Corrective Action Plans

Finding 1182559 (2025-004)

Material Weakness 2025

IN

Procurement, Suspension & Debarment Subrecipient Monitoring School Nutrition Programs § 200.214 § 200.303

FINDING 2025-004 Finding Subject: Child Nutrition Cluster- Suspension and Debarment Contact Person Responsible for Corrective Action: Jeff Layden Contact Phone Number and Email Address: 765.457.8101, jeff.layden@nwsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description o...

FINDING 2025-004 Finding Subject: Child Nutrition Cluster- Suspension and Debarment Contact Person Responsible for Corrective Action: Jeff Layden Contact Phone Number and Email Address: 765.457.8101, jeff.layden@nwsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Jeff Layden, Director of Operations, oversees our food service department. He will work with our food service vendor to ensure EPLS are checked before awarding any contract for goods or services. Anticipated Completion Date: Immediate. INDIANA STATE

View Audit 394000

Finding 1182545 (2025-003)

Material Weakness 2025

Career Academy of South Bend, INC

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

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

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

View Audit 393976

Finding 1182539 (2025-001)

Material Weakness 2025

City of Torrance

CA

Reporting Subrecipient Monitoring HUD Housing Programs

The City acknowledges the findings and notes that the delays were the result of internal technical issues that affected timely access to the reporting system during the first two quarters. These issues have since been resolved, and the City has met all subsequent reporting deadlines. Effective May 2...

The City acknowledges the findings and notes that the delays were the result of internal technical issues that affected timely access to the reporting system during the first two quarters. These issues have since been resolved, and the City has met all subsequent reporting deadlines. Effective May 2025, the City corrected the internal technical issues that affected access to IDIS and now verifies system accessibility prior to each reporting deadline. The City will continue to perform ongoing monitoring to ensure the reporting process remains timely and compliant going forward. Date of Implementation: May 2025 Responsible Official or Department: Community Development

View Audit 393965

Finding 1182538 (2025-004)

Material Weakness 2025

Navigator Schools

CA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.430

Management concurs with Finding 2025 - 4 and acknowledges that controls over the review and approval of timecards for federally funded staff were not consistently applied. In response, we will reinforce timekeeping expectations, clarify roles, and ensure that policies and procedures are aligned with...

Management concurs with Finding 2025 - 4 and acknowledges that controls over the review and approval of timecards for federally funded staff were not consistently applied. In response, we will reinforce timekeeping expectations, clarify roles, and ensure that policies and procedures are aligned with 2 CFR § 200.430. We will conduct targeted training for supervisors to reinforce expectations. Central office monitoring will now include quarterly internal audit reviews and follow-up, creating a continuous feedback loop that supports compliance. These enhancements reflect management’s commitment to ensuring that payroll charges to federal programs are accurate, well supported, and reliably documented going forward.

View Audit 393962

Finding 1182526 (2025-001)

Material Weakness 2025

City of Seaside

CA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting

The City concurs with the finding. The City determined that FFATA reporting delays were due to administrative and system access limitations within SAM.gov. On March 13, 2026, the City restored and assigned appropriate user roles and permissions to CDBG staff, enabling submission of required reports....

The City concurs with the finding. The City determined that FFATA reporting delays were due to administrative and system access limitations within SAM.gov. On March 13, 2026, the City restored and assigned appropriate user roles and permissions to CDBG staff, enabling submission of required reports. The City is currently retroactively reporting all applicable subawards using the original obligation dates and has reviewed subrecipient agreements to identify all reportable awards. To ensure ongoing compliance, the City will: • Notify its HUD CPD representative of corrective actions taken • Update its CDBG Policies and Procedures Manual to incorporate FFATA requirements • Integrate FFATA reporting into the subrecipient agreement workflow • Maintain a tracking log to monitor reporting status and deadlines • Provide staff training and implement periodic supervisory review The City has determined the issue was administrative in nature and did not impact program eligibility or expenditures.

View Audit 393947

Finding 1182525 (2025-001)

Material Weakness 2025

Munson Healthcare and Subsidiaries

MI

Subrecipient Monitoring Procurement, Suspension & Debarment Material Weakness

Condition: Testing identified that the Organization issued subawards under ALN 93.912 but did not submit the required FFATA subaward reports to SAM.gov during the audit period. After identification of this noncompliance, the Organization submitted the required FFATA subaward report to SAM.gov. Plann...

Condition: Testing identified that the Organization issued subawards under ALN 93.912 but did not submit the required FFATA subaward reports to SAM.gov during the audit period. After identification of this noncompliance, the Organization submitted the required FFATA subaward report to SAM.gov. Planned Corrective Action: Missing report will be filed. Contact person responsible for corrective action: Lauren Matus & Nicole Sulak Anticipated Completion Date: 02/03/2026

View Audit 393943

Finding 1182511 (2025-015)

Material Weakness 2025

State of Kansas

KS

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019 – 7/31/2027) & NU51CK000384 (8/1/2024 – 7/31/2029) Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: The Kansas Department of Health and Environment (Department) submits quarterly workplan milestone progress reports; however, the reports provided are cumulative in nature and prior quarterly versions are not retained. As a result, auditors were unable to review progress and supporting information for each individual quarter, as only the most recent cumulative report was available. We were also unable to verify the dates that the quarterly performance reports were submitted. The Department prepares and submits quarterly workplan milestone progress reports and annual performance reports; however, documented evidence of supervisory or management review and approval of these reports prior to submission was not consistently maintained. As a result, the Department was unable to provide documentation demonstrating that the reports were reviewed for accuracy, completeness, or compliance with reporting requirements. Recommendation: We recommend that the Department implement procedures to retain copies of each quarterly workplan milestone progress report at the time of submission. Maintaining discrete quarterly reports will improve documentation, support compliance with program requirements, and allow for effective monitoring and audit review of progress throughout the reporting period. In addition, we recommend that the Department implement formal procedures to document the review and approval of the quarterly and annual performance reports prior to submission. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The ELC program director will download quarterly workplan milestone updates to capture quarterly progress. These will initially be signed as approved electronically by the program staff and the ELC director. A more permanent solution will be a software solution that will allow the upload of the quarterly milestone update files prior to submission to ELC CAMP, with review and approval queues. The same procedure will also be used for annual performance measures. A standard operating procedure will be created to ensure formal documentation of this process. Name(s) of the contact person(s) responsible for corrective action: Sheri Tubach Planned completion date for corrective action plan: March 1, 2026, for the interim plan and August 1, 2026, for the permanent solution

View Audit 393917

Finding 1182507 (2025-013)

Material Weakness 2025

State of Kansas

KS

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

Federal Agency: U.S. Department of Labor State Department/Agency: Kansas Department of Labor Federal Program Name: Unemployment Insurance (UI) Assistance Listing Number: 17.225 Award Number: Various Award Period: July 1, 2024 to June 30, 2025 Compliance Requirement: Reporting Type of Finding: Signif...

Federal Agency: U.S. Department of Labor State Department/Agency: Kansas Department of Labor Federal Program Name: Unemployment Insurance (UI) Assistance Listing Number: 17.225 Award Number: Various Award Period: July 1, 2024 to June 30, 2025 Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: During our testing of ETA – 191, Financial Status of UCFE/UCX one of the two reports tested lacked documentation that the report was reviewed prior to submission. Recommendation: We recommend that the Department formalize its review procedures by maintaining documented evidence of reviews for key reports related to federal programs. Management should establish clear documentation standards, such as reviewer sign‑off, date of review, and evidence of follow‑up on identified issues, to demonstrate that oversight controls are consistently performed. Views of responsible officials: There is no disagreement with the finding. Action taken in response to finding: The Department will require that reviewed ETA-191 reports be saved with documented evidence of review, including date stamp and typed reviewer name, prior to submission. Updated documentation procedures are being implemented to ensure consistent retention of review evidence. To address this finding, the Department will implement enhanced documentation controls for ETA reports, including: • Establishing a standardized review checklist for ETA-191. • Requiring documented reviewer sign-off prior to submission, including typed name and date of review. • Ensuring all reviewed and finalized versions of reports are saved with date stamps to evidence completion of the review process. • Incorporating verification of documented review into supervisory oversight procedures. These measures will formalize existing practices and ensure sufficient audit trail documentation is maintained to demonstrate compliance with internal control requirements. Name(s) of the contact person(s) responsible for corrective action: Nicole Struckhoff, Deputy UI Director of Tax and Administration Planned completion date for corrective action plan: June 30, 2026 (End of 2nd Quarter 2026)

View Audit 393917

Finding 1182502 (2025-010)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring Reporting § 200.1 § 200.303

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, and 2501KSTANF Period: October 1, 202...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, and 2501KSTANF Period: October 1, 2023 – September 30, 2025 Compliance Requirement: Reporting - Federal Funding Accounting and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Condition: Kansas Department of Children and Families (Department) was unable to provide FFATA reports for various subawards. Recommendation: We recommend that the Kansas Department of Children and Families implement procedures to identify all subawards subject to Federal Funding Accountability and Transparency Act (FFATA) reporting requirements, including subawards passed through to both in‑state and out‑of‑state subrecipients. DCF should provide training to relevant staff on FFATA requirements and establish a review process to ensure required FFATA reports are submitted accurately and timely for all applicable subaward. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Department for Children and Families (DCF) will update FFATA reporting procedures to include second-tier FFATA reporting for subawards given by other subrecipient Kansas state agencies awarded by an Interagency Agreement. The Interagency Agreement template for subrecipients will be updated to include language detailing any possible subawards given by other state agencies. The subrecipient state agency will determine if the relationship is a subrecipient, vendor or beneficiary for funds passed through to other organizations. If federal funds passed through have a subrecipient relationship, then the other state agency will notify the DCF of subaward amount. DCF staff will provide the other state agency with the federal portion for each subaward and FFATA reporting forms needing completed. The other state agency will complete the FFATA reporting forms for each subaward receiving $30,000 or more federal funds and provide those forms to DCF. DCF staff will submit accurately and timely the FFATA requirements for each subaward given by another subrecipient Kansas state agency. Name(s) of the contact person(s) responsible for corrective action: Brian Carlgren, Director of Grants, Contracts and Payables and James Heckard, Deputy Director of Pre-Award Management Planned completion date for corrective action plan: June 30, 2026

View Audit 393917

Finding 1182501 (2025-009)

Material Weakness 2025

State of Kansas

KS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.332

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Education and Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, an...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Education and Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, and 2501KSTANF Period: October 1, 2023 – September 30, 2025 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Condition: Subawards issued by the Kansas Department of Education and Kansas Department of Children and Families (Departments) did not include all required subaward information. Subawards underwent suspension and debarment verification from sam.gov but this process was not formally documented. Recommendation: We recommend that the Departments develop a subaward template that includes all required federal award information and update its procedures and internal controls to ensure that all required federal award information is included in subawards at the time of issuance. We recommend that management enhance its procurement procedures to require and retain documented evidence that vendors are verified as not suspended or debarred prior to the award of contracts or payment of federal funds. Maintaining this documentation will help ensure compliance with federal requirements and support the government’s assurance that federal funds are expended only with eligible vendors. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The Kansas State Department of Education does have a subaward template for use by agency staff that includes space for all required federal award information. Staff managing the Preschool Pilot Program grants to subrecipients will now use this template when awarding funds from TANF. KSDE staff will also contact the Department for Children and Families to ensure KSDE has the appropriate federal award information to include in the grant award notification. Once grant award notifications are issued, KSDE program staff will notify the Department for Children and Families to ensure they have the appropriate information for FFATA reporting. KSDE staff making the subawards will also retain documentation that each vendor was verified as not suspended or debarred prior to issuing the grant award notification. This documentation will include the following: a tracking spreadsheet that will log when the verification took place and by whom, along with taking a screenshot of the webpage when the verification takes place. Additionally, beginning in school year 2026-2027 the assurances signed by subrecipients will have language that require the subrecipient to certify that they are not suspended or debarred. Name(s) of the contact person(s) responsible for corrective action: Amanda Petersen, Director of Early Childhood, and John Hess, Director of Fiscal Services and Operations Planned completion date for corrective action plan: June 30, 2026

View Audit 393917

Finding 1182495 (2025-006)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring § 200.303 § 200.332 § 200.501

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019 – 7/31/2027) & NU51CK000384 (8/1/2024 – 7/31/2029) Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: Subawards issued by the Kansas Department of Health and Environment (Department) did not include all required subaward information and failed to obtain the Unique Identity ID for all subawards. The Department did not obtain the required audit information (Single Audit or another applicable audit) from its subrecipient during the audit period. Recommendation: We recommend that the Department develop a subaward template that includes all required federal award information and update its procedures and internal controls to ensure that all required federal award information is included in subawards at the time of issuance. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: A subaward template has been created and the ELC program director will ensure that all sub-recipient agreements contain the needed information prior to the start of the budget period. Name(s) of the contact person(s) responsible for corrective action: Sheri Tubach, Deputy State Epidemiologist Planned completion date for corrective action plan: March 9, 2026

View Audit 393917

Finding 1182493 (2025-005)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.1 § 200.303

Federal Agency: Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019 – 7/...

Federal Agency: Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019 – 7/31/2027) & NU51CK000384 (8/1/2024 – 7/31/2029) Compliance Requirement: Reporting - Federal Funding Accounting and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: During the audit period, the entity did not submit required FFATA reports for certain first‑tier subawards subject to FFATA reporting requirements. As a result, required information was not reported in SAM.gov by the last day of the month following the month in which the subaward obligation occurred. Recommendation: We recommend that management implement policies and procedures to ensure compliance with FFATA reporting requirements. This should include identifying all federal awards and subawards subject to FFATA, establishing a process to track reporting deadlines, and providing training to personnel responsible for grant administration to ensure FFATA reports are submitted timely and accurately in SAM.gov. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Currently, all sub awardee payments are being processed by KDHE; however, moving forward, the fiscal analyst will work with the program to make sure that they have the needed information if another state agency is going to be processing the payments on KDHE’s behalf. Moving forward, the fiscal analyst will contact the program to get amounts for any subrecipient agreements/awards, which KDHE will not be the agency processing the payments for, so that any required FFATA reporting can be submitted. Name(s) of the contact person(s) responsible for corrective action: Shelley Russell, Fiscal Management Public Services Executive IV and Danette Cox, Fiscal Analyst Planned completion date for corrective action plan: Immediately. New processes will be used if another state agency will be processing the payments on KDHE’s behalf.

View Audit 393917

Finding 1182491 (2025-004)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring § 200.303 § 200.332

Federal Agency: U.S. Department of Homeland Security State Department/Agency: Kansas Division of Emergency Management Federal Program Name: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Numbers: 97.036 Award Period: July 1, 2024 through June 30, 2025 Awar...

Federal Agency: U.S. Department of Homeland Security State Department/Agency: Kansas Division of Emergency Management Federal Program Name: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Numbers: 97.036 Award Period: July 1, 2024 through June 30, 2025 Award Number: Various Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Condition: During our testing of subrecipient monitoring, we noted that for certain subawards the Kansas Division of Emergency Management (KDEM) did not timely issue the subaward letter to the subrecipients, which should have been communicated within 30 days of subaward being obligated or before subaward payments were made. Recommendation: We recommend that KDEM continues to implement its corrective action plan from prior year and continue to enhance its internal controls and procedures to ensure that the subaward letter is issued to subrecipients timely to ensure all required federal award information is communicated to the subrecipient at the time of the subaward. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: KDEM Fiscal and Compliance office will continue to implement corrective action plan from SFY24. A report will be downloaded of newly obligated projects from Grants Portal every two weeks to ensure project award letters are created and dropped into the Grants Portal for the applicant within 30 days of obligation. Currently fiscal staff is completing this within days to one week of obligation. Name(s) of the contact person(s) responsible for corrective action: Jennifer Deal, Fiscal & Grants Management Section Chief and Lupe Olaya, Grants Compliance Coordinator Planned completion date for corrective action plan: Currently in place.

View Audit 393917

Finding 1182489 (2025-003)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring Reporting § 200.1 § 200.303

Federal Agency: U.S. Department of Homeland Security State Department/Agency: Kansas Division of Emergency Management Federal Program Name: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Numbers: 97.036 Award Period: July 1, 2024 through June 30, 2025 Awar...

Federal Agency: U.S. Department of Homeland Security State Department/Agency: Kansas Division of Emergency Management Federal Program Name: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Numbers: 97.036 Award Period: July 1, 2024 through June 30, 2025 Award Number: Various Compliance Requirement: Reporting - Federal Funding Accounting and Transparency Act (FFATA) Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: During testing of the Federal Funding Accountability and Transparency Act (FFATA) report, it was noted that the Kansas Division of Emergency Management (KDEM) did not timely report certain subawards to FSRS for the fiscal year. Recommendation: We recommend that KDEM continue to implement its corrective action plan from the prior year. Management should continue to enhance its procedures and internal controls to ensure that subawards are accurate, reported timely and reviewed timely to FSRS. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: KDEM Fiscal and Compliance office will continue to implement corrective action plan from SFY24. A report will be downloaded of newly obligated projects from Grants Portal every two weeks to ensure projects are reported timely for FFATA requirements. Currently fiscal staff is collecting this information on a weekly basis and submitting it at the beginning of next month. For example, all February projects are reported at the beginning of March. Name(s) of the contact person(s) responsible for corrective action: Jennifer Deal, Fiscal & Grants Management Section Chief and Lupe Olaya, Grants Compliance Coordinator Planned completion date for corrective action plan: Currently in place.

View Audit 393917

Finding 1182481 (2025-004)

Material Weakness 2025

Eastern Oregon University

OR

Student Financial Aid Subrecipient Monitoring Significant Deficiency

Recommendation: We recommend the University review the GLBA Safeguards Rule and implement appropriate processes and controls to ensure compliance with all applicable provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response ...

Recommendation: We recommend the University review the GLBA Safeguards Rule and implement appropriate processes and controls to ensure compliance with all applicable provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT Department, in conjunction with Human Resources and individual directors and department heads, will institute an annual system inventory of data classification and owner, ensuring job roles and position descriptions are mapped to access profiles. The CIO will review the current classification process for assigning role-based access and the related IT ticketing process for access to ensure existence of documented approvals for provisioning and role changes through a defined access request and approval workflow. IT will also work with HR to establish onboarding/position change/separation controls and timelines triggered by HR provisioning with same-day termination (within 24-hours) upon termination and role change reviews with transfers. IT will also enforce multi-factor authentication (MFA) administrative access where feasible. The relevant Policy and Procedure Manuals will be updated to define access privileges and approval processes, and staff will be trained annually and with onboarding. Name(s) of the contact person(s) responsible for corrective action: Russ Fagan, Chief Information Officer Planned completion date for corrective action plan: March 31, 2026

View Audit 393884

Finding 1182462 (2025-002)

Material Weakness 2025

Heritage Behavioral Health Center, Inc.

IL

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.308 § 200.309 § 200.403

Finding 2025-002: Noncompliance with OMB Compliance Supplement; Period of Performance (H) for Assistance Listing Number (ALN) 93.958 Block Grants for Community Mental Health Services Criteria: The Code of Federal Regulations (CFR) Sections 200.308, 200.309, and 200.403(h) states “a non-Federal entit...

Finding 2025-002: Noncompliance with OMB Compliance Supplement; Period of Performance (H) for Assistance Listing Number (ALN) 93.958 Block Grants for Community Mental Health Services Criteria: The Code of Federal Regulations (CFR) Sections 200.308, 200.309, and 200.403(h) states “a non-Federal entity may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the Federal awarding agency or pass-through entity made the Federal award that were authorized by the Federal awarding agency or pass-through entities.” Costs incurred before or after the period of performance are unallowable unless explicitly approved. Condition: During our testing of expenditures charged to ALN 93.958, we identified 2 transactions out of a total sample of 15 totaling $192 that were incurred outside of the award’s period of performance. Corrective Action Plan: To ensure compliance and accurate reporting, we established internal control protocols for the formal review of service dates, verifying that all expenditures correspond to the appropriate period of performance. The Controller's signature on formal, documented month end checklists will serve as confirmation that all year-end invoices have been checked for appropriate period distribution. Responsible Person for Corrective Action Plan: Addy Hiles (Controller) Implementation Date for Corrective Action Plan: September 2025

View Audit 393858

Finding 1182445 (2025-007)

Material Weakness 2025

Plymouth Community School Corporation

IN

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

FINDING 2025-007 Finding Subject: Title I Grants to Local Educational Agencies - Earmarking Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke, Brittany Sabinas & Jill VanDriessche Contact Phone Number and Email Address: 574-936-3115,...

FINDING 2025-007 Finding Subject: Title I Grants to Local Educational Agencies - Earmarking Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke, Brittany Sabinas & Jill VanDriessche Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Business Manager/Treasurer provides to the corporation grant administrator monthly grant reports, as well as a grant tracking spreadsheet. The appropriations for each grant are entered into Komputrol, according to the budget located in the approved grant documents. The appropriations are presented to the Grant Administrator for approval. All spending from each grant is approved by the corporation grant administrator. More robust documentation will be created to ensure our earmarked funds are being expended as a requirement of this grant. With the more robust documentation, we will ensure the expenses are recorded properly by the Business Manager/Treasurer. The Accounts Payable Specialist will be a second approver of the spending as well as a signatory on the monthly grant reimbursement requests. Anticipated Completion Date: March 1, 2025 and ongoing

View Audit 393841

Finding 1182425 (2025-003)

Material Weakness 2025

Plymouth Community School Corporation

IN

School Nutrition Programs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2025-003 Finding Subject: Child Nutrition Cluster, Internal Controls Audit Findings: Material Weakness Contact Person Responsible for Corrective Action: Jennifer Felke & Amy Kraszyk Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Official...

FINDING 2025-003 Finding Subject: Child Nutrition Cluster, Internal Controls Audit Findings: Material Weakness Contact Person Responsible for Corrective Action: Jennifer Felke & Amy Kraszyk Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will oversee and review the process in place to ensure accuracy of eligible students. The Food Service Director will approve the uploaded Direct Certification reports after reviewing to ensure directly certified students were properly processed. The Business Manager/Treasurer will be the final approver of all Direct Certification reports. The Food Service Director will verify that contractors and subrecipients of the federal award are not suspended, debarred or otherwise excluded. The Food Service Director will complete this task for any expense expected to exceed $25,000 by checking SAMS exclusions, collecting a certification from that vendor or adding a clause or condition to the covered transaction with that vendor. The Business Manager/Treasurer will be the second reviewer/approver for suspension and disbarment. Anticipated Completion Date: March 1, 2026 and ongoing

View Audit 393841

Finding 1182417 (2025-002)

Material Weakness 2025

Meals on Wheels of Wake County, Inc.

NC

Subrecipient Monitoring Eligibility Reporting

We concur with the recommendation. We acknowledge Meals on Wheels of Wake County was understaffed in eligibility staffing during this period. Thus, some assessments were delayed. We have since added 1.5 FTE to assist in this process. However, it should be acknowledged that we see our clients in thei...

We concur with the recommendation. We acknowledge Meals on Wheels of Wake County was understaffed in eligibility staffing during this period. Thus, some assessments were delayed. We have since added 1.5 FTE to assist in this process. However, it should be acknowledged that we see our clients in their home or at congregate sites on a routine/daily basis, therefore are completely aware of their condition and eligibility. Additionally, Title III Nutrition programs do not mean test. For Home Delivered Meals, there are criteria for being considered homebound. For congregate the only requirement is to be 60 years of age and sign up for meals. We have implemented procedures to ensure the meal recipients are evaluated and assessed in a timely manner.

View Audit 393839

Finding 1182409 (2025-006)

Material Weakness 2025

Washington County

OR

Subrecipient Monitoring § 200.332 § 200.521

AL 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Finding: Evidence was not retained of monitoring subrecipients’ financial and single audit reporting or of any follow up actions as a result of monitoring. Auditor Recommendation: The County should develop and implement policies a...

AL 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Finding: Evidence was not retained of monitoring subrecipients’ financial and single audit reporting or of any follow up actions as a result of monitoring. Auditor Recommendation: The County should develop and implement policies and procedures to ensure that all subrecipient monitoring is performed and retained. Corrective Actions Taken or Planned: The County agrees and concurs. The County anticipates providing more training to grant program managers and additional reviews during FY26 as the program closes out. Point of Contact for corrective actions: Sarah Keane, Deputy CFO sarah_keane@washingtoncountyor.gov

View Audit 393821

Finding 1182405 (2025-002)

Material Weakness 2025

City of Buffalo Section 8 Housing Assistance Payments Program Ny409

NY

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting

View of Responsible Officials and Planned Corrective Action Plan—These issues have been resolved with the implementation of consistent procedures for these funds. It is now completed within 30 days of contract execution through sam.gov.

View Audit 393813

Finding 1182403 (2025-005)

Material Weakness 2025

The Inner Voice, Inc.

IL

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.318 § 200.319 § 200.320

FINDING 2025-005 – Procurement, Suspension, and Debarment (Partially Repeated from Prior Year Finding 2024-002) Audit Finding Description: For fourteen (14) out of fourteen (14) procurement transactions tested related to procurement and suspension and debarment compliance, the following was noted: 1...

FINDING 2025-005 – Procurement, Suspension, and Debarment (Partially Repeated from Prior Year Finding 2024-002) Audit Finding Description: For fourteen (14) out of fourteen (14) procurement transactions tested related to procurement and suspension and debarment compliance, the following was noted: 1. The Inner Voice, Inc. did not complete the appropriate procurement process. 2. The Inner Voice, Inc. did not maintain appropriate documentation to support the procurement method utilized. 3. The Inner Voice, Inc. did not maintain documentation evidencing that suspension and debarment searches were performed. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Corrective Action Plan: Management will review procurement policies and procedures to align with Uniform Guidance requirements. This will include documentation of procurement methods, adherence to competitive procurement standards, and verification of suspension and debarment status. Management will also provide training to concerned staff to ensure consistent implementation of the updated policies. Name of Contact Person Responsible for Corrective Action: Diana Mitchell, CPO / Khurram Navaid, CFO Planned Completion Date: March 01, 2026

View Audit 393811

Finding 1182374 (2025-003)

Material Weakness 2025

City of Portsmouth

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance § 200.308 § 200.309 § 200.403

2025-003 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are obligated and/or incurred within the period of performance. Explanation of disagreement with audit fin...

2025-003 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are obligated and/or incurred within the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City acknowledges the finding related to documentation supporting the period of performance for expenditures reported under the SLFRF revenue loss category. Because the City applied the standard allowance for revenue loss and did not track specific expenditures to the grant at the transaction level, some expenditures initially provided for testing were outside the period of performance, although sufficient eligible expenditures existed within the allowable period. To address this issue, the Finance Department will implement procedures to maintain supporting schedules identifying government service expenditures incurred within the applicable period of performance that support amounts reported under the revenue loss category. Finance will also implement a review process to verify that expenditures identified for compliance or audit testing meet applicable period of performance and obligation requirements. These procedures will strengthen documentation and ensure expenditures supporting SLFRF revenue loss are clearly identified and supported for compliance purposes. Name(s) of the contact person(s) responsible for corrective action: Michael Tucker, Deputy Finance Director Planned completion date for corrective action plan: Implemented immediately and effective for all current and future federal awards.

View Audit 393804

Finding 1182367 (2025-002)

Material Weakness 2025

City of Portsmouth

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance § 200.308 § 200.309 § 200.403

2025-002 Special Education Cluster - Assistance Listing Number 84.027, 84.173 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are incurred within the period of performance included in the grant award. Explanation of disagreement with audit finding:...

2025-002 Special Education Cluster - Assistance Listing Number 84.027, 84.173 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are incurred within the period of performance included in the grant award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will implement procedures to ensure that expenditures charged to federal awards are incurred within the approved period of performance in accordance with 2 CFR §§ 200.308, 200.309, and 200.403. The School Department will enhance its grant monitoring procedures by maintaining a tracking schedule of grant periods of performance and reviewing invoices and payment requests for compliance with grant award dates prior to processing. School Department Finance staff will also provide guidance to departments administering grants to ensure expenditures are incurred and submitted within the allowable grant period. These procedures will strengthen internal controls and reduce the risk of expenditures being charged outside the approved period of performance. Name(s) of the contact person(s) responsible for corrective action: Brian Cisneros, Business Administrator Planned completion date for corrective action plan: Implemented immediately and effective for all current and future federal awards.

View Audit 393804

Finding 1182332 (2025-001)

Material Weakness 2025

Myers Senior Residence, Inc. Hud Project No. 031-Ee074

NJ

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

Department of Housing and Urban Development Myers Senior Residence, Inc. HUD Project No. 031-EE074 respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: January 1, 2025 – December 31, 2025 The finding from the schedule of findings and questione...

Department of Housing and Urban Development Myers Senior Residence, Inc. HUD Project No. 031-EE074 respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: January 1, 2025 – December 31, 2025 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Housing and Urban Development 2025-001 Section 202 Capital Advances, Section 8/202 Project Rental Assistance Payments, Section 202 – Demonstration Pre-Development Planning Grant – Assistance Listing No. 14.157 Recommendation: The Organization should review its budgeting process to ensure compliance with HUD funding requirements for the reserve for replacement account. Additionally, they should implement regular monitoring to prevent future underfunding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and will take steps to adjust the budget and ensure the Reserve for Replacement account is adequately funded moving forward. Name(s) of the contact person(s) responsible for corrective action: John Westervelt, President Planned completion date for corrective action plan: 03/31/2026

View Audit 393782

Corrective Action Plans

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