EOHHS’ CMS-64 quarterly reporting process and internal files to identify efficiencies and areas to automate to reduce the likelihood of human error. Anticipated Completion Dates: 2025-063a: May 14, 2026 2025-063b / 2025-063c: Ongoing Contact Persons: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov

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