Corrective Action Plans

Finding 1182500 (2025-008)

Material Weakness 2025

State of Kansas

KS

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment (KDHE) Federal Program Name: Medicaid Cluster Assistance Listing Numbers: 93.775, 93.777, 93.778 Award Period: July 1, 2024 through June 30, 2025 Award Number: Various Co...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment (KDHE) Federal Program Name: Medicaid Cluster Assistance Listing Numbers: 93.775, 93.777, 93.778 Award Period: July 1, 2024 through June 30, 2025 Award Number: Various Compliance Requirement: Special Tests and Provisions – Provider Health and Safety Standards Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: Kansas Department of Health and Environment (Department) was unable to provide supporting documentation that it had performed recertification surveys within the required timeframe which is used to meet the provider health and safety standards. Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. We recommend the Department ensure appropriate measures are in place to verify providers are meeting the prescribed health and safety and maintain all records of these verifications. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: In response to the findings, the SSA will initiate a comprehensive review of all surveys remaining open status within ACO to determine the scope and underlying causes of incomplete administrative closure. A structured tracking tool will be developed to reconcile each survey and verify that required documentation, compliance dates, and certification actions were properly entered. The SSA will engage CMS Regional Office for guidance and coordination on appropriate closure actions and implement enhanced quality assurance controls, including routine reconciliation and verification prior to finalizing surveys. This will hopefully prevent recurrence. The SSA is also in the process of upgrading its information technology software systems to accommodate these processes. The SSA will generate a report of all surveys remaining in open status in ACO and prioritize reviews of initial certification or recertifications surveys and enforcement-related cases. Each survey will be reconciled to confirm required actions. Each survey will be reconciled to confirm required actions were completed, including issuing of the CMS 2567, if applicable, acceptance of the plans of corrections, entry of revisit and compliance dates, and completion of certification actions. To help prevent recurrence, the SSA will implement routine ACO reconciliation and establish a Quality Assurance (QA) verification step prior to finalizing surveys. Name(s) of the contact person(s) responsible for corrective action: Jerry Smith, LSCSW, Bureau Director Marilyn St Peter, RN, Deputy Director Bureau of Facilities and Licensing Catherine Lenz BS RN, Deputy Bureau Director Planned completion date for corrective action plan: October 1, 2026

View Audit 393917

Finding 1182497 (2025-007)

Material Weakness 2025

State of Kansas

KS

Procurement, Suspension & Debarment § 200.214 § 200.303

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

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Award Number and Period: NU50CK000549 (7/1/2019 – 7/31/2027) & NU51CK000384 (8/1/2024 – 7/31/2029) Compliance Requirement: Suspension and Debarment Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: Kansas Department of Health and Environment (Department) was unable to provide supporting documentation that it had performed suspension and debarment verification procedures before the start of procurement contracts. Recommendation: We recommend that the Department enhances its procedures and internal controls to ensure that it verifies and maintains documentation of its contractors’ suspension and debarment status prior to the execution of all contracts. Verification can be performed by either checking SAM exclusions and maintaining documentation when the verification occurred, collecting a signed certification from the contractor prior to contract execution, or adding a clause or condition to the contract. We further recommend that documentation is readily available for audit. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The sub-recipient agreement will be updated to provide space for the date the verification occurred by checking SAM exclusions. Additionally, a copy of the SAMS verification will be downloaded and kept with the executed sub-recipient agreement. If SAMS verification can’t be located, then that will be denoted on the sub-recipient agreement and a signed certification from the contractor will be collected prior to contract execution. This signed certification will be kept with the sub-recipient agreement once the agreement is executed. Name(s) of the contact person(s) responsible for corrective action: Sheri Tubach, Deputy State Epidemiologist Planned completion date for corrective action plan: March 9, 2026

View Audit 393917

Finding 1182495 (2025-006)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring § 200.303 § 200.332 § 200.501

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

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

View Audit 393917

Finding 1182493 (2025-005)

Material Weakness 2025

State of Kansas

KS

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

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

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

View Audit 393917

Finding 1182491 (2025-004)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring § 200.303 § 200.332

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

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

View Audit 393917

Finding 1182489 (2025-003)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring Reporting § 200.1 § 200.303

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

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

View Audit 393917

Finding 1182483 (2025-005)

Material Weakness 2025

Eastern Oregon University

OR

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Recommendation: We recommend the University implement procedures to ensure evidence of the key control review over payments to program participants is documented and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to...

Recommendation: We recommend the University implement procedures to ensure evidence of the key control review over payments to program participants is documented and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Eastern Oregon University implemented a standardized internal review and documentation process for new scholarship and other program participant payment requests. The process now requires documentation showing that award criteria were reviewed and met, a secondary review was completed, the payment or disbursement amount was verified for accuracy before release, and post-disbursement reconciliation was performed. To support this process, the University created a form to document each step of the review and retain evidence of completion. The responsible department has also been instructed on the documentation expectations and records retention requirements so that evidence of these control activities is maintained and available for future audit review. This corrective action has been implemented for all new requests going forward. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Financial Aid Director Planned completion date for corrective action plan: Completed.

View Audit 393884

Finding 1182476 (2025-003)

Material Weakness 2025

Eastern Oregon University

OR

Allowable Costs / Cost Principles Eligibility Significant Deficiency § 200.303

Recommendation: We recommend the University enhance its procedures for reviewing professional judgement decisions to ensure that evidence of review is documented and retained Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to ...

Recommendation: We recommend the University enhance its procedures for reviewing professional judgement decisions to ensure that evidence of review is documented and retained Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will review its procedures and document retention practices to ensure that key controls related to professional judgment determinations are documented and evidenced for audit purposes. The University will evaluate existing processes and supporting records and will implement any needed improvements to strengthen documentation and audit support. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Director of Financial Aid Planned completion date for corrective action plan: Completed

View Audit 393884

Finding 1182471 (2025-002)

Material Weakness 2025

Eastern Oregon University

OR

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

Recommendation: We recommend the University retain evidence that key controls over COD reporting were performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office completes COD reporting on a...

Recommendation: We recommend the University retain evidence that key controls over COD reporting were performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office completes COD reporting on a weekly basis and will maintain a documentation set for each reporting cycle in a central location using consistent naming conventions. The documentation set will include COD submission batch acceptance files and receipt acknowledgements, edit and error reports with resolution notes and dates, internal system disbursement rosters showing dates and amounts, and adjustment logs. These records will be used to support monthly federal aid reconciliations with the Business Affairs Office. Designated staff responsible for COD submission tracking will also maintain the related reconciliation support documentation. The Financial Aid Policy and Procedure Manual will be updated accordingly, and staff will be trained annually and during onboarding. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Director of Financial Aid Planned completion date for corrective action plan: March 31, 2026

View Audit 393884

Finding 1182469 (2025-001)

Material Weakness 2025

Eastern Oregon University

OR

Student Financial Aid Matching / Level of Effort / Earmarking Reporting § 200.303

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend that the University implement a key control to ensure that enrollment data, changes in status, and effective dates within NSLDS match the records of the institution and a...

Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.007, 84.033, 84.379 Recommendation: We recommend that the University implement a key control to ensure that enrollment data, changes in status, and effective dates within NSLDS match the records of the institution and are reported timely, and to store evidence of the key control having occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University reports enrollment more frequently than the required 60 days to capture status changes in a timely manner. Reporting occurs each term at the end of the second week, the Tuesday after Census, Monday of week 7, and the end of the term. The Registrar and Financial Aid Office created a process to communicate accurate last dates of academic engagement (LDAs) for unofficial withdrawals so that withdrawal dates match LDAs used in Return of Title IV (R2T4) calculations and unofficial withdrawals are reported to NSLDS through the regular NSC process. The Offices have also instituted a shared tracking and review process to regularly spot-check enrollment reports to ensure that data reported in Banner matches NSC reports and is correctly uploaded to NSLDS. Documentation of unofficial withdrawals, LDAs, error reports, and tracking of sampling outcomes with any needed corrections are maintained in the school’s files and shared between offices. The Registrar’s Office will review Banner and NSC submissions to ensure accurate and matching LDAs and status dates; the Financial Aid Office is responsible for confirming NSC submittals have successfully uploaded to NSLDS and reflect correct data that matches R2T4 and unofficial withdrawal info. Manual reporting to NSLDS will only be used for emergency updates to meet timeliness requirements, with multiple follow-up verification for NSC or roster file overwrites. Policy and Procedures Manuals will be updated accordingly, and staff in both offices will be trained annually and with onboarding. Name(s) of the contact person(s) responsible for corrective action: Emily Sharratt, Registrar; Jason Hibbert, Director of Financial Aid Planned completion date for corrective action plan: March 31, 2026

View Audit 393884

Finding 1182457 (2025-002)

Material Weakness 2025

Eastern Carver County Schools Independent School District No. 112

MN

Procurement, Suspension & Debarment § 200.303

Material Weakness in Internal Control Over Compliance and Other Matters Recommendation: We recommend that the District follow its procurement policies as well as requirements within the Uniform Guidance to perform the proper verification procedures on all covered transactions entered into with feder...

Material Weakness in Internal Control Over Compliance and Other Matters Recommendation: We recommend that the District follow its procurement policies as well as requirements within the Uniform Guidance to perform the proper verification procedures on all covered transactions entered into with federal funds. Also, the District should ensure there is a formally documented control to ensure all vendors are checked for suspension and debarment prior to entering into a covered transaction. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procedures and policies over procurement and suspension and debarment to ensure that the District performs the proper suspension and debarment procedures prior to entering into a covered transaction, either through a sam.gov check or by including self-certification language in the contract and retain documentation of this process. Name(s) of the contact person(s) responsible for corrective action: David Brecht, Executive Director of Finance and Operations. Planned completion date for corrective action plan: June 30, 2026

View Audit 393848

Finding 1182455 (2025-001)

Material Weakness 2025

Eastern Carver County Schools Independent School District No. 112

MN

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.303

Material Weakness in Internal Control Over Compliance Recommendation: We recommend that the District review its procurement policies and controls to ensure there is a formally documented control to ensure all vendors are checked for suspension and debarment prior to entering into a covered transacti...

Material Weakness in Internal Control Over Compliance Recommendation: We recommend that the District review its procurement policies and controls to ensure there is a formally documented control to ensure all vendors are checked for suspension and debarment prior to entering into a covered transaction. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procedures and policies over procurement and suspension and debarment to ensure that the District performs the proper suspension and debarment procedures prior to entering into a covered transaction, either through a sam.gov check or by including self-certification language in the contract and retain documentation of this process. Name(s) of the contact person(s) responsible for corrective action: David Brecht, Executive Director of Finance and Operations. Planned completion date for corrective action plan: June 30, 2026

View Audit 393848

Finding 1182448 (2025-008)

Material Weakness 2025

Plymouth Community School Corporation

IN

Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

FINDING 2025-008 Finding Subject: COVID-19, Education Stabilization Fund - Special Test and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Amanda Bender Contact Phone Number and Email Address:...

FINDING 2025-008 Finding Subject: COVID-19, Education Stabilization Fund - Special Test and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Amanda Bender Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Business Manager/Treasurer will require wage rate information for construction contracts in excess of $2,000 that if financed by federal assistance funds. The Business Manager will ensure the wages paid on those contracts are not less than those established for the locality of the project by the Department of Labor. The Payroll Specialist/Deputy Treasurer will be the second approver of such confirmation of labor rates in these situations and circumstances. The corporation will require all vendors that are contracted through the use of federal assistance funds to provide their certified payrolls throughout the project process. These payrolls will be verified to be in compliance by the Treasurer and Deputy Treasurer and kept on file with fund paperwork. Anticipated Completion Date: March 1, 2026 and ongoing

View Audit 393841

Finding 1182445 (2025-007)

Material Weakness 2025

Plymouth Community School Corporation

IN

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

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

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

View Audit 393841

Finding 1182443 (2025-006)

Material Weakness 2025

Plymouth Community School Corporation

IN

Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.328 § 200.329 § 200.400

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Jill VanDriessche Contact Phone Num...

FINDING 2025-006 Finding Subject: Title I Grants to Local Educational Agencies - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Jill VanDriessche Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. We believe this finding to be the result of an isolated incident that was reported to SBOA and Title. Description of Corrective Action Plan: The Business Manager/Treasurer provides to the corporation grant administrator monthly grant reports, as well as a grant tracking spreadsheet. The appropriations for each grant are entered into Komputrol, according to the budget located in the approved grant documents. The appropriations are presented to the Grant Administrator for approval. All spending from each grant is approved by the corporation grant administrator. Any wages paid via the corporation payroll that is charged to grant funds is approved by the business manager/treasurer and the corporation grant administrator. The Payroll Specialist/Deputy Treasurer completes the payroll and sends the distribution account records to the Business Manager/Treasurer and Grant Administrator. Any payroll claims for payment via grant funds is required to have three signatures for approval. We believe the system of internal control in place has been strong and in compliance since March 2025. Anticipated Completion Date: March 1, 2025 and ongoing

View Audit 393841

Finding 1182441 (2025-005)

Material Weakness 2025

Plymouth Community School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Special Tests & Provisions § 200.302 § 200.303

FINDING 2025-005 Finding Subject: Child Nutrition Cluster, Special Tests and Provisions, School Food Accounts Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke, Brittany Sabinas, Amanda Bender Contact Phone Number and Email Address: ...

FINDING 2025-005 Finding Subject: Child Nutrition Cluster, Special Tests and Provisions, School Food Accounts Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke, Brittany Sabinas, Amanda Bender Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Since January 2025, the internal controls that resulted in this finding have been corrected. The finding stated that “The lack of internal controls and noncompliance over Special Tests and Principles, School Food Accounts is an isolated incident.” The Business Manager/Treasurer receives deposit emails from the Indiana State Comptroller. The Business Manager codes the deposit for the Accounts Payable Specialist to receipt. The Business Manager completes a monthly bank reconciliation that is reviewed by the Deputy Treasurer and Accounts Payable Specialist as part of the month end process. Anticipated Completion Date: January, 2025 and ongoing

View Audit 393841

Finding 1182433 (2025-004)

Material Weakness 2025

Plymouth Community School Corporation

IN

Allowable Costs / Cost Principles School Nutrition Programs Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.400

FINDING 2025-004 Finding Subject: Child Nutrition Cluster, Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Amy Kraszyk Contact Phone Number and Email Address: 574-9...

FINDING 2025-004 Finding Subject: Child Nutrition Cluster, Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Jennifer Felke & Amy Kraszyk Contact Phone Number and Email Address: 574-936-3115, jfelke@plymouth.k12.in.us, Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Since January 2025, the internal controls that resulted in this finding have been corrected. The finding stated that “The lack of internal controls and noncompliance over Allowable Activities and Allowable Costs/Cost Principles is an isolated incident.” The Food Service Director and the Business Manager/Treasurer meet monthly to review the school lunch accounts and to concur with the month end balances. The Deputy Treasurer approves all monthly fund transfers completed by the Business Manager. Anticipated Completion Date: January 1, 2025 and ongoing

View Audit 393841

Finding 1182425 (2025-003)

Material Weakness 2025

Plymouth Community School Corporation

IN

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

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

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

View Audit 393841

Finding 1182403 (2025-005)

Material Weakness 2025

The Inner Voice, Inc.

IL

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

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

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

View Audit 393811

Finding 1182392 (2025-004)

Material Weakness 2025

The Inner Voice, Inc.

IL

Allowable Costs / Cost Principles § 200.303 § 200.426 § 200.430

FINDING 2025-004 – Payroll Allocations Audit Finding Description: Audit procedures over expenditures revealed the following: For one (1) of forty (40) expenditure transactions tested, The Inner Voice, Inc. did not adequately track or review time and effort documentation for accuracy. For this select...

FINDING 2025-004 – Payroll Allocations Audit Finding Description: Audit procedures over expenditures revealed the following: For one (1) of forty (40) expenditure transactions tested, The Inner Voice, Inc. did not adequately track or review time and effort documentation for accuracy. For this selection, the time study used to allocate salary did not agree with the actual hours reported and paid. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Corrective Action Plan: Management will enhance policies and procedures related to time and effort reporting by strengthening review and approval processes for payroll allocations and providing additional staff training. These actions will improve consistency and reinforce internal controls over federal awards. Name of Contact Person Responsible for Corrective Action: Khurram Navaid, CFO/ Monika Mader, Exec. Manager Planned Completion Date: January 01, 2026

View Audit 393811

Finding 1182363 (2025-001)

Material Weakness 2025

Wesleyan University

CT

Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

Upon identification of the configuration error, the University corrected its National Student Clearinghouse (NSC) file submission settings to ensure enrollment status changes are properly processed and transmitted to NSLDS. The University has implemented a new monitoring control whereby an employee ...

Upon identification of the configuration error, the University corrected its National Student Clearinghouse (NSC) file submission settings to ensure enrollment status changes are properly processed and transmitted to NSLDS. The University has implemented a new monitoring control whereby an employee independent of the enrollment reporting function performs a review of NSLDS to verify that data submitted through NSC has been accurately and timely transmitted in accordance with required timeframes. This control is designed to provide timely detection of any future transmission failures and ensure corrective action is taken within the required reporting windows.

View Audit 393798

Finding 1182326 (2025-003)

Material Weakness 2025

Madison-Grant United School Corporation

IN

Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

FINDING 2025-003 Finding Subject: Education Stabilization Fund – Wage Rate Requirements Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 and bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding. Descripti...

FINDING 2025-003 Finding Subject: Education Stabilization Fund – Wage Rate Requirements Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 and bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will ensure that construction contracts in excess of $2,000 financed by federal assistance funds include a provision that the contractor or subcontractor comply with Wage Rate Requirements. Anticipated Completion Date: January 1, 2026

View Audit 393770

Finding 1182323 (2025-002)

Material Weakness 2025

Madison-Grant United School Corporation

IN

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

FINDING 2025-002 Finding Subject: Child Nutrition Cluster – Procurement, Suspension, and Debarment Contact Person Responsible for Corrective Action: Kathy Bernaix, Food Service Director and Bengamin Mann, CFO Contact Phone Number and Email Address: 765-536-0008 and kbernaix@mgusc.k12.in.us and bmann...

FINDING 2025-002 Finding Subject: Child Nutrition Cluster – Procurement, Suspension, and Debarment Contact Person Responsible for Corrective Action: Kathy Bernaix, Food Service Director and Bengamin Mann, CFO Contact Phone Number and Email Address: 765-536-0008 and kbernaix@mgusc.k12.in.us and bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will have two sign offs on our print out from sam.gov evidencing multiple reviewers of the ELPS. Anticipated Completion Date: January 1, 2026

View Audit 393770

Finding 1182305 (2025-001)

Material Weakness 2025

Sunman-Dearborn Community School Corporation

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Mary Ann Baines Contact Phone Number and Email Address: 812-623-2291; mbaines@sunmandearborn.k12.in.us Views of Responsible Officials: We co...

FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Mary Ann Baines Contact Phone Number and Email Address: 812-623-2291; mbaines@sunmandearborn.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The purchase that was we did not verify that they were not suspended, debarred or otherwise excluded was an equipment purchase that was made directly by Sunman-Dearborn Community School Corporation. Typically those types of purchases go through our procurement center (The Wilson Center) and they check the suspension and debarrement as part of the bid. I have met with the Director of Support Services and Director of Student Services, that if a purchase is equal to or exceeds $25,000, we must go to the SAM.gov website to make sure the company we want to use is not listed under the Suspension and Debarred companies. Anticipated Completion Date: This corrective action plan is completed. I met with the Director of Student Services and Support Services, today, January 12, 2026.

View Audit 393736

Finding 1182300 (2025-001)

Material Weakness 2025

Catholic Reflief Services - US Conference of Catholic Bishops

MD

Subrecipient Monitoring § 200.303

Suggested Action(s) 1.1. Ensure that all FFATA reports are filed in a timely manner by strengthening the existing internal controls and conducting refresher training to CRS country office personnel emphasizing timely submission of FFATA reports. Responsible Official 1.1 Heads of Programming and Oper...

Suggested Action(s) 1.1. Ensure that all FFATA reports are filed in a timely manner by strengthening the existing internal controls and conducting refresher training to CRS country office personnel emphasizing timely submission of FFATA reports. Responsible Official 1.1 Heads of Programming and Operations, and Finance Managers 1.2 Global Finance and GAPS teams Action Taken 1.1 Refresher training on timing requirement of FFATA reporting for subawards ≥$30,000. 1.2 Review existing internal control procedures surrounding FFATA submissions. Status and Completion Date In progress to be completed June 30, 2026.

View Audit 393727

Corrective Action Plans

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