Corrective Action Plans

Finding 1236717 (2025-007)

Material Weakness 2025

Itasca County

MN

Eligibility Reporting Significant Deficiency

ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal...

ELIGIBILITY Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2501MNTANF Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that the County ensure every page is scanned in. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure each application is scanned in with every page. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025

View Audit 412269

Finding 1236716 (2025-006)

Material Weakness 2025

Itasca County

MN

Eligibility Reporting Significant Deficiency

CASEFILE REVIEW (PRIOR YEAR 2024-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Commu...

CASEFILE REVIEW (PRIOR YEAR 2024-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2405MN5ADM, 2405MN5MAP Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2025 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025

View Audit 412269

Finding 1236709 (2025-002)

Material Weakness 2025

Waushara County

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

CLTS Annual Reporting Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend the County develop and implement a process to require review and approval of the CLTS annual report prior to the submission of the report to the state to help ensure that the data reported a...

CLTS Annual Reporting Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend the County develop and implement a process to require review and approval of the CLTS annual report prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Waushara County Human Services' Finance Manager will complete the Annual Reconciliation in tandem with the Children's Long-Term Support Supervisor. Prior to submission, the report will be reviewed by Waushara County's Deputy Director. The Deputy Director will document in writing that the report has been reviewed and approved for submission. Name(s) of the contact person(s) responsible for corrective action: Kim Krueger, Human Services Financial Manager and Jenna Holland, Deputy Director Planned completion date for corrective action plan: 1/1/27.

View Audit 412261

Finding 1236677 (2025-004)

Material Weakness 2025

Town of York

ME

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management’s response/corrective action plan: The Town will be engaging in training as we have in the past to educate departments of the requirements of accepting federal funds including establishing an internal review process for compliance with reporting requirements. A second individual will revi...

Management’s response/corrective action plan: The Town will be engaging in training as we have in the past to educate departments of the requirements of accepting federal funds including establishing an internal review process for compliance with reporting requirements. A second individual will review reports before they are filed.

View Audit 412224

Finding 1236660 (2025-001)

Material Weakness 2025

Central New Mexico Electric Co-Op

NM

Allowable Costs / Cost Principles Cash Management Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: (Prepared by Cooperative Management) The Cooperative will install controls in the subsequent year to make sure that all requests for reimbursement are reviewed by an independent party for accuracy prior to being submitted to any granting...

Views of Responsible Officials and Planned Corrective Actions: (Prepared by Cooperative Management) The Cooperative will install controls in the subsequent year to make sure that all requests for reimbursement are reviewed by an independent party for accuracy prior to being submitted to any granting agency. Contact: Alexa Sandoval – Chief Financial Officer

View Audit 412190

Finding 1236651 (2025-001)

Material Weakness 2025

Cultural Vistas, Inc.

DC

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

AEECA/ESF PD Programs -Assistance Listing No. 19.900 Professional and Cultural Exchange Programs - Citizen Exchanges - Assistance Listing Number 19.415 Recommendation: Cultural Vistas, Inc. should strengthen controls over the calculation and review of fringe benefit charged to federal awards. Contro...

AEECA/ESF PD Programs -Assistance Listing No. 19.900 Professional and Cultural Exchange Programs - Citizen Exchanges - Assistance Listing Number 19.415 Recommendation: Cultural Vistas, Inc. should strengthen controls over the calculation and review of fringe benefit charged to federal awards. Controls should include a documented review to verify that fringe benefit cost charges are calculated using the currently approved NICRA and that charges to federal awards do not exceed the allowable rate prior to submission of reimbursement requests and federal financial reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has not applied for the fringe benefit negotiated indirect rate as offiscal year 2026. For any future fringe benefit NICRA, a Finance team member will review the charges to the federal award against the allowable rate quarterly to ensure the correct rate was applied. If the amount exceeds the allowable rate, an adjustment will be made on a quarterly basis to reduce the fringe benefit expense according to the allowable rate. Name(s) of the contact person(s) responsible for corrective action: Megan Bah Planned completion date for corrective action plan: July 14, 2026

View Audit 412177

Finding 1236606 (2025-003)

Material Weakness 2025

Bristol Bay Borough, Alaska

AK

Period of Performance Allowable Costs / Cost Principles Reporting § 200.512

Name of Contact Person: Rhys Winter, Manager Corrective Action Plan: The Borough has engaged accounting resources and staff with the appropriate time and expertise to expedite the completion of future financial reports. Completion Date: March 30, 2027

View Audit 412160

Finding 1236604 (2025-001)

Material Weakness 2025

Congregation Beth Mikroh

NY

Internal Control / Segregation of Duties Reporting School Nutrition Programs § 200.512

Recommendation: The Organization should implement an effective monitoring system to keep track of the compliance calendar, which includes financial reporting deadlines, and automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additi...

Recommendation: The Organization should implement an effective monitoring system to keep track of the compliance calendar, which includes financial reporting deadlines, and automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year-end. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. Additionally, the Organization should implement a system that will file documents in an organized manner and make them easily accessible to the Organization and auditors. Furthermore, the Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight. Anticipated Completion Date: 05/31/2027 Actions Taken: The Organization has begun implementing the above-mentioned recommendations. The Organization will ensure that it has a working monitoring system of the compliance calendar to assist in meeting the reporting deadline. Additionally, the Organization has already engaged the audit firm for its upcoming fiscal year-end, and the audit firm has put it on its calendar to begin the audit process well in advance. The Organization’s board of directors has agreed to oversee the auditing and reporting processes to a greater extent. They have also begun working on developing a more organized filing system for the Child Nutrition programs’ documents and training staff members about the reporting requirements. With these actions, the Organization expects to comply with the Uniform Guidance for single audits deadline for the fiscal year end August 31, 2026. Rabbi Yanky Bodenheimer, executive director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-425-4880. Contact Person Responsible for Corrective Action: Yanky Bodenheimer, Executive Director.

View Audit 412158

Finding 1236601 (2025-006)

Material Weakness 2025

Hopeworks

NM

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Management concurs that program staff did not consistently follow the organization's written Rent Reasonableness Policy, which included a provision limiting eligible units to those less than 10 years old. Upon review of the applicable HUD Continuum of Care regulations and guidance, management determ...

Management concurs that program staff did not consistently follow the organization's written Rent Reasonableness Policy, which included a provision limiting eligible units to those less than 10 years old. Upon review of the applicable HUD Continuum of Care regulations and guidance, management determined that HUD rent reasonableness requirements focus on comparability of rent based on factors such as location, size, type, quality, amenities, facilities, and management services. HUD does not establish a prohibition based solely on the age of a unit. The units identified in the audit were determined to be rent reasonable based on market comparisons and otherwise met applicable program requirements. However, management acknowledges that the organization's written policy had not been updated to align with current HUD requirements and therefore was not followed as written. Corrective action has been taken to revise the Rent Reasonableness Policy to remove the age-based restriction and align the policy with HUD requirements. Staff have been retrained on the revised policy, and management review controls have been implemented to ensure future rent reasonableness determinations are documented and performed consistently with HUD regulations

View Audit 412152

Finding 1236551 (2025-002)

Material Weakness 2025

Douglas County

MN

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

Recommendation: ll is recommended County management implements a review process in place to ensure the information added into the METS and MAXIS systems malches supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in ...

Recommendation: ll is recommended County management implements a review process in place to ensure the information added into the METS and MAXIS systems malches supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will add a review process to ensure the casefile eligibility determinations match the supporting documentation provided. Name of the contact person responsible for corrective action plan: Tabitha Kremmin, Community Human Services Director Planned completion date for corrective action ptan: December 31, 2026

View Audit 412094

Finding 1236506 (2025-003)

Material Weakness 2025

GULF OF ALASKA KEEPER

AK

Reporting Significant Deficiency

Finding 2025-003: Noncompliance over Reporting Name of Contact: Eileen Zaiser, Controller Corrective Action: Controller will maintain a digital calendar with multiple reminders of program reporting dates to begin one month in advance of each due date. He/she will relay due-date reminders to responsi...

Finding 2025-003: Noncompliance over Reporting Name of Contact: Eileen Zaiser, Controller Corrective Action: Controller will maintain a digital calendar with multiple reminders of program reporting dates to begin one month in advance of each due date. He/she will relay due-date reminders to responsible staff and monitor status of report completion to ensure timely submission. Proposed Completion Date: September 10, 2026.

View Audit 412036

Finding 1236504 (2025-001)

Material Weakness 2025

GULF OF ALASKA KEEPER

AK

Allowable Costs / Cost Principles Significant Deficiency

Finding 2025-001: Lack of Internal Control over Activities Allowed or Unallowed and Allowable Cost Principles – Cash Disbursements – Approvals Name of Contact: Chris Pallister, Executive Director Corrective Action: The Organization will establish a Purchase Order system. Purchases exceeding $500 in ...

Finding 2025-001: Lack of Internal Control over Activities Allowed or Unallowed and Allowable Cost Principles – Cash Disbursements – Approvals Name of Contact: Chris Pallister, Executive Director Corrective Action: The Organization will establish a Purchase Order system. Purchases exceeding $500 in a single transaction will require a PO. Purchase order approvals will be restricted to specified personnel or directors who are responsible for monitoring the budget. Approved PO’s will be recorded and matched to the respective purchases in the accounting system by the Controller. Contracts requiring recurring or variable payments will be assigned a Blanket Purchase Order. Those payments exceeding $25,000 will require written approval from the Board Treasurer. Proposed Completion Date: September 15, 2026.

View Audit 412036

Finding 1236341 (2025-003)

Material Weakness 2025

Community Foundation of Northern Nevada

NV

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.303

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer ...

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer of the quarterly financial reports. Corrective Action Plan: Previous reports were compiled by the Foundation’s vendors and submitted by the prior CFO. Future reports will be prepared by the Accountant and reviewed by the CFO prior to submission. Responsible Individuals: Alisha Kinnison, Accountant and Matt Lazar, CFO Anticipated Completion Date: July 2025

View Audit 412006

Finding 1236339 (2025-001)

Material Weakness 2025

Keene Housing

NH

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency

Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: The Authority should implement a process and control to ensure that all proper documentation is being maintained for HQS inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit...

Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: The Authority should implement a process and control to ensure that all proper documentation is being maintained for HQS inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Keene Housing has implemented a process to ensure that all proper documentation is being maintained for HQS inspections. Name(s) of the contact person(s) responsible for corrective action: Ellen Wishart, Director of Voucher Program Planned completion date for corrective action plan: immediately, August 1, 2026

View Audit 412003

Finding 1236337 (2025-005)

Material Weakness 2025

Kanabec County

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

ALLOWABLE COSTS Recommendation: It is recommended the County implement procedures to ensure appropriate individuals are included in the account codes used for reporting and on the random moment studies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...

ALLOWABLE COSTS Recommendation: It is recommended the County implement procedures to ensure appropriate individuals are included in the account codes used for reporting and on the random moment studies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure appropriate individuals are included. Name of the contact person responsible for corrective action plan: Kelly Christianson, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2026

View Audit 412000

Finding 1236335 (2025-004)

Material Weakness 2025

Kanabec County

MN

Internal Control / Segregation of Duties Eligibility Significant Deficiency

CASEFILE REVIEWS Recommendation: It is recommended the County implement procedures to ensure proper documentation in the casefiles and that it matches the information input into the eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. A...

CASEFILE REVIEWS Recommendation: It is recommended the County implement procedures to ensure proper documentation in the casefiles and that it matches the information input into the eligibility system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will retain documentation related to applicable federal requirements. Name of the contact person responsible for corrective action plan: Kelly Christianson, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2026

View Audit 412000

Finding 1236328 (2025-001)

Material Weakness 2025

Special Health Resources for Texas, Inc.

TX

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Previous corrective actions included revised registration forms, pre-visit schedule preparation, post-visit audits, and staff training. While these measures improved monitoring, SHR identified the need for stronger point-of-service controls and increased operational oversight. We are revising our SF...

Previous corrective actions included revised registration forms, pre-visit schedule preparation, post-visit audits, and staff training. While these measures improved monitoring, SHR identified the need for stronger point-of-service controls and increased operational oversight. We are revising our SFS and front-office policies and procedures to clearly define documentation requirements, staff responsibilities, and management accountability. A key revision will require patients requesting or renewing SFS eligibility to provide all required documentation at the time of service. The previous process allowing additional time after the visit to submit documentation will be discontinued. Patients without required documentation will be handled according to the revised policy regarding SFS eligibility and financial responsibility. SHR is also establishing an Assistant Director of Operations (ADOO) position responsible for standardized front-office training, monitoring, and accountability across all clinic locations. The ADOO will train front-office staff and Clinic Managers on SFS eligibility requirements, point-of-service documentation, and revised policies and procedures.The ADOO will conduct routine audits of SFS eligibility records and front-office documentation. Deficiencies will be documented and addressed with the applicable Clinic Manager and staff through retraining, corrective follow-up, and accountability measures as appropriate. Corrective actions will be tracked through resolution, with recurring or significant deficiencies escalated through Operations leadership. These strengthened point-of-service requirements, revised policies, standardized training, routine auditing, and defined accountability measures will provide SHR with a consistent process for identifying and correcting deficiencies and supporting sustained SFS compliance across all clinic locations.

View Audit 411958

Finding 1236327 (2025-001)

Material Weakness 2025

Shalom Health Care Center, Inc.

IN

Special Tests & Provisions Eligibility Significant Deficiency

Significant Deficiency Over Financial Reporting – The following steps have been taken or will be taken to address Finding 2025-001: • Shalom Health Care Center, Inc. has been updated the verbiage in the Sliding Fee Discount Schedule policy and procedures so that the definition of family in the polic...

Significant Deficiency Over Financial Reporting – The following steps have been taken or will be taken to address Finding 2025-001: • Shalom Health Care Center, Inc. has been updated the verbiage in the Sliding Fee Discount Schedule policy and procedures so that the definition of family in the policy better matches the procedures that were being implemented. • Shalom Health Care Center, Inc will be reviewing the updated Sliding Fee Discount Schedule policy and procedures with all employees. • Shalom Health Care Center, Inc will also make sure there is another level of review to make sure that the sliding fee discounts are assigned accordingly based on income and household size. Management did challenge this as being a Significant Deficiency and believes that it should be listed as a note. Management believes additional consideration should be given to the nature, scope, and impact of the exceptions before concluding that the matter constitutes a significant deficiency in compliance with 42 CFR 51c.303(f). The Organization maintained a Board of Directors approve Sliding Fee and Discount Program policy which highlight the family definition and income definition, maintained and annually updated its sliding fee discount schedule in accordance with applicable federal poverty guidelines. The issue identified by the auditors did not involve the design of the discount schedule itself or the incorporation of the federal poverty guidelines. Rather, the exceptions resulted from staff members applying an interpretation of family size that differed from the definition established in the Organization's internal policy when processing individual applications. Accordingly, management believes the audit report should clearly distinguish between an error in applying the Organization's internal methodology and a violation of a federal compliance requirement. Management has requested that the auditors identify the specific provision of 42 CFR 51c.303(f) that was allegedly violated in each of the three cited cases. Management does agree that the procedures did not follow the policy and that this is more of an issue of process and controls. Management respectfully disagrees with the Finding 2025-001, particularly the classification given as a Significant Deficiency and the characterization of the exceptions as noncompliance with the federal requirement cited in the finding. Management requested the auditors to reconsider whether the circumstances support classification as a Significant Deficiency. At a minimum, management requests that the finding clearly distinguish between (1) compliance with the federal requirement and (2) the Organization's internal procedures for determining family size and calculating the sliding fee discount. Based on the limited number of exceptions, the absence of questioned costs, the lack of evidence of intentional noncompliance, and the fact that the Organization maintained and updated its sliding fee schedule in accordance with the applicable poverty guidelines, management believe that the finding should have given a lesser finding classification and a note in the audit report.)

View Audit 411956

Finding 1236252 (2025-004)

Material Weakness 2025

MacOmb County

MI

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

The County acknowledges that certain required reports were not submitted within the required timeframes. This finding is consistent with the 2024 Single Audit, and due to the timing of the two audits, the County had limited opportunity to implement the prior corrective action. The County will begin ...

The County acknowledges that certain required reports were not submitted within the required timeframes. This finding is consistent with the 2024 Single Audit, and due to the timing of the two audits, the County had limited opportunity to implement the prior corrective action. The County will begin requesting required information during the first month of the performance year and will track and follow up on outstanding requests until received. These efforts will be documented to support compliance and the timely submission of required reports.

View Audit 411844

Finding 1236242 (2025-004)

Material Weakness 2025

Pipestone County

MN

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303 § 200.318

Finding Number: 2025-004 Finding Title: Federal Awards Internal Control Policy and Procedures 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: County management will develop and formally adopt a federal exp...

Finding Number: 2025-004 Finding Title: Federal Awards Internal Control Policy and Procedures 1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: County management will develop and formally adopt a federal expenditures policy to establish procedures for administering and monitoring federal awards in accordance with Uniform Guidance requirements. The policy will address internal controls over compliance, allowable costs, reporting requirements, record retention, and other applicable federal compliance requirements. Management will also communicate the policy to appropriate personnel responsible for administering federal programs. 3. Official Responsible for Ensuring CAP: Steve Ewing, County Administrator, is the official responsible for ensuring corrective action plan. 4. Planning Completion Date for CAP: 12/31/2026 5. Plan to Monitor Completion of CAP: County management will review the policy periodically to ensure it remains current with federal requirements and will monitor compliance with the policy through the administration and oversight of federal programs.

View Audit 411842

Finding 1236169 (2025-015)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Reporting Procurement, Suspension & Debarment § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Missouri State Emergency Management Agency Audit Finding Number: 2025-015 – SEMA FFATA Reporting Name of the contact person responsible for corrective action: Nikol Enyart Anticipated completion date for cor...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Missouri State Emergency Management Agency Audit Finding Number: 2025-015 – SEMA FFATA Reporting Name of the contact person responsible for corrective action: Nikol Enyart Anticipated completion date for corrective action: Completed Corrective action planned is as follows: To avoid future errors, a comparison of the reports received from grant staff with those entered in SAM.GOV will be conducted, and any necessary corrections will be made before the reporting deadline. The absence of UEI numbers will be followed up monthly, and a tracking sheet will be maintained to document the follow-up and will be accessible to the Fiscal Manager for viewing.

View Audit 411772

Finding 1236167 (2025-012)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services, Division of Senior and Disability Services Audit Finding Number: 2025-012 - Medicaid SPPC Participant Choice Agreements Name of the contact person responsible for co...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services, Division of Senior and Disability Services Audit Finding Number: 2025-012 - Medicaid SPPC Participant Choice Agreements Name of the contact person responsible for corrective action: Kim Toebben Anticipated completion date for corrective action: DHSS anticipates that the work described below will be completed by July 2029. Corrective action planned is as follows: The Department of Health and Senior Services (DHSS), Division of Senior and Disability (DSDS) agrees with the auditor’s findings and appreciates the opportunity to respond to the missing Participant Choice Statements in the records of 14 Home and Community Based Services (HCBS) participants. DHSS is monitoring this issue closely and taking this finding seriously. DSDS continues to work diligently to improve the percentage of forms signed and uploaded while conducting reassessments. In May 2025, DSDS implemented a new case management system that expanded reporting capabilities and strengthened DSDS’s capacity to monitor missing documentation. Additionally, DSDS continues to rely on established quality assurance practices, which include monthly random case record reviews of assessor documentation to ensure accuracy and completeness. In addition, DSDS has been working to expand partnerships with new contractors to assist with reassessment volume. The goal is to shift from a high volume of provider-based reassessors to more value-based partners. These value-based partners receive enhanced monitoring to qualify for a higher reimbursement rate. If quality standards are not met, they are no longer eligible for enhanced payment. This model is designed to build partnerships with contracted assessors who consistently produce accurate, timely, and high-quality work. These expanded partnerships are beginning to provide state staff with more time to focus on their assigned workload, ultimately improving overall documentation quality. DSDS’s goal is to continue to increase the number of these partners and their caseload capacity so that all assessors have adequate time to complete thorough, high-quality assessments with proper documentation. Existing partners have set scaling plans to increase the number of assessments they are supporting DSDS with over the next year. While DSDS is committed to resolving documentation gaps, the division is unable to immediately correct all missing Participant Choice Statements due to staffing limitations and the size of the program. With more than 70,000 participants statewide, managing active caseloads while addressing legacy documentation issues presents ongoing operational challenges. DSDS will utilize quality assurance processes, targeted training, and enhanced reporting to identify issues and implement necessary improvements and remediations at time of assessment. Missing Participant Choice Statements will be completed at each participant’s next reassessment. Moving forward, DSDS’s efforts will center on ensuring that Participant Choice Statements are consistently completed during the assessment itself rather than relying on remediation after the fact. The continued expansion of value-based partnerships is expected to significantly support this shift. As these partners assume a greater share of reassessments, DSDS anticipates improved consistency, timeliness, and documentation quality at the point of assessment. This increased capacity allows state staff to focus more on oversight and quality assurance, strengthening long-term compliance, and reducing the need for follow-up corrections.

View Audit 411772

Finding 1236166 (2025-006)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Reporting Procurement, Suspension & Debarment § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2025-006 - DSS Medicaid FFATA Reporting Name of the contact person responsible for correctiv...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2025-006 - DSS Medicaid FFATA Reporting Name of the contact person responsible for corrective action: Clarissa Engelbrecht Anticipated completion date for corrective action: N/A Recommendation: The DSS through the DFAS strengthen internal controls to ensure information is timely reported for the Medicaid program and complete FFATA reporting in accordance with the applicable requirements. DSS Response: The DSS agrees with this finding. The DSS has experienced staff transitions and actively works to ensure staff familiarity with federal regulations and desk procedures. Corrective action planned is as follows: The DSS will strengthen FFATA reporting internal controls to timely report and complete FFATA reporting in accordance with regulation. DSS will also maintain FFATA reporting compliance based on available guidance.

View Audit 411772

Finding 1236149 (2025-008)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Reporting Procurement, Suspension & Debarment § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2025-008 - DSS SSBG FFATA Reporting Name of the contact person responsible for corrective ac...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2025-008 - DSS SSBG FFATA Reporting Name of the contact person responsible for corrective action: Clarissa Engelbrecht Anticipated completion date for corrective action: July 16, 2026 Recommendation: The DSS through the DFAS review, strengthen, and enforce internal controls to ensure information is timely reported for the SSBG program and complete FFATA reporting in accordance with its policy. DSS Response: The DSS agrees with this finding. The DSS has experienced staff transitions and actively works to ensure staff familiarity with federal regulations and desk procedures. Corrective action planned is as follows: The DSS will strengthen FFATA reporting internal controls for second and subsequent year funding to timely report and complete FFATA reporting in accordance with our policy, updated July 2026. The DSS will also maintain FFATA reporting compliance based on available guidance.

View Audit 411772

Finding 1236148 (2025-007)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2025-007 - Social Services Block Grant Post-Expenditure Reporting Name of the contact person...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – Division of Finance and Administrative Services (DFAS) Audit Finding Number: 2025-007 - Social Services Block Grant Post-Expenditure Reporting Name of the contact person responsible for corrective action: Clarissa Engelbrecht Anticipated completion date for corrective action: June 1, 2026 Recommendation: The DSS through the DFAS strengthen internal controls and procedures to ensure annual SSBG Post-Expenditure Reports are accurately prepared and submitted. DSS Response: The DSS agrees with this finding. This agreement is based on the understanding—clarified during the exit meeting—that while DSS is the lead agency, it is not the SAO’s intent to hold DSS accountable for the accuracy of data submitted by the Department of Health and Senior Services (DHSS) for this reporting. Corrective action planned is as follows: The DSS will strengthen internal controls for the SSBG Expenditure Reporting. DSS will work to streamline the process with DHSS prior to the next reporting deadline to ensure this report is prepared and submitted accurately.

View Audit 411772

Corrective Action Plans

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