Corrective Action Plans

Finding 1182565 (2025-003)

Material Weakness 2025

MUNICIPALITY OF BELMONT, WEST VIRGINIA

WV

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.317 § 200.318 § 200.327

City Clerk will be putting the Grant award Policies and Procedures in place

View Audit 394015

Finding 1182562 (2025-001)

Material Weakness 2025

Illinois Central College District 514

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The College acknowledges that a submission error occurred in Spring 2023, resulting in several students not being included in the routine semester enrollment submissions to the National Student Clearinghouse (NSC). Beginning in Spring 2024, our Institutional Research department initiated a comprehen...

The College acknowledges that a submission error occurred in Spring 2023, resulting in several students not being included in the routine semester enrollment submissions to the National Student Clearinghouse (NSC). Beginning in Spring 2024, our Institutional Research department initiated a comprehensive process to resubmit corrected enrollment files to the NSC, covering Spring 2023, Summer 2023, and Fall 2023. In collaboration with NSC, we followed their established process to rectify the error, which required reloading each submission one at a time in succession from the original submission with the error. This process caused delays in our subsequent submissions until the corrections were fully completed. To prevent recurrence, we have implemented enhanced checks and controls prior to each submission to review the file and file size to ensure the correct number of students are submitted to NSC. Additionally, all submissions post-Spring 2023 have been reviewed, and we have confirmed that this was an isolated incident. Due to the timing of when the College was notified by NSC, this item carried forward into audit year 2025.

View Audit 394014

Finding 1182560 (2025-004)

Material Weakness 2025

City of Southfield, Michigan

MI

HUD Housing Programs § 200.303

Condition: The City had insufficient controls in place related to reviews of Section 8 employee timesheets. Planned Corrective Action: The City acknowledges this finding and has updated our procedures to include the City Administrators’ review and approval, as evidenced by his signature, on all Sect...

Condition: The City had insufficient controls in place related to reviews of Section 8 employee timesheets. Planned Corrective Action: The City acknowledges this finding and has updated our procedures to include the City Administrators’ review and approval, as evidenced by his signature, on all Section 8 employee timesheets. The City believes this finding will be corrected by June 30, 2026. Contact person responsible for corrective action: Austen Michaels Anticipated Completion Date: June 30, 2026

View Audit 394002

Finding 1182559 (2025-004)

Material Weakness 2025

Northwestern School Corporation

IN

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

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

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

View Audit 394000

Finding 1182555 (2025-003)

Material Weakness 2025

Northwestern School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2025-003 Finding Subject: Child Nutrition Cluster- Internal Controls Contact Person Responsible for Corrective Action: Camden Parkhurst Contact Phone Number and Email Address: 765.457.8101, camden.parkhurst@nwsc.k12.in.us Views of Responsible Officials: We concur with the finding. Descriptio...

FINDING 2025-003 Finding Subject: Child Nutrition Cluster- Internal Controls Contact Person Responsible for Corrective Action: Camden Parkhurst Contact Phone Number and Email Address: 765.457.8101, camden.parkhurst@nwsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Activities Allowed or Unallowed, Allowable Cost/Cost Principals E-Funds has been automatically debited from our account since its inception. The auto debt was falling at a time each month that caused us to miss adding to our Allowance of Claims. We will correct the time that this is added to our statements so that it will make the Allowance of Claims for each month. Eligibility This was a one time issue when we were switching our software to Meal Magic. This was only related to one direct certification cluster to start the 23-24 school year. We have multiple people from our food service department prepare and sign off on direct certifications on a monthly basis to ensure we are accurate and complaint. Anticipated Completion Date: Immediate. INDIANA STATE

View Audit 394000

Finding 1182545 (2025-003)

Material Weakness 2025

Career Academy of South Bend, INC

IN

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

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

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

View Audit 393976

Finding 1182519 (2025-001)

Material Weakness 2025

Kewanee Community Unit School District No. 229

IL

Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.303

Condition - The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan - A second person person (business manager) compares the meal counts in the claim to: the Skywa...

Condition - The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan - A second person person (business manager) compares the meal counts in the claim to: the Skyward daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimursement rates. The reviewer will then sign and date a reconciliation sheet before submission. Anticipated Date of Completion: December 7, 2025; Name of Contact Person - Dan Nolan, Business Manager; Management Response - The corrective action plan was discussed with the employee responsible for filing the claim, the business manager, and the superintendent. After discussion, the plan was approved by the superintendent.

View Audit 393927

Finding 1182512 (2025-016)

Material Weakness 2025

State of Kansas

KS

Questioned Costs Student Financial Aid Eligibility § 200.303

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department for Children and Families (KDCF) Federal Program Name: Adoption Assistance Title IV-E Assistance Listing Number: 93.659 Award Number: 2402KSADPT, 2502KSADPT Award Period: July 1, 2024 through June...

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department for Children and Families (KDCF) Federal Program Name: Adoption Assistance Title IV-E Assistance Listing Number: 93.659 Award Number: 2402KSADPT, 2502KSADPT Award Period: July 1, 2024 through June 30, 2025 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Condition: During testing of eligibility requirements, it was noted that three participants out of forty tested did not have supporting documentation in their case files for nonrecurring adoption expenses paid on their behalf. Recommendation: We recommend that KDCF strengthen internal controls to ensure that supporting documentation for nonrecurring adoption expenses is obtained, reviewed, and retained prior to payment to mitigate the risk of noncompliance in the future. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: KDCF policy requires that all case files contain documentation supporting state expenditures and all associated payments, in accordance with Policy #0430 Contents of Foster Care, Adoption and Independent Living Services Case Records. Additionally, staff must follow the procedures outlined in Policy #6924 Payment Procedures for Non-Recurring Expenses. Non-recurring expense payments are made according to the authorization provided on forms PPS 6140 or PPS 6130. A PPS 2833 Client Purchase Agreement must be completed by PPS staff, with a copy of the PPS 6130 or PPS 6140 attached to document the authorization for payment. An itemized bill should also be attached when available. While this policy is in place, this finding indicates the need to reinforce internal controls to ensure full compliance. To address the deficiency and prevent recurrence, KDCF will implement the following corrective actions: 1. Reinforcement of Documentation Requirements: Adoption program and I-VE program leadership will review the audit findings with regional adoption staff, I-VE payment specialists, Regional I-VE Administrators and Regional Foster Care Administrators. During this meeting Adoption program and I-VE program leadership will review the corrective action plan and emphasize the importance of the need for complete and accurate documentation in regard to adoption assistance. 2. Enhanced File Review Process Prior to Payment: KDCF will implement a detailed Adoption Assistance Packet Checklist. This is an internal double-check step requiring staff to verify that all required supporting documents for non-recurring adoption expenses are present before submitting or approving payment. This verification will be incorporated into the existing payment workflow to ensure consistency across regions. 3. Targeted Training and Guidance: Updated reminders and written guidance will be issued to all adoption staff outlining specific documentation requirements and the procedures for retaining them. Training will emphasize the allowable cost requirements under Title IV-E and the purpose of maintaining complete records for federal compliance and audit readiness. 4. Ongoing Monitoring: Program leadership will conduct periodic spot checks of adoption subsidy files to validate that required documents are consistently included and will address any identified gaps with staff promptly. These actions will strengthen internal controls and help ensure that documentation supporting nonrecurring adoption expenses is properly obtained and retained in all adoption case files moving forward. Name(s) of the contact person(s) responsible for corrective action: Adoption Program Manager and Kim Fay, I-VE Program Manager Planned completion date for corrective action plan: January 1, 2027

View Audit 393917

Finding 1182511 (2025-015)

Material Weakness 2025

State of Kansas

KS

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

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

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

View Audit 393917

Finding 1182509 (2025-014)

Material Weakness 2025

State of Kansas

KS

Internal Control / Segregation of Duties Questioned Costs Reporting § 200.303

Federal Agency: U.S. Department of Labor State Department/Agency: Kansas Department of Labor Federal Program Name: Unemployment Insurance (UI) Assistance Listing Number: 17.225 Award Number: Various Award Period: Various Compliance Requirement: Reporting Type of Finding: Significant Deficiency in In...

Federal Agency: U.S. Department of Labor State Department/Agency: Kansas Department of Labor Federal Program Name: Unemployment Insurance (UI) Assistance Listing Number: 17.225 Award Number: Various Award Period: Various Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Condition: During the audit period, the Department did not submit the ETA 9050, ETA 9052, and ETA 9055 reports accurately. Testing identified discrepancies between the data reported to the U.S. Department of Labor and the supporting underlying records, including variances within validation samples used to support reported figures. As a result, the reported information did not fully and accurately reflect program activity for the audit period. Recommendation: We recommend that the Department continue efforts to strengthen controls over the preparation and review of ETA reports, including completing data reconciliation procedures related to the new system implementation. This should include validating migrated data, resolving discrepancies identified within validation samples, and implementing review procedures to ensure reported information is accurate, complete, and supported prior to submission to the U.S. Department of Labor. Views of responsible officials: The Department does not disagree with the audit finding. Management acknowledges the reporting discrepancies identified and has been actively addressing these issues through quarterly SQSP corrective action reporting to USDOL. Action taken in response to finding: The Department has: • Prioritized system correction and data validation tickets. • Expanded use of the Data Validation program to identify root causes. Enhanced review procedures for ETA reports prior to submission. The Department acknowledges the finding and has already implemented corrective measures through its established oversight and reporting framework. The identified reporting discrepancies have been incorporated into the State Quality Service Plan (SQSP) Corrective Action Plans (CAPs) and are reported quarterly to the U.S. Department of Labor (USDOL). To address the root causes associated with the new system implementation and data migration, the Department is taking the following actions: • Leveraging the Data Validation (DV) program to identify and analyze underlying data integrity issues affecting ETA 9050, 9052, and 9055 reports. • Conducting ongoing validation of TUBA-generated reports to ensure accuracy, completeness, and consistency with source data. • Strengthening SQL programming logic and report queries to address discrepancies identified during validation testing. • Submitting and prioritizing system enhancement and defect-resolution tickets to address identified programming and data issues. These efforts are monitored through quarterly SQSP reporting to USDOL, and progress is reviewed regularly by program leadership to ensure timely resolution of identified issues. Name(s) of the contact person(s) responsible for corrective action: Nicole Struckhoff, Deputy UI Director of Tax and Administration Planned completion date for corrective action plan: December 31, 2026 While substantial remediation efforts are expected to be completed by the end of 2026, enhanced data reconciliation and quarterly validation procedures will remain ongoing to ensure continued accuracy, completeness, and reliability of ETA report submissions.

View Audit 393917

Finding 1182507 (2025-013)

Material Weakness 2025

State of Kansas

KS

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

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

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

View Audit 393917

Finding 1182505 (2025-012)

Material Weakness 2025

State of Kansas

KS

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

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

Federal Agency: U.S. Department of Labor State Department/Agency: Kansas Department of Labor Federal Program Name: Unemployment Insurance (UI) Assistance Listing Number: 17.225 Award Number: Various Award Period: July 1, 2024 to June 30, 2025 Compliance Requirement: Activities Allowed or Unallowed & Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: During test work of Activities Allowed or Unallowed & Allowable Costs/Cost Principles, one transaction was identified that lacked evidence that the transaction was reviewed. Recommendation: We recommend that the Department strengthen its review and monitoring procedures over federal expenditures to ensure that all transactions are appropriately reviewed for compliance with applicable federal program requirements. Management should implement controls to ensure transactions are adequately supported, reviewed in a timely manner, and documented, including supervisory review of expenditures charged to federal programs. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Management held a training session and reiterated the importance of proper approvals to pay invoices. Staff were reminded of the process of preparing invoices for payment. Additionally, the approval of vouchers procedures were updated to include checking to make sure proper approval was received for invoices prior to payment to provide a double check for the process. Name(s) of the contact person(s) responsible for corrective action: Dawn Palmberg, CFO Planned completion date for corrective action plan: Corrective action and retraining was implemented 12/16/2025.

View Audit 393917

Finding 1182503 (2025-011)

Material Weakness 2025

State of Kansas

KS

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.303

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

Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, and 2501KSTANF Period: October 1, 2023 – September 30, 2025 Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The entity did not have a documented control in place to evidence an independent review of the ACF‑199 TANF Data Report for accuracy and completeness prior to submission to the federal awarding agency. The report was generated from system data and submitted without documented supervisory review or approval before transmission. Recommendation: We recommend that management design and implement a documented review and approval control over the ACF‑199 TANF Data Report prior to submission to the federal awarding agency. The control should include evidence of review to verify the accuracy and completeness of the report, such as documented supervisory sign‑off, electronic approval, or retention of review documentation. Implementing a consistent pre‑submission review process will strengthen internal controls over federal reporting and provide reasonable assurance of compliance with reporting requirements. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: DCF will design and implement a documented review and approval control over the ACF-199 TANF Data Report prior to submission to the Administration for Children and Families (ACF). DCF will include in the documented process the manner in which DCF will verify the accuracy and completeness of the report prior to submission to ACF. DCF will also include in the documented process the manner in which DCF will ensure the process is followed consistently and thoroughly. Name(s) of the contact person(s) responsible for corrective action: Carla Whiteside-Hicks, Economic and Employment Services Director and Melissa Vo, Program Integrity Assistant Director Planned completion date for corrective action plan: June 30, 2026

View Audit 393917

Finding 1182502 (2025-010)

Material Weakness 2025

State of Kansas

KS

Subrecipient Monitoring Reporting § 200.1 § 200.303

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

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

View Audit 393917

Finding 1182501 (2025-009)

Material Weakness 2025

State of Kansas

KS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.332

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

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

View Audit 393917

Finding 1182500 (2025-008)

Material Weakness 2025

State of Kansas

KS

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 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

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking § 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

Questioned Costs Allowable Costs / Cost Principles Eligibility § 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

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