Corrective Action Plans

Finding 1236505 (2025-002)

Material Weakness 2025

AK

Cash Management Subrecipient Monitoring § 200.305

Finding 2025-002: Noncompliance over Cash Management Name of Contact: Chris Pallister, Executive Director Corrective Action: Federal cash drawdowns will be based on cash needs not to exceed 30 days. In collaboration with the Exec Director, Controller will prepare a report of anticipated cash disburs...

Finding 2025-002: Noncompliance over Cash Management Name of Contact: Chris Pallister, Executive Director Corrective Action: Federal cash drawdowns will be based on cash needs not to exceed 30 days. In collaboration with the Exec Director, Controller will prepare a report of anticipated cash disbursements for each month, along with projected ending grant funds on hand. The report will be submitted to the Exec Director or Treasurer for review and to request written approval for the drawdown. Such approval shall be obtained prior to requesting the drawdown. Cash draw requests will be reconciled to actual program expenditures on a quarterly basis. Proposed Completion Date: October 1, 2026.

View Audit 412036

Finding 1236499 (2025-006)

Material Weakness 2025

Chicago Housing Authority

IL

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

Finding 2025-006 I. Procurement, Suspension and Debarment Procurement Approval and Executed Agreement Compliance Management agrees with the finding and has outlined the following corrective actions: • Obtain Board approval for a new intergovernmental agreement for Chicago Police Department at the Se...

Finding 2025-006 I. Procurement, Suspension and Debarment Procurement Approval and Executed Agreement Compliance Management agrees with the finding and has outlined the following corrective actions: • Obtain Board approval for a new intergovernmental agreement for Chicago Police Department at the September 2026 board meeting. • Complete a full review of 2025 and 2026 procurement files by the end of Q1-2027 to ensure all required Board approvals and executed agreements are retained. • Strengthen internal workflows to prevent procurement actions from proceeding without verified approvals and executed agreements through inclusion of a new checklist which will be reflected in an updated standard operating procedures (SOP). • Provide refresher training to procurement staff on 2 CFR 200 documentation retention requirements by December 2026. Suspension and Debarment Compliance Management concurs with the findings and will implement: • Semiannual targeted training to reinforce staff responsibilities for verifying vendor eligibility and documenting compliance to begin December 2026. • Enhanced managerial monitoring through a standardized checklist to ensure required suspension/debarment checks are completed and retained before issuing purchase orders. Implemented January 2027. Responsible for Corrective Action: Tamika Carson, Director of Procurement; Sheila Johnson, Deputy Chief Procurement Anticipated Completion Date: Q1-2027

View Audit 412020

Finding 1236496 (2025-002)

Material Weakness 2025

Chicago Housing Authority

IL

Subrecipient Monitoring HUD Housing Programs Internal Control / Segregation of Duties § 200.303

Finding 2025-002 N. Special Tests and Provisions: N16. Environmental Contaminants Testing and Remediation Low-Rent and RAD (UPCS): Management has designed a control to further strengthen work order compliance. The control includes: • As CHAs third party vendor completes its NSPIRE inspections, the P...

Finding 2025-002 N. Special Tests and Provisions: N16. Environmental Contaminants Testing and Remediation Low-Rent and RAD (UPCS): Management has designed a control to further strengthen work order compliance. The control includes: • As CHAs third party vendor completes its NSPIRE inspections, the Property and Office Management team will run a report day of inspection and/or day after to capture/identify work orders requiring 24hr completion. • CHA monitors 24-hour work orders daily and generates weekly remediation reports covering all required timeframes (24-hour, 30-day, 60-day). • Weekly reports are generated by CHA and provided to the PPMs for review and work order closure. • Work orders which remain open past due dates trigger warning letters to the respective property managers. Additionally, comments are added to the weekly reports to document reasons for outstanding compliance. Weekly reports are stored on SharePoint and accessible by management. • Property Managers are provided with warning letters for untimely closed work orders. 3 warning letters triggers a default by the PPM as enacted by the Department of Procurement and Contracts. • The above process has been enacted as of Aug 2026 and will be captured in a standard operating procedure (SOP) by Q3-2026. Responsible for Corrective Action: Anthony Myers, Director, Property Operations; Takina Clark, Property Operations; Pamela Fairley, Director RAD Anticipated Completion Date of: 3Q-2026 Low-Rent and RAD (Environmental): The Green and Healthy Homes Program, in coordination with Property Operations and Private Property Management (PPM), is implementing process improvements to strengthen environmental contaminant testing, moisture assessment, and mold remediation practices across CHA properties. Key actions include finalizing internal, partner, and vendor guidelines and SOPs—covering product specifications, guidance, and decision mapping—targeted for distribution in Q4-2026. CHA established a dedicated environmental vendor pool as of September 1, 2026, enabling standardized training and compliance monitoring for moisture assessments and remediation work. PPM staff will receive ongoing quarterly training on identifying and triaging suspected mold, implementing prevention strategies, and applying best practice remediation responses. Resident education will focus on prevention and safe housekeeping practices. Pending the release of new Illinois Department of Public Health mold and moisture regulations, CHA will conduct targeted training and certification outreach to ensure compliance once rulemaking is complete. Two PPM training sessions were completed in Q2 & Q3 2026. Completion and ongoing compliance will be validated through (a) workflow process improvement efforts, (b) distribution of updated guidelines/SOPs, (c) implementation of quality assurance audits of remediation work (sampling one out of every four relevant projects), and (d) enhanced data capture within Yardi to support screening during inspections. Relevant projects include work orders that are flagged as either mold/moisture or lead-based paint hazard. Audits will include a desktop review to determine whether property is a target property (per building year data and 24 CFR Part 35) and whether property management took appropriate moisture/mold remediation steps or lead-safe work practices. Responsible for Corrective Action: Elizabeth Poole, Director Healthy Homes Anticipated Completion Date: Q4-2026

View Audit 412020

Finding 1236485 (2025-005)

Material Weakness 2025

Chicago Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Finding 2025-005 N. Special Tests and Provisions: N4. Vacant Units HCV agrees with the auditor’s recommendation to reassess its internal control over vacant units to ensure claims are reduced or reduced in a timely manner. Project Based Voucher (PBV) Program Compliance staff will review and update w...

Finding 2025-005 N. Special Tests and Provisions: N4. Vacant Units HCV agrees with the auditor’s recommendation to reassess its internal control over vacant units to ensure claims are reduced or reduced in a timely manner. Project Based Voucher (PBV) Program Compliance staff will review and update written quality control procedures of PBV program administrators to ensure vacancy payment processes are efficient, properly controlled, and compliant with HUD requirements. PBV Program Compliance will provide updated procedures and training to all impacted teams. In addition, the HCV Program Compliance Manager will strengthen existing compliance monitoring activities to identify and address any exceptions related to vacancy payment processing. Responsible for Corrective Action: Isaelena Albarran, HCV Program Compliance Manager Anticipated Completion Date: Q4-2026

View Audit 412020

Finding 1236482 (2025-003)

Material Weakness 2025

Internews Network

CA

Subrecipient Monitoring § 200.303 § 200.329 § 200.331 § 200.333

Views of Responsible Officials: Management acknowledges the finding and agrees that certain subrecipient monitoring documentation requested during the audit was not available for review. Management believes that the underlying monitoring, oversight, and compliance procedures were performed in accord...

Views of Responsible Officials: Management acknowledges the finding and agrees that certain subrecipient monitoring documentation requested during the audit was not available for review. Management believes that the underlying monitoring, oversight, and compliance procedures were performed in accordance with organizational policies and Federal requirements during the period under audit. As with procurement activities, significant reductions in force following the termination of U.S. Government funding resulted in the rapid reassignment or discontinuation of responsibilities and limited the organization's ability to consolidate all supporting records. Documentation was maintained in multiple locations, and not all files were transitioned to a centralized repository before staff departures occurred. As a result, management was unable to provide complete supporting documentation for all items selected for testing. To address this issue, management has already revised its subrecipient management and monitoring policy. The updated policy clearly defines roles, responsibilities, record retention requirements, and documentation standards within the organization's current operating structure. The revised policy has been formally communicated and distributed across the organization. Management believes these actions will strengthen accountability, improve documentation consistency, and enhance the accessibility of subrecipient records in the future.

View Audit 412014

Finding 1236480 (2025-001)

Material Weakness 2025

Internews Network

CA

Subrecipient Monitoring Reporting § 200.303

Views of Responsible Officials: Management acknowledges the finding and the challenges encountered in providing supporting documentation for FFATA reporting activities during the audit. Management maintains that established FFATA reporting procedures were followed and that required reporting activit...

Views of Responsible Officials: Management acknowledges the finding and the challenges encountered in providing supporting documentation for FFATA reporting activities during the audit. Management maintains that established FFATA reporting procedures were followed and that required reporting activities were performed during the period under audit. Following the abrupt termination of significant U.S. Government funding, Internews implemented substantial reductions in force that affected personnel responsible for grant compliance, reporting oversight, and record retention. As a result, key staff members with primary responsibility for FFATA reporting and supporting documentation were no longer available to assist with the retrieval, explanation, or validation of records requested during the audit process. While management believes that applicable FFATA reporting requirements were met, the organization was unable to provide sufficient supporting documentation to demonstrate compliance for all items selected for testing. Management recognizes the need to strengthen record retention and knowledge-transfer procedures to ensure continuity of documentation during periods of organizational transition and staffing reductions. Management will evaluate opportunities to further centralize reporting records and strengthen controls surrounding the retention of compliance documentation.

View Audit 412014

Finding 1236329 (2025-002)

Material Weakness 2025

Special Health Resources for Texas, Inc.

TX

Subrecipient Monitoring Material Weakness Program Income

SHR will correct the identified non-Ryan White Part B (RWB) patients who were incorrectly included in the RWB program income. The corrective action consists of generating a report of all RWB patients and matching this report to a separate report listing patient receipts collected. This process will ...

SHR will correct the identified non-Ryan White Part B (RWB) patients who were incorrectly included in the RWB program income. The corrective action consists of generating a report of all RWB patients and matching this report to a separate report listing patient receipts collected. This process will occur on a monthly basis, with RW program collections being posted as community income. This process will also include reconciling the results with an independent report generated by our external collection agency. This QA procedure will ensure that patients included in the RWB program income report are appropriately classified as RWB patients and are not community clinic patients who are not eligible for inclusion in RWB program income. SHR will continue to monitor the effectiveness of these controls and will make additional adjustments as necessary to ensure that RWB program income is accurately classified, recorded, and reported in accordance with applicable program requirements.

View Audit 411958

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 1236323 (2025-001)

Material Weakness 2025

Medical Debt Resolution, Inc.

NY

Subrecipient Monitoring Reporting

Finding Number: 2025-001 Compliance Requirement: Reporting Programs: United States Department of the Treasury • ALN Number: 21.027 • ALN Name: Coronavirus State and Local Fiscal Recovery Funds • Contract Periods: August 1, 2025 – September 30, 2025 (County of Orange, Florida); October 1 - December 3...

Finding Number: 2025-001 Compliance Requirement: Reporting Programs: United States Department of the Treasury • ALN Number: 21.027 • ALN Name: Coronavirus State and Local Fiscal Recovery Funds • Contract Periods: August 1, 2025 – September 30, 2025 (County of Orange, Florida); October 1 - December 31, 2025 (County of Orange, Florida); October 1, 2025 - December 31, 2025 (Oakland County, Michigan); January 1, 2025 – March 31, 2025 (Kalamazoo, Michigan) Management’s Corrective Action Plan: Management acknowledges the finding and agrees that additional improvements are needed to ensure timely submission of required grant reports and consistent retention of supporting documentation. The exceptions identified resulted from two primary factors. The Orange County report was submitted after the due date due to an unusually short 10-day reporting deadline. The remaining late reports occurred while management was implementing corrective actions associated with the prior-year reporting finding and strengthening its grant reporting processes. While those improvements were underway, certain reporting requirements were not completed within the required timeframe. Management has since submitted all outstanding reports, and all identified reporting deficiencies were resolved prior to the audit completion deadline of September 30, 2026. To prevent recurrence, management has implemented and continues to enhance a centralized grant reporting tracker, assigned clear reporting ownership and oversight responsibilities, strengthened monitoring of upcoming deadlines, and standardized the retention of submission confirmations and related supporting documentation. Management will continue periodic reviews of reporting compliance to ensure reporting obligations are completed timely and adequately documented. Responsible Officials: Vice President, Finance & Administration (Fiscal Reporting) and Vice President, Government Initiatives (Performance Reporting)

View Audit 411940

Finding 1236318 (2025-001)

Material Weakness 2025

Centra Health, Inc.

VA

Student Financial Aid Subrecipient Monitoring Internal Control / Segregation of Duties

2025-001 – Special tests and provisions: Centra has continued to make progress on maturing the Information Security Program, protection of student data, and compliance with GLBA requirements. Currently, Centra is fully compliant with eleven (11) of the fifteen (15), and partially compliant with the ...

2025-001 – Special tests and provisions: Centra has continued to make progress on maturing the Information Security Program, protection of student data, and compliance with GLBA requirements. Currently, Centra is fully compliant with eleven (11) of the fifteen (15), and partially compliant with the remaining four (4) GLBA requirements. Of the remaining four (4) controls that are in partial compliance, we have plans to ensure full compliance by the end of September 2026, with a mitigating control step for one (1) until the full replacement of the College student information system is complete. These initiatives are tracked, resourced, and scheduled, ensuring that residual gaps are closed in alignment with GLBA requirements. Name of Contact Person Responsible for Corrective Action: John Hunt Centra Health Corporate Director, Information Security and Disaster Recovery 561-613-7342 john.hunt@centrahealth.com

View Audit 411931

Finding 1236295 (2025-001)

Material Weakness 2025

County of Jefferson

PA

Subrecipient Monitoring Internal Control / Segregation of Duties

Contact Person: Jessica Park, CFO Finding 2025-001 Subrecipient Monitoring AL 93.778 Medical Assistance Program and DHS Medical Assistance Criteria: PA DHS compliance require the County to perform subrecipient monitoring procedures over MATP funding disbursed to the Program’s vendor. Condition: Duri...

Contact Person: Jessica Park, CFO Finding 2025-001 Subrecipient Monitoring AL 93.778 Medical Assistance Program and DHS Medical Assistance Criteria: PA DHS compliance require the County to perform subrecipient monitoring procedures over MATP funding disbursed to the Program’s vendor. Condition: During the audit, it was noted that the County was not performing subrecipient monitoring over the Program’s vendor. Cause: The County does not have adequate controls in place or the expertise to ensure proper subrecipient monitoring procedures. Effect: The Program’s vendor may be using grant funding inappropriately. This is a repeat finding from the prior year – Finding 2024-001. Questioned Costs: The amount of questioned costs, if any, is undeterminable Recommendation: The County should implement internal control procedures that ensure the vendor is being properly monitored. Management Response: Management is working with their internal audit team to establish a process and schedule for sub-recipient monitoring of the program vendor. Anticipate Completion Date: Second Quarter of 2026

View Audit 411910

Finding 1236274 (2025-002)

Material Weakness 2025

Mercy Flights, Inc.

OR

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.327

2025-002: Procurement and Suspension and Debarment Statement of Condition: The Organization did not appropriately monitor expenditures for the vendor tested to trigger verification of the vendor status of suspension or debarment prior to the expenditures reaching the $25,000 covered transaction thre...

2025-002: Procurement and Suspension and Debarment Statement of Condition: The Organization did not appropriately monitor expenditures for the vendor tested to trigger verification of the vendor status of suspension or debarment prior to the expenditures reaching the $25,000 covered transaction threshold. Additionally, the Organization’s procurement policy did not fully comply with the federal procurement standards outlined in the Uniform Guidance. Management Response and Corrective Action Plan: The Organization has revised its existing vendor policies and procedures to ensure it complies with the federal procurement standards outlined in the Uniform Guidance, including the testing of vendor status for suspension or debarment prior to engaging in any federal award-funded transactions with excluded parties. Responsibility of: Controller, Jennifer Laret and Chief Financial Officer, Jill Borovansky Planned Implementation Date of Corrective Action Plan: 2026 Audit

View Audit 411883

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 1236213 (2025-002)

Material Weakness 2025

THE NATIONAL INSTITUTE FOR CRIMINAL JUSTICE REFORM

CA

Cash Management Subrecipient Monitoring § 200.305

Views of Responsible Officials and Corrective Action Plan: Management acknowledges and concurs with this finding and is developing formal policies and procedures related to cash management compliance requirements. NICJR’s drawdowns were due to extraordinary circumstances. There was an unprecedented ...

Views of Responsible Officials and Corrective Action Plan: Management acknowledges and concurs with this finding and is developing formal policies and procedures related to cash management compliance requirements. NICJR’s drawdowns were due to extraordinary circumstances. There was an unprecedented action taken by the federal government in announcing the pending cancellation of more than $800 million grants to thousands of non-profit organizations around the country. During the significant uncertainty surrounding the changing funding environment as well as our commitment to our subgrantee organizations, NICJR continued submitting reimbursement requests while awaiting additional guidance. NICJR will create a cash management policy to minimize the time elapsed between payment and request of funds to meet requirements of 2 CFR 200.305(b). Name of Responsible Person: Leah Wilson, Chief of Staff Implementation Date: July 1, 2026

View Audit 411825

Finding 1236209 (2025-002)

Material Weakness 2025

Waikiki Health

HI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2025.002 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...

Finding 2025.002 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit and again in 2024. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, including clarification of documentation requirements, acceptable forms of income verification, and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representative (PSR) staff to consistently assess and apply sliding fee discounts. The SOP includes clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership, provide corrective follow-up, and provide any needed training for PSR personnel on the updated policy and procedures. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls. Waikiki Health is also considering engaging an outside firm to assist with streamlining the sliding fee scale process and strengthening related internal controls.

View Audit 411822

Finding 1236198 (2025-001)

Material Weakness 2025

Blue Star Families, Inc.

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Views of Responsible Officials: Blue Star Families leadership appreciates the Auditors’ procurement reporting in the context of the revised Uniform Guidance guidelines. BSF will implement stronger policies and procedures into our vendor selection processes and the verification of an entity’s status ...

Views of Responsible Officials: Blue Star Families leadership appreciates the Auditors’ procurement reporting in the context of the revised Uniform Guidance guidelines. BSF will implement stronger policies and procedures into our vendor selection processes and the verification of an entity’s status in SAM.gov per these findings.

View Audit 411799

Finding 1236195 (2025-003)

Material Weakness 2025

Town of Centerville

IN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.302 § 200.303

FINDING 2025-003 Finding Subject: Federal Award Findings and Questioned Costs Contact Person Responsible for Corrective Action: Sarah Rice Contact Phone Number and Email Address: 765-855-5515, srice@town.centerville.in.us Views of Responsible Officials: Option 1: “We concur with the finding.”  Drin...

FINDING 2025-003 Finding Subject: Federal Award Findings and Questioned Costs Contact Person Responsible for Corrective Action: Sarah Rice Contact Phone Number and Email Address: 765-855-5515, srice@town.centerville.in.us Views of Responsible Officials: Option 1: “We concur with the finding.”  Drinking Water State Revolving Fund – Written Policies/Procedures to Determine Allowability of Costs using Federal Grant Funds- I will be getting in touch with our council president to make sure we come up with a policy on how to use federal funding with clear guidance on what costs are constituted as direct and indirect charges. Anticipated Completion Date: February 28, 2027 INDIANA

View Audit 411798

Finding 1236183 (2025-002)

Material Weakness 2025

County of Armstrong

PA

Subrecipient Monitoring

Finding 2025-002 Subrecipient Monitoring AL 93.778 and Medical Assistance Program and DHS Medical Assistance Transportation Program Criteria: Internal control procedures require the County to perform subrecipient monitoring procedures over the funding disbursed to the Program’s vendor. These monitor...

Finding 2025-002 Subrecipient Monitoring AL 93.778 and Medical Assistance Program and DHS Medical Assistance Transportation Program Criteria: Internal control procedures require the County to perform subrecipient monitoring procedures over the funding disbursed to the Program’s vendor. These monitoring procedures include documenting the procedures performed and the results of those procedures along with documenting the risk assessment associated with the selected procedures. Condition: During the audit, it was noted that the County was not performing subrecipient monitoring over the Program’s vendor. Cause: The County does not have adequate controls in place or the expertise to ensure proper subrecipient monitoring procedures. Effect: The Program’s vendor may be using grant funding inappropriately. This is a repeat finding from the prior year – Finding 2024- 002. Questioned Costs: The amount of questioned costs, if any, is undeterminable. Recommendation: The County should implement internal control procedures that ensure the vendor is being properly monitored and document those procedures and results of procedures. Management Response: Management is working to implement and document proper subrecipient monitoring internal controls. Anticipate Completion Date: Immediate

View Audit 411788

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 1236168 (2025-014)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring § 200.303 § 200.332

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Missouri State Emergency Management Agency Audit Finding Number: 2025-014 – SEMA Subrecipient Monitoring Name of the contact person responsible for corrective action: Nikol Enyart Anticipated completion date...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Missouri State Emergency Management Agency Audit Finding Number: 2025-014 – SEMA Subrecipient Monitoring Name of the contact person responsible for corrective action: Nikol Enyart Anticipated completion date for corrective action: Completed Corrective action planned is as follows: Since the discovery of the shortfall in the monitoring of subrecipients, SEMA has taken action to get the program back on track. SEMA has maintained forward momentum in completing the risk assessments within the time dictated by the policy. SEMA has completed all desk monitoring reports for the medium-risk subrecipients and all site visits for high-risk subrecipients. SEMA has also crosstrained multiple employees in the steps and processes to achieve high output for this process. SEMA has created a separate tracker to focus directly on the desk monitoring and site visits that have been completed or still need to be completed. This tracker is monitored by the Deputy Recovery Division Manager. SEMA also generates reports on the 15th and 30th of each month outlining progress made during those two weeks, which are submitted to the Recovery Division Manager. This report was first created and submitted on January 31, 2025.

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 1236164 (2025-004)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Eligibility Material Weakness § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-004 - Medicaid and CHIP Eligibility Determination Timeliness Name of the contact...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-004 - Medicaid and CHIP Eligibility Determination Timeliness Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: 12/31/2027 Recommendation: The DSS through the MHD and the FSD continue to review, strengthen, and enforce internal controls to ensure participant eligibility is determined within the required timeframes. DSS Response: The DSS agrees with this finding. DSS has made significant progress in reducing the backlog of applications. DSS continues to develop and implement technologies intended to assist the department and participants with necessary actions such as submitting applications, verifying income and resources, and providing required information. The estimated implementation date of this technology is December 31, 2027. Corrective action planned is as follows: The DSS will continue to work towards completing applications within the established timeframes outlined in 42 CFR 435.912(c)(3) and 42 CFR 457.340(d).

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Finding 1236163 (2025-003)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Subrecipient Monitoring Eligibility § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-003 - Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-003 - Medicaid and CHIP MAGI-Based Participant Eligibility Redeterminations Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: 12/31/2026 Recommendation: The DSS through the MHD and the FSD strengthen internal controls to ensure redeterminations are completed as required. DSS Response: The DSS disagrees with this finding. Throughout SFY 2025, the agency was actively monitoring and strategizing to work towards completing all renewals by the deadline of December 31, 2025. While the DSS was unable to complete all renewals by the deadline of December 31, 2025, progress throughout all of SFY 2025 continued. Additionally, the DSS does not consider this within the scope of the SFY 2025 audit because federal requirements did not require all renewals to be complete until December 31, 2025, which falls in SFY 2026. DSS resumed initiating renewals starting in April 2023 under the unwinding plan submitted to CMS with the goal to complete all unwinding related renewals prior to the deadline of August 31, 2024. However, DSS encountered staffing challenges in completing all unwinding renewals by the established deadline. On August 29, 2024, CMS released guidance recognizing the challenges that many states faced impacting the ability to complete unwinding related renewals and restore routine operations within the original timelines established, extending the allowance for states to continue to use the exception under 42 CFR 435.912(e) through December 31, 2025. With the backlog of MAGI annual renewals and the changes that will be implemented from the passage of HR. 1 (the Big, Beautiful Bill), a new plan to complete redeterminations was formed based on federal flexibilities. The DSS continued to complete redeterminations for MAGI participants throughout the unwinding period; however, around April 2025 leadership began revising the procedures of eligibility staff and leveraging additional staff to ensure case actions, including annual renewals, were completed timely. The department contracted to increase temporary staff through 2026 to focus on working the backlog for MAGI annual renewals by December 31, 2026.

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Finding 1236161 (2025-001)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Subrecipient Monitoring Eligibility § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-001 – Medicaid and CHIP Eligibility System Internal Controls Name of the contact...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Social Services (DSS) – MO HealthNet Division (MHD) and Family Support Division (FSD) Audit Finding Number: 2025-001 – Medicaid and CHIP Eligibility System Internal Controls Name of the contact person responsible for corrective action: Stacy Kaylor Anticipated completion date for corrective action: 4/1/26 Recommendation: The DSS through the MHD and the FSD strengthen internal controls to timely prevent, detect, and correct improper dual enrollments in the MEDES and the FAMIS for participants of the Medicaid program and the CHIP. The DSS should review the dual enrollments for the participants identified in this finding, correct any improper enrollments in the applicable eligibility system(s), and recoup any related improper payments and claims. DSS Response: The DSS agrees with this finding. Corrective action planned is as follows: A report was developed in October 2025 to identify individuals with multiple active Medicaid Eligibility (ME) Codes that include different coverage types. The report is filtered through the FAMIS system to ensure both levels of coverage are active when the report is worked. Staff began working this report manually in Spring of 2025 and they identified higher priority tasks such as closing Adult Expansion Group (AEG) coverage for individuals who have been determined eligible for a mandatory Non-MAGI coverage type. Staff have significantly reduced the number of individuals with dual coverage as of Spring 2026. Please note that there are certain ME Codes that can run concurrently with other coverage. In order to reduce staff burden and improve efficiency, program staff will work with system staff to automate the manual processes that are done with this report to ensure dual coverage is closed in a timely manner. There is no estimated completion date at this time, but the DSS hopes to have some level of automation by December 31, 2027.

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