Corrective Action Plans

Finding 1236155 (2025-013)

Material Weakness 2025

State of Missouri

MO

Special Tests & Provisions Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.514

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-013 - Medicaid Facility Survey Timeliness Name of the contact person responsible for corrective action: Tracy Niekamp, Administrator, Secti...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-013 - Medicaid Facility Survey Timeliness Name of the contact person responsible for corrective action: Tracy Niekamp, Administrator, Section for Long Term Care Regulation, Division of Regulation and Licensure Anticipated completion date for corrective action: December 31, 2028 Corrective action planned is as follows: Corrective Action Plan related to the finding regarding revisits not being performed within 60 days. DHSS disagrees with the finding and contends a finding, and corrective action plan is not required related to the three revisits not performed within 60 days. The SAO has determined these exceptions to be nonmaterial noncompliance and as such, a finding in the single audit is not required. In addition, Centers for Medicare and Medicaid Services (CMS) is well aware of DHSS’ compliance level with this requirement and has deemed it met. During Federal Fiscal Year 2025, DHSS met the performance standard set out by the CMS for onsite revisits as outlined in Fiscal Year (FY) 2025 State Performance Standards System (SPSS) Guidance. Admin Info: 25-03-ALL. The SAO’s exception listing is inaccurate. Despite documentation provided to the SAO, the SAO demonstrated a misunderstanding or disregard of CMS’ grading system. One exception did not fall into the SAO’s cited category and failed to meet the deficiency threshold requiring a 60-day revisit. For the other two exceptions, additional complaints were received between the original visit and revisit which, according to CMS guidelines, had to be resolved before the revisit could occur. Further, DHSS follows CMS’ stated work priorities to conduct surveys and revisits as mandated by CMS Mission and Priority Document. See the explanation below regarding the increase in severe complaints, including immediate jeopardy (IJ) complaints (which require an onsite investigation within 24 hours to seven days), and the impact on SLCR’s decision to address immediate threats to residents as required by CMS. Corrective action plan related to the delayed issuance of Statements of Deficiencies and Plans of Correction (SODs) within the required 10-day timeframe. DHSS partially agrees with this finding. While DHSS agrees that the 14 SODs were not issued within 10 days, DHSS disagrees that, as a nonmaterial noncompliance finding, this issue should be reported in the single audit and therefore disagrees that a corrective action plan is needed. DHSS has continued to make significant progress in meeting expectations since FY2023. During the FY23 audit, 19 of the sampled statements of deficiency did not meet the 10-day timeframe for release to the facility. Results of the FY24 and FY25 audits showed improvement in DHSS performance as the number of sampled statements of deficiency that did not meet the 10-day timeframe for release to the facility decreased to 13 and 14 respectively. As previously stated, since 2019, DHSS has seen increases in the number and severity of complaints, and the severity of violations found in long term care facilities. Complaints increased overall by thirty-six percent (36%) from 9,011 complaints in FY2019 to 12,237 in FY2024. In FY2025, DHSS received 12,203 complaints. The largest increase has been in severe complaints, including immediate jeopardy complaints (which require an onsite investigation within 24 hours to seven days) and non-immediate jeopardy, high priority complaints (require onsite investigation within 15 working days). Because of the seriousness of these complaints, and to adhere to the CMS Mission and Priority document, often surveyors must be reassigned to investigate these complaints, which results in a delay in conducting revisits or sending a statement of deficiencies timely. In addition to frequency and severity of complaints, changes to the survey process, and increased regulatory requirements, DHSS continues to see a high volume of citations issued per recertification survey and complaint investigations. Since 2019, the average number of health citations issued to a facility during a recertification survey has increased by 25% and the number of citations issued from stand-alone complaint findings has increased 100% during the same timeframe. These increases require additional time devoted to investigating often complex violations, increased time spent on write-up activities, including the creation of the Statement of Deficiency, plan of correction review, onsite and offsite revisit activity and communication with complainants and facilities. Increases in this workload often require team members to begin investigating new complaints, prior to the write-up activities or revisits to other processes being completed. Additionally, subsequent complaint investigations often cause revisits to be delayed due to open enforcement cases and substantial compliance date conflicts. Regulatory noncompliance identified during the survey is discussed with administration at the facility while surveyors are on site. Findings of immediate jeopardy require a prompt plan of correction to address the immediacy of the violation prior to surveyors exiting the process. For all violations, facilities typically begin to take immediate corrective action, not waiting for receipt of the written SOD from SLCR. DHSS continues to experience staffing shortages, particularly in the Registered Nurse job classification, which impacts the ability to complete work consistently within the prescribed time frames. Each recertification survey requires at least one team member to be Registered Nurse and due to the nature of many complaints, a Registered Nurse must also complete these investigations. There has been no meaningful increase in the federal budget in more than a decade, which further impacts the ability to hire and retain Registered Nurses. In addition, there is an ongoing shortage in the labor market for these professionals. The shortage has driven salaries well beyond the surveyor salary structure. DHSS has experienced turnover among surveyors leaving for other opportunities at a much higher salary. DHSS has and will continue to request increased funding from CMS to support competitive salaries for Registered Nurses and fully fund the federal portion of the survey and certification workload. DHSS will continue its endeavors to hire retired, federally qualified surveyors part-time to help with survey and complaint backlog. DHSS continually works toward identifying inefficiencies and implementing measures to address them, such as bundling complaint investigations with other regulatory processes. As a short-term, time-limited solution possible through one-time additional funding from the CMS and Centers for Disease Control and Prevention- Epidemiology and Laboratory Capacity (CDC-ELC), DHSS contracted with three third-party contractors to assist with workload completion. (Note: That funding terminated on March 24, 2025.) DHSS will maintain current contracts with the entities so that if funding becomes available contract surveys can be set up shortly after. DHSS will continue to track timeframes for completion of Statements of Deficiencies and revisits and make every effort to meet those timeframes. DHSS will continue to assign workload based on CMS’ stated priorities in the Mission and Priority Document, taking into account the potential for direct impact on residents. DHSS will provide training to surveyors related to writing statements of deficiency to ensure a clear, concise, legally defensible document is produced and to reduce the review time required.

View Audit 411772

Finding 1236149 (2025-008)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Reporting Procurement, Suspension & Debarment § 200.303

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

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

View Audit 411772

Finding 1236148 (2025-007)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

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

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

View Audit 411772

Finding 1236148 (2025-007)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-007 - Social Services Block Grant Post-Expenditure Reporting Name of the contact person responsible for corrective action: Becky Harris and...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-007 - Social Services Block Grant Post-Expenditure Reporting Name of the contact person responsible for corrective action: Becky Harris and Angela Burgess Anticipated completion date for corrective action: 06/30/2026 Corrective action planned is as follows: The Department of Health and Senior Services will revise and document the procedures involved in completing and validating the data included in the shared spreadsheet for inclusion in the annual Post-Expenditure Report. The procedures will continue to be reviewed on an ongoing basis and updated as needed. Procedures will be documented by the Fiscal Oversight and Reporting team, the Division of Senior and Disability Services (DSDS) team, and the Division Liaison Services – DSDS team to ensure consistency in the data being reported.

View Audit 411772

Finding 1236147 (2025-009)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring § 200.303 § 200.331 § 200.332

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Office of Administration Audit Finding Number: 2025-009 - SLFRF Program Subrecipient Monitoring Name of the contact person responsible for corrective action: Stacy Neal Anticipated completion date for correc...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Office of Administration Audit Finding Number: 2025-009 - SLFRF Program Subrecipient Monitoring Name of the contact person responsible for corrective action: Stacy Neal Anticipated completion date for corrective action: Already Completed Recommendation A: Continue to work with the state agencies to ensure documented determinations are prepared to determine whether all recipients of SLFRF program funds are subrecipients or contractors. OA agrees with the auditor’s finding. Corrective action has already been accomplished. After receiving the FY24 audit finding in FY26 (specifically September 30, 2025), OA established Memorandums of Understandings (MOU) in November of 2025 with partner agencies. These MOUs clarify the definition of a subrecipient as provided in 2 C.F.R § 200.1 and delineate responsibilities for making and documenting subrecipient versus contractor determinations. Because these corrective actions are already complete, OA considers this a timing-related finding. Because these corrective actions are already complete, OA considers this a timing-related finding. Recommendation B: Develop policies and procedures outlining pre-payment monitoring procedures and document monitoring performed prior to making payments. The OA should also continue to ensure subrecipient monitoring tasks delegated to state agencies are adequately communicated. Procedures should be established to ensure subrecipient monitoring procedures are appropriately completed in accordance with the Uniform Guidance, including performing risk assessments for each subrecipient, monitoring for compliance with federal requirements and subaward terms and conditions, and ensuring subaward goals and objectives are achieved. OA agrees with the auditor’s finding. Corrective action has already been accomplished. After receiving the FY24 audit finding in FY26 (specifically September 30, 2025), OA established Memorandums of Understandings (MOU) in November of 2025 with partner agencies to ensure agencies understood their responsibilities for subrecipient monitoring included subrecipient specific risk assessments and monitoring. Because these corrective actions are already complete, OA considers this a timing-related finding.

View Audit 411772

Finding 1236146 (2025-016)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring Procurement, Suspension & Debarment HUD Housing Programs § 200.303 § 200.516

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Economic Development Audit Finding Number: 2025-016 – DED FFATA Reporting Name of the contact person responsible for corrective action: Christopher McCormick Anticipated completion date for cor...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Economic Development Audit Finding Number: 2025-016 – DED FFATA Reporting Name of the contact person responsible for corrective action: Christopher McCormick Anticipated completion date for corrective action: June 30, 2026 The Department partially agrees with the auditor's findings. The Departments Corrective Action Plan below includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. The Department agrees that we need to strengthen internal controls to ensure information is timely and accurately reported for the CDBG program and complete FFATA reporting in accordance with the applicable requirements. The one (1) award that was not reported as required was a clerical error and was not repeated. The Department disagrees with the findings that exceed the scope of the current audit period (July 1, 2024 – June 30, 2025). The correct audit population comprises new subawards, and amendments executed during the audit period, rather than all active subawards. The reported items were submitted before June 30, 2024, and correspond to prior award periods that are now closed. Furthermore, the Department's internal control mechanisms identified the FFATA reporting discrepancy in September 2024. The Department subsequently conducted a retrospective review and reported all outstanding amendments. Because the Department discovered and corrected the breakdown through its own internal controls, we believe the finding is inconsistent with the regulatory intent regarding systemic non-compliance. The Department maintains that FFATA does not require the reporting of deobligations or a reconciliation with USASpending.gov. Per 2 CFR §170 Appendix A, the regulatory requirement is as follows: “…the recipient must report each subaward that equals or exceeds $30,000 in Federal funds... The recipient must also report a subaward if a modification increases the Federal funding to an amount that equals or exceeds $30,000. All reported subawards should reflect the total amount of the subaward.” The Department adheres to the literal language of this regulation. The requirement specifies reporting the total amount of the subaward, rather than a "net" amount or a "remaining balance." In accounting and auditing standards, "Total," "Balance," and "Net" are distinct terms with specific applications; had the regulation intended for deobligations to be factored into the reported figure, it would have specified a "net", “balance”, or "liquidated" balance. The Department disagrees with the finding that subawards were reported in the incorrect year. For annual federal funds, the Department operates on a First-In, First-Out (FIFO) basis. In the standard course of business, subaward invoices are typically paid from the specific pool of funds from which they were awarded. However, as older funding streams approach expiration, an invoice for a subaward originally awarded and properly reported to FFATA in FY2022 may be relieved using FY2019 funds. Since the subawards were reported accurately at the time of the award action, they remain in compliance with FFATA regulations. Corrective Plan of Action: The CDBG program will implement the following measures to ensure ongoing compliance and strengthen oversight: • Training and Regulatory Review: The Department will conduct comprehensive FFATA training for the reporting team, specifically focusing on the requirements set forth in 2 CFR Part 170. This review will ensure that all staff are aligned with federal reporting standards and the literal requirements of the regulation. • Internal Control Enhancement: A thorough evaluation of existing internal controls related to FFATA reporting is underway. The Department will identify and implement any necessary improvements to provide reasonable assurance that all reporting remains accurate and compliant. • Best Practice Research and Benchmarking: The Department will engage with peer agencies in other states to determine if a reconciliation process with USAspending.gov is utilized as a best practice. • Process Implementation: If an effective reconciliation model is identified through this benchmarking, the Department will evaluate its feasibility and integrate a similar reconciliation process into the State of Missouri’s standard operating procedures to further bolster reporting integrity.

View Audit 411772

Finding 1236144 (2025-011)

Material Weakness 2025

State of Missouri

MO

Subrecipient Monitoring § 200.303 § 200.332 § 200.514

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-011 - CACFP Subrecipient Monitoring Name of the contact person responsible for corrective action: Sarah Walker, Administrator, Bureau of Co...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-011 - CACFP Subrecipient Monitoring Name of the contact person responsible for corrective action: Sarah Walker, Administrator, Bureau of Community Food and Nutrition Assistance (BCFNA), Division of Community and Public Health Anticipated completion date for corrective action: Not Applicable The Missouri Department of Health and Senior Services (DHSS) disagrees with this finding because the BCFNA subrecipient monitoring, claim recoupment and risk assessment procedures comply with the U.S. Department of Agriculture (USDA), the federal funding agency. In addition, the similar fiscal year 2023 audit finding was closed by the USDA after reviewing DHSS’s corrective action plan and supporting documentation. The SAO stated, “While our review found the sample monitoring reviews were performed in accordance with the policies and procedures outlined in the Internal Nutritionist Manual, we identified areas where these policies and procedures could be strengthened and improved to ensure facilities/sponsors comply with program requirements and submit proper claims.” The SAO is holding DHSS to higher performance audit standards instead of Single Audit compliance audit standards as well as to higher standards than required by federal guidance and regulations. The SAO’s stated, “In May 2024, when the BCFNA changed the risk assessment and scoring system, the BCFNA ceased assigning a grade of A, B, B-, or C to each review and widened the score ranges and associated review requirements. DHSS officials indicated the scores assessed by the new system are frequently higher than those assessed under the previous manual system. The impact of these changes on the frequency and effectiveness of the monitoring reviews is unclear.” While working with the software provider during the development, testing, and implementation stages over the course of several years, the new point range was thoroughly reviewed prior to implementation. This ensured reviews are classified appropriately for risk categories. The new system provides a monitoring process more stringent than USDA requirements. All monitoring is reviewed by supervisory staff to ensure a comprehensive assessment. During testing, it was found that the new system frequently returned a higher point level, as every finding now results in a point. The increased score range was required to more precisely reflect monitoring reviews and reflects an even more stringent monitoring process than is required by USDA. The SAO reported “….BCFNA only identifies and seeks recoupment for the overclaims made during the test month.” As noted in previous CAPs, BCFNA pursues recoupment of overclaims of only the test month per USDA requirements, although when warranted, additional reviews are conducted beyond the test month. In addition, BCFNA officials pursue recoupment of overclaims for facilities/sponsors with terminated contracts on a case-by-case basis, taking into consideration various factors. The USDA established an acceptable level of risk with respect to the CACFP program and provided approved risk management processes and requirements. The previous and current risk assessment processes are in compliance with federal requirements. BCFNA has a structured risk assessment process that informs its monitoring extent and frequency, which leads to subrecipients being monitored more frequently than every three years as required by the USDA. The USDA is aware of the risk assessment process used by BCFNA and did not require any changes to the process after the previous three similar findings by the SAO. As stated in previous CAPs on similar findings, the DHSS is in compliance with USDA guidelines and requirements for CACFP and implementing the SAO’s recommendations would cause undue burden on the participants and providers of this program which USDA warns against. In addition, the SAO applied the same testing methodology and error projection approach to determine materiality for this finding as it did for finding 2025-010. Accordingly, DHSS maintains the same position and arguments previously presented.

View Audit 411772

Finding 1236143 (2025-010)

Material Weakness 2025

State of Missouri

MO

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-010 - CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Administrator, Bureau o...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2025 State Agency: Department of Health and Senior Services Audit Finding Number: 2025-010 - CACFP Subrecipient Reimbursements Name of the contact person responsible for corrective action: Sarah Walker, Administrator, Bureau of Community Food and Nutrition Assistance (BCFNA), Division of Community and Public Health Anticipated completion date for corrective action: Not Applicable The Missouri Department of Health and Senior Services (DHSS) disagrees with this finding because the controls over meal reimbursements are in compliance with the federal U.S. Department of Agriculture (USDA) requirements and guidance. In addition, the nearly identical audit finding of fiscal year 2023 was not sustained by the federal funding agency. One hundred percent of the 43 overclaim exceptions noted by the SAO were either under the USDA’s acceptable minimum threshold of $600 or were recouped from subsequent claims in accordance with USDA and DHSS program requirements. The remaining 7 errors were underclaims. None of the error items noted by the SAO which exceeded the established USDA threshold resulted in questioned costs. The following SAO statement is factually incorrect: “Since meal reimbursements are made without any supporting documentation, the BCFNA relies on system edit checks and subrecipient monitoring procedures to prevent and detect meal reimbursement claim errors.” BCFNA is in compliance with USDA regulation as well as DHSS policies and procedures in regard to reviewing supporting documentation. In accordance with USDA regulations, sponsors are required to maintain documentation for three years in addition to the current year. However, this documentation is not required to be submitted to the state agency prior to every month’s claim reimbursement. The SAO said, “If similar errors were made on the remaining population of CACFP meal reimbursements totaling approximately $69.9 million, unallowable costs could be significant.” The SAO’s projection of a full year of ineligible sponsor claims is not supportable to determine this finding is material noncompliance. The sample of those sponsors is not representative of the population and cannot be assumed to be a claim error for the whole year, as it is based on a biased population of reviews performed by DHSS. DHSS’s risk-based monitoring approach of reviewing higher risk subrecipients more frequently would lead to higher claim amounts than a sample of the population as a whole. Each of the claims in question were recouped in subsequent months in accordance with USDA regulations and BCFNA policies and procedures, resulting in no loss of federal program funds or questioned costs. Further, all but one of the items with $2,000 or more in overclaims were due at least in part to temporary eligibility issues resulting from untimely submission of Income Eligibility Forms (IEFs). These were identified as a result of BCFNA’s well-designed monitoring processes and remedied in following months when parents or guardians provided the completed eligibility forms and should not be automatically assumed to account for a full year of overclaims.

View Audit 411772

Finding 1236134 (2025-003)

Material Weakness 2025

WILLAMETTE HEALTH COUNCIL

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility

Finding 2025-003 Finding Type: Significant Deficiency in Internal Control Over Compliance Compliance Requirement: Procurement and suspension and debarment Corrective Action Planned Willamette Health Council will implement and document policies and procedures to verify that subrecipients and vendors ...

Finding 2025-003 Finding Type: Significant Deficiency in Internal Control Over Compliance Compliance Requirement: Procurement and suspension and debarment Corrective Action Planned Willamette Health Council will implement and document policies and procedures to verify that subrecipients and vendors are not excluded or disqualified prior to issuing subawards or contracts (and periodically thereafter; if deemed appropriate) consistent with the Uniform Guidance and 2 CFR §180.300. Person(s) Responsible • Josie Silverman-Méndez, Executive Director • Julie Bennett, Finance Manager Anticipated Completion Date • October 31, 2026

View Audit 411763

Finding 1236132 (2025-001)

Material Weakness 2025

WILLAMETTE HEALTH COUNCIL

OR

Subrecipient Monitoring

Finding 2025-001 Finding Type: Material Weakness in Internal Control Over Compliance and Material Noncompliance Compliance Requirement: Subrecipient monitoring Corrective Action Planned Willamette Health Council will implement formal, written policies and procedures consistent with Uniform Guidance ...

Finding 2025-001 Finding Type: Material Weakness in Internal Control Over Compliance and Material Noncompliance Compliance Requirement: Subrecipient monitoring Corrective Action Planned Willamette Health Council will implement formal, written policies and procedures consistent with Uniform Guidance requirements, specifically those requirements detailed in 2 CFR §200.332 Requirements for passthrough entities. Additionally, management will also identify all subrecipients that received CSLFRF subawards and will: • Determine whether each subrecipient was required to have a single audit or program-specific audit for applicable prior period(s). • Obtain and review available audit reports or Federal Audit Clearinghouse submissions. • Document the review and any findings applicable to the CSLFRF subaward. • Issue management decisions and perform follow-up where required. • Evaluate whether any adjustments to Willamette Health Council’s books and records are necessary. Person(s) Responsible • Josie Silverman-Méndez, Executive Director • Julie Bennett, Finance Manager Anticipated Completion Date • December 31, 2026

View Audit 411763

Finding 1236122 (2025-002)

Material Weakness 2025

The Healthcare Connection INC

OH

Subrecipient Monitoring HUD Housing Programs

93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend management continue to strengthen review cont...

93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend management continue to strengthen review controls over the setup, maintenance, and application of sliding fee discount schedules, including periodic monitoring procedures to identify and promptly correct exceptions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has established a system of review and documentation of an internal audit that is conducted monthly to ensure slides are being applied properly. Name(s) of the contact person(s) responsible for corrective action: Jolene Joseph Planned completion date for corrective action plan: December 31, 2025

View Audit 411751

Finding 1236116 (2025-001)

Material Weakness 2025

Gibson County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2025-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Michael A. Watkins Contact Phone Number and Email Address: 812-385-4927 / mwatkins@gibsoncounty-in.gov Views of Responsible Offi...

FINDING 2025-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Michael A. Watkins Contact Phone Number and Email Address: 812-385-4927 / mwatkins@gibsoncounty-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County recognizes that a vendor's absence from the SAM.gov registry does not guarantee compliance and requires formal verification. To resolve this issue immediately, the County Auditor's office will perform a look-back review on SAM.gov for all vendors currently paid with SLFRF funds to ensure their eligibility during our contract periods. Going forward, for any expenditure involving federal grant funds, county staff will be required to obtain the vendor's Unique Entity Identifier (UEI) and print a copy of the SAM.gov exclusion search report. This verification step must be completed and documented before we execute any new contracts or approve claim payments. Additionally, the County Attorney will prepare a standard certification addendum. We will require our multi-year vendors to sign this form to certify their continuous eligibility through the end of the SLFRF grant performance period. Anticipated Completion Date: September 1, 2026

View Audit 411748

Finding 1236104 (2025-002)

Material Weakness 2025

MARCO RURAL WATER COMPANY, INC.

SC

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

The Company will continue to use supervisory reviews such as monitoring financial reports and budget reports and will use other secondary reviews where possible.

View Audit 411727

Finding 1236101 (2025-004)

Material Weakness 2025

Shelby County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

FINDING 2025-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number and Email Address: 317-392-6310; aglackman@co.shelby.in.us Views of Respons...

FINDING 2025-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number and Email Address: 317-392-6310; aglackman@co.shelby.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately, which will include implementing a federal procurement policy. The Auditor will start checking all vendors paid from grants for suspension, debarred or excluded from being able to enter into contracts. Anticipated Completion Date: December 31, 2026

View Audit 411726

Finding 1236067 (2025-002)

Material Weakness 2025

Fairbanks Rescue Mission, Inc.

AK

Subrecipient Monitoring § 200.332

Financial Statement Finding: 2025-002 Significant Deficiency in Internal Control over Subrecipient Monitoring Name and Contact Person: Pete Kelly, Chief Executive Officer Corrective Action: A process is being developed to ensure that the review performed is properly documented and retained for all s...

Financial Statement Finding: 2025-002 Significant Deficiency in Internal Control over Subrecipient Monitoring Name and Contact Person: Pete Kelly, Chief Executive Officer Corrective Action: A process is being developed to ensure that the review performed is properly documented and retained for all subawardee’s risk assessments through reviewing their status via sam.gov. Proposed Completion Date: March 2027

View Audit 411688

Finding 1236020 (2025-002)

Material Weakness 2025

Catholic Charities of Spokane

WA

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

Catholic Charities of Spokane will strengthen internal controls over compliance to ensure that all required eligibility, intake, exit, and program‑specific documentation is completed and reviewed prior to providing assistance and charging costs to federal awards. Corrective actions include the follo...

Catholic Charities of Spokane will strengthen internal controls over compliance to ensure that all required eligibility, intake, exit, and program‑specific documentation is completed and reviewed prior to providing assistance and charging costs to federal awards. Corrective actions include the following: • Management has reassigned responsibilities to ensure that case management and supervisory staff are clearly accountable for completing and reviewing required documentation before assistance is released. • The organization has implemented enhanced supervisory review procedures, including documented review of participant files to confirm required documentation is complete prior to billing HUD funding. • Standardized documentation checklists have been implemented for Continuum of Care participant files to promote consistency and completeness of required records. • Targeted training has been provided to staff involved in program administration to reinforce HUD Continuum of Care documentation and eligibility requirements. • Management will perform periodic monitoring of participant files to verify ongoing compliance and to identify and remediate documentation issues on a timely basis.

View Audit 411621

Finding 1236008 (2025-003)

Material Weakness 2025

Brighter Bites

TX

Subrecipient Monitoring

Action Taken: Management concurs with the finding. Management's determination that the entity was a contractor was correct, and the procedures applied to the agreement were appropriate for a contractor arrangement. The deficiency was in the executed document, which used subaward language inconsisten...

Action Taken: Management concurs with the finding. Management's determination that the entity was a contractor was correct, and the procedures applied to the agreement were appropriate for a contractor arrangement. The deficiency was in the executed document, which used subaward language inconsistent with the substance of the relationship. Brighter Bites will adopt a contractor versus subrecipient determination form, complete and retain for every federally funded agreement prior to execution. Subaward and contractor agreement templates have been separated so that subaward language is used only where the determination concludes the entity is a subrecipient. No federally funded agreement is executed until the determination form and matching template are approved by the VP of Finance. Management reviewed all open agreements during the audit period to confirm proper classification and that subrecipient monitoring was performed where required. No additional misclassifications were identified. Anticipated Completion Date: 06/30/2026

View Audit 411614

Finding 1235987 (2025-005)

Material Weakness 2025

Cooperative Development Institute Inc.

MA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.327 § 200.329

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2025-005 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants – Assistance Listing No. 14.251 Recommendation: We recommend the Organization implement a formal reporting calendar and review control process to track due dates,...

DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2025-005 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants – Assistance Listing No. 14.251 Recommendation: We recommend the Organization implement a formal reporting calendar and review control process to track due dates, ensure timely submission, and retain documentation of report filings in accordance with federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented a formal reporting calendar and enhanced its review procedures to track filing deadlines, support timely submission of required reports, and retain documentation of filings in accordance with federal requirements. Name(s) of the contact person(s) responsible for corrective action: David Court, Resource Development Director Planned completion date for corrective action plan: June 30, 2026

View Audit 411579

Finding 1235957 (2025-001)

Material Weakness 2025

Liberty County Board of Education

GA

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

FA 2025-001 Improve Controls over Procurement and Suspension and Debarment Compliance Requirements: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Description: Procurement and Susp...

FA 2025-001 Improve Controls over Procurement and Suspension and Debarment Compliance Requirements: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Description: Procurement and Suspension and Debarment Material Weakness Material Noncompliance U.S. Department of Health and Human Services None 93.243 - Substance Abuse and Mental Health Services Projects of Regiona l and National Significance 5H79SM088573-02 (Year: 2025) $80,321 A review of expenditures cha rged to the Substance Abuse and Mental Health Services Projects of Regional and National Significance program revea led that the School District's internal control procedures were not operating appropri ately to ensure that the School District's procurement and suspension and debarment procedures were followed. Corrective Action Plans: Procedures have been reviewed with program and department leaders to ensure that all expenditures have proper approval before submitt ing for payment. Expenditures without proper approval will be returned to the responsible department. Board Policy DJED has been reviewed with all department heads to ensu re understanding of policy and requirements for obtaining multiple quotes for certain thresholds. Additional procedures will be added to how vendors are verified of being suspended or debarred. Currently the vendor is verified of not being suspended or debarred when they are added to the accounting system and then once annually if they have been paid $25,000 or more during a certain time frame. Additional procedures will be added to have the vendors verified at year end who have been paid $25,000 or more with federal fun ds. Estimated Completion Date: August 31, 2026 Contact Person: Stephanie Clark, Chief Financial Officer Telephone: 912-876-4854 Email: sclark@liberty.k12.ga.us

View Audit 411564

Finding 1235956 (2025-002)

Material Weakness 2025

Liberty County Board of Education

GA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.318 § 200.320 § 200.403

FA 2025-002 Improve Controls over Expenditures Compliance Requirements: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Description: Activities Allowed or Unallowed Allowable Cost...

FA 2025-002 Improve Controls over Expenditures Compliance Requirements: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Numbers and Titles: Federal Award Number: Questioned Costs: Description: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Significant Deficiency Nonmaterial Noncompliance U.S. Department of Agricu lture Georgia Department of Education 10.553 - School Breakfast Program; 10.555 - National School Lunch Program 255GA324N1199 (Year: 2025) $40,701 A review of expenditures charged to the Child Nutrition Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were appropriately reviewed, approved, and documented. Corrective Action Plans: Procedures have been reviewed with program and department leaders to ensure that all expenditures have proper approval before submitting for payment. Expenditures without proper approval will be returned to the responsible department. Board Policy DJED has been reviewed with all department heads to ensure understanding of policy and requirements for obtaining mult iple quotes for certain thresholds. Guidelines have been reviewed with the program manager and school nutrition bookkeeper to ensure all expenditures are recorded in the correct fiscal years. Estimated Completion Date: August 31, 2026 Contact Person: Stephanie Clark, Chief Financial Officer Telephone: 912-876-4854 Email: sclark@liberty.k12.ga.us

View Audit 411564

Finding 1235952 (2025-001)

Material Weakness 2025

Quinault Housing Authority

WA

Subrecipient Monitoring Eligibility Significant Deficiency

Management Response Quinault Housing Authority agrees with the finding and has taken steps to strengthen itsprocedures for monitoring and documenting required annual inspections of occupied housing units. The Authority will maintain a centralized inspection tracking system identifying each occupied ...

Management Response Quinault Housing Authority agrees with the finding and has taken steps to strengthen itsprocedures for monitoring and documenting required annual inspections of occupied housing units. The Authority will maintain a centralized inspection tracking system identifying each occupied unit, the date of the most recent inspection, and the date the next annual inspection is due. The tracking system will be reviewed periodically by designated personnel to identify inspections that are approaching their due dates and to ensure that all required annual inspections are scheduled and completed timely. Management will also implement a secondary review of the inspection tracking system to verify that completed inspections have been properly documented and that any outstanding or overdue inspections are promptly addressed. These procedures are intended to ensure continued compliance with the Authority's Admission and Occupancy Policy and to reduce the risk that required annual inspections are inadvertently missed. Anticipated Completion Date September 17, 2026 Responsible Party Mariah Ralston

View Audit 411563

Finding 1235927 (2025-008)

Material Weakness 2025

Municipality of Gurabo

PR

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.403

FEMA Public Assistance Advances and Completed Reimbursement Management position. Management accepts the need to address the reported documentation and control deficiency. The original $666,000 and subsequent advances have been fully reimbursed to the Municipality’s FEMA fund; completed reimbursement...

FEMA Public Assistance Advances and Completed Reimbursement Management position. Management accepts the need to address the reported documentation and control deficiency. The original $666,000 and subsequent advances have been fully reimbursed to the Municipality’s FEMA fund; completed reimbursement is distinct from resolution of the historical finding. Management response. The original $666,000 was reimbursed in full to the Municipality’s FEMA fund bank account before the issuance of the Single Audit Report for the fiscal year ended June 30, 2025. The Municipality provided the supporting evidence of these reimbursements to the independent auditors for their review and examination before issuance of their report. The reimbursement occurred after June 30, 2025 and is reported as subsequent corrective action. No principal remains outstanding on these municipal interfund advances. The reimbursement evidence is available, upon request, for review and examination by the cognizant agency for audit, if designated, or the applicable oversight agency for audit; FEMA; COR3; and any other pertinent regulatory or oversight entity and its authorized representatives. Héctor Rubén Caraballo Díaz, Director of Finance, will coordinate timely access to the supporting records and municipal personnel under 2 CFR 200.337. The Municipality will protect sensitive information in public filings while providing authorized reviewers the records needed for their examination. The supporting package includes the municipal advance chronology, COR3 reimbursement and credit documentation, and the May 11, 2026 bank confirmation for a cash transfer to the FEMA account. Management’s full-repayment representation reflects the combined settlement of the advances and related credits. Management confirms that no principal remains outstanding for the original $666,000. Management’s representation of full reimbursement is not a representation that FEMA or COR3 has issued a final allowability or closeout determination. The transfer confirmation records approval and transmission; the resolution file will also retain evidence of the receiving-account posting and the reconciliation supporting the application of credits. These records substantiate completed repayment and preserve the distinction between settlement of principal and compliance with the original award conditions. Finding 2025-008 retains $666,000 in questioned costs for insufficient documentation of the final use and disposition of the original advance. Management’s reimbursement disclosure supplements that finding and does not depend on a change to its wording. Reimbursement does not retrospectively authorize the original use of restricted cash or automatically eliminate the historical finding. The responsible agency or pass-through entity will determine the disposition of questioned costs and any required remedy under 2 CFR 200.521. Management requests full consideration of the reimbursement evidence and appropriate credit for amounts already restored. Restoration to the municipal FEMA fund is not, by itself, repayment to the grantor or formal agency resolution. Corrective Action 1. Completed: reimburse the original $666,000, and provide the supporting evidence to the independent auditors for review and examination before report issuance. Preserve the evidence, dated transmittal, recipients, and index of documents provided. Delivery for examination is not represented as auditor agreement with management’s conclusions. 2. Complete the reviewed reconciliation of advances, COR3 credits, and the May reimbursement to bank and interfund records, and retain the separate tracing of the original use. Document credit eligibility, the source of legally available repayment funds, any excess, and the fiscal year 2026 entries. This reconciliation documents completed interfund settlement and the amounts for which management requests credit in agency resolution. 3. Preserve the posting of the May transfer in the receiving FEMA bank account, the reciprocal municipal ledger entries, and the dated delivery of the evidence to the auditors. For each COR3 credit applied, document the project, underlying eligible expenditure, original municipal funding, entitlement to reimbursement, and absence of duplicate recovery. A COR3 receipt by itself does not demonstrate repayment of an interfund advance. 4. Prohibit advances of FEMA cash for unrelated municipal operations. Permit an interfund reimbursement only after review establishes the specific award, eligible cost previously paid, lawful purpose, available support, and absence of duplicate reimbursement. 5. Retain a transaction-level account of the original $666,000 advance and its ultimate use, distinct from the later restoration. Identify the affected disaster and award, disbursements, eligible-cost support, and any unsupported use. Present the original questioned amount, amounts restored, any amount the agency sustains, and additional remedies separately; repayment will not be netted against the historical finding to imply that no reportable condition occurred. 6. Maintain monthly FEMA bank, project, interfund, and reimbursement reconciliations, with separate preparer and reviewer approval. Resolve exceptions promptly and retain the evidence supporting each release of funds. 7. Provide the reconciled resolution file to COR3 and request written disposition of Finding 2025-008 and its $666,000 questioned cost. Evaluate and address substantiated interest, grant repayment, accounting adjustments, or other remedies required by applicable rules or a written agency determination, preserving available review or appeal rights. Obtain instructions identifying the required recipient, award, amount, and credit for the completed restoration; do not assume that an interfund reimbursement extinguishes a separate grant repayment obligation. 8. Assess Federal cash balances, disbursement timing, and any applicable interest or excess-cash return requirement under the governing award and payment rules. Document the period and legal basis of any amount due rather than estimating interest without authority. The restoration will not be used to support duplicate Federal reimbursement or an unsupported new draw. 9. Keep the reimbursement evidence available for regulatory examination now. Submit the evidence already available to COR3 by September 30, 2026, identify supplemental reconciliation work due October 31, 2026, and complete the resolution submission by November 30, 2026 or any earlier agency deadline. Preserve the distinction between documents already delivered to the auditors and later supplements; do not describe subsequent workpapers as having been provided before report issuance. Implementation Milestones Required Action Owner Completion Evidence Target Date Reimburse original and subsequent advances to the FEMA fund. Finance Director Advance chronology, COR3 credits, May 11 transfer evidence Completed May 11, 2026 Provide reimbursement evidence to the independent auditors. Finance Director Evidence for review and examination; dated preissuance transmittal; regulatory access Completed before report issuance Approve transfer controls and reconcile the completed settlement. Finance Director Approved procedure, signed reconciliation, ledger support Sep. 30, 2026 controls; Oct. 31, 2026 reconciliation and tracing Provide available reimbursement evidence to COR3; complete resolution file and request written disposition. Finance and FEMA Program Staff / Resolution file, transmittal, agency correspondence Sep. 30, 2026 initial evidence; Nov. 30, 2026 complete file; decision external Demonstrate monthly preventive controls. Finance and FEMA Program Staff / Three consecutive reviewed monthly reconciliations Dec. 31, 2026 Responsible official. Héctor Rubén Caraballo Díaz, Director of Finance Anticipated completion. Principal reimbursement completed May 11, 2026; evidence delivered to the auditors before issuance. Documented preventive controls and three monthly reviews by December 31, 2026. Formal resolution of any retained questioned costs remains subject to COR3 or FEMA under 2 CFR 200.521. Evidence of completion. Retain evidence of full settlement of the original $666,000 and subsequent advances, the application of credits, reconciliation to the FEMA fund and municipal ledgers, and preissuance delivery to the auditors. Demonstrate preventive controls for three monthly cycles. Track any retained questioned cost and additional remedy until the responsible agency documents its disposition, with appropriate recognition of restored amounts. Auditor revision of the finding is not a closure condition.

View Audit 411534

Finding 1235902 (2025-002)

Material Weakness 2025

Washington Tourism Alliance

WA

Subrecipient Monitoring Reporting Significant Deficiency

FINDING 2025-002 – Reporting; Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance. Responsible Person: Mike Moe, Director of Strategic Partnership and Tourism Development Corrective Action: SWT has established a procedure requiring documented evidence of the orig...

FINDING 2025-002 – Reporting; Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance. Responsible Person: Mike Moe, Director of Strategic Partnership and Tourism Development Corrective Action: SWT has established a procedure requiring documented evidence of the original submission date to be retained for all future grant reports subject to reporting deadlines, including evidence generated by the applicable grant-management system. Anticipated Completion Date: January 1, 2026 (implemented) Federal regulations and grant and contract conditions require that applicable reports be filed timely. State of Washington Tourism did not submit three quarterly performance reports in accordance with award agreement timeframe. Upon timely initial filing of the quarterly reports, we were asked to make belated adjustments to expense reimbursements. The A19 invoice reports the submission date as the date of final acceptance. We were previously able to screenshot the initial submission dates in the Commerce Contract Management System, but have since lost access to the system as the grant program ended 12/31/2025. The Washington Department of Commerce did not deem our submissions as late, but were unable to provide a blanket statement of timeliness, or provide proof of the initial submission date. The Destination Planning Grant Program has ended, so we will not be required to submit quarterly reports going forward. If future grant programs require timely report submissions, the Director of Strategic Partnership and Tourism Development will save documented support of the initial submission date. Mike Moe Director of Strategic Partnership and Tourism Development mike@stateofwatourism.com

View Audit 411515

Finding 1235901 (2025-014)

Material Weakness 2025

Caddo County

OK

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

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 411508

Finding 1235900 (2025-013)

Material Weakness 2025

Caddo County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compli...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 411508

Corrective Action Plans

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