Corrective Action Plans

Finding 1186587 (2025-002)

Material Weakness 2025

MA

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

CORRECTIVE ACTION PLAN March 18, 2026 Housing for Rockdale Elders, Inc. respectfully submits the following corrective action plans for the year ended October 31, 2025: Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street Suite 1200 Braintree MA 02184 Audit period: Nove...

CORRECTIVE ACTION PLAN March 18, 2026 Housing for Rockdale Elders, Inc. respectfully submits the following corrective action plans for the year ended October 31, 2025: Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street Suite 1200 Braintree MA 02184 Audit period: November 1, 2024 - October 31, 2025 The findings from the October 31, 2025 schedule of findings and questioned costs is discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding 2025-002 - Special Tests and Provisions - Significant Deficiency Recommendation: We recommend that the Corporation establish internal controls over its residual receipts compliance requirements to ensure that the Corporation is in compliance with Uniform Guidance and its regulatory agreement. Action Taken: Management agrees with the finding and is in the process of revising internal controls to address this issue. Additionally, on February 9, 2026, this was corrected.

View Audit 394285

Finding 1186586 (2025-702)

Material Weakness 2025

State of Wisconsin

WI

Reporting Subrecipient Monitoring § 200.510

Finding 2025-702: Research and Development Cluster—Reporting in the Schedule of Expenditures of Federal Awards Planned Corrective Action: The Universities of Wisconsin (UW) will revise documented procedures for preparing the Schedule of Expenditures of Federal Awards (SEFA) to include updated steps ...

Finding 2025-702: Research and Development Cluster—Reporting in the Schedule of Expenditures of Federal Awards Planned Corrective Action: The Universities of Wisconsin (UW) will revise documented procedures for preparing the Schedule of Expenditures of Federal Awards (SEFA) to include updated steps for the compilation of federal grant activities using the new accounting system by June 30, 2026. Existing procedures will be strengthened and implemented to review whether federal expenditures related to agreements with other state agencies that specify the relevant assistance listing number are property classified in the SEFA. Additional training and guidance will be provided to UW university and administration stakeholders on revised documented procedures as a critical part of the improvement in the SEFA reporting process. Anticipated Completion Date: November 2026 Person responsible for corrective action: Josh Smith Senior Associate Vice President for Finance Universities of Wisconsin josh.smith@wisconsin.edu

View Audit 394279

Finding 1186585 (2025-701)

Material Weakness 2025

State of Wisconsin

WI

Equipment & Real Property Management § 200.313

Finding 2025-701: Research and Development Cluster—Physical Inventory Requirements for Federal Equipment Planned Corrective Action: The University agrees with the condition that we did not perform a physical inventory of all federal equipment during FY 2024-25, because we did not conduct physical in...

Finding 2025-701: Research and Development Cluster—Physical Inventory Requirements for Federal Equipment Planned Corrective Action: The University agrees with the condition that we did not perform a physical inventory of all federal equipment during FY 2024-25, because we did not conduct physical inventories at a sufficient number of departments to ensure departments last inventoried during FY 2022-23 were included. To ensure compliance with 2 CFR § 200.313, we will have 97% (3092) of all federal equipment last inventoried before June 2023 completed by June 30, 2026. For the remaining 3% (85), we will have them completed by the end of December 31, 2026, as we’ll need time to conduct a formal inventory of the remaining departments. We will update our procedures to require an annual selection of a sufficient number of departments to ensure that at least 50% of all federal equipment is inventoried each year. Lastly, we will implement and document a required review of the federal equipment listing annually to identify any items that have not been physically inventoried within the last two years and complete any required physical inventories by end of fiscal year. Anticipated Completion Date: December 31, 2026 Person responsible for corrective action: Cha Ying Lor, Finance Associate Director Division of Business Services Accounting Services – Financial Information Management chaying.lor@wisc.edu

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Finding 1182964 (2025-305)

Material Weakness 2025

State of Wisconsin

WI

Eligibility Significant Deficiency

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-305: Grants to States for Medicaid – Posting of Managed Care Entity Financial Audits. This is the department’s Corrective Action Plan.  Recommendation (2025-305): Grants to States for Medicaid – P...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-305: Grants to States for Medicaid – Posting of Managed Care Entity Financial Audits. This is the department’s Corrective Action Plan.  Recommendation (2025-305): Grants to States for Medicaid – Posting of Managed Care Entity Financial Audits We recommend the Wisconsin Department of Health Services develop and implement procedures to ensure the results of the periodic audits of managed care organizations are posted to the State’s website in a timely manner. Wisconsin Department of Health Services Planned Corrective Action: DHS will establish a tracking process to post the summary results of the managed care entity financial audits to the State’s website in a timely manner. Anticipated Completion Date: June 30, 2026 Persons responsible for corrective action Grant Cummings, Director Bureau of Rate Setting, Division of Medicaid Services grantr.cummings@dhs.wisconsin.gov

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Finding 1182963 (2025-304)

Material Weakness 2025

State of Wisconsin

WI

Eligibility Reporting Significant Deficiency § 200.302

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-304: Grants to States for Medicaid – Medical Status Code Errors. This is the department’s Corrective Action Plan.  Recommendation (2025-304): Grants to States for Medicaid – Medical Status Code Er...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-304: Grants to States for Medicaid – Medical Status Code Errors. This is the department’s Corrective Action Plan.  Recommendation (2025-304): Grants to States for Medicaid – Medical Status Code Errors. We recommend the Wisconsin Department of Health Services ensure the accuracy of the medical status code by: • Implementing and testing the needed updates to CARES to correct the errors in the assigned medical status code; • Completing an assessment of the effect of the identified errors in the medical status code on accounting entries, required federal reporting, and making any necessary corrections; and • Prepare and maintain documentation of its annual review and assessment. Wisconsin Department of Health Services Planned Corrective Action: The Division of Medicaid Services (DMS) identified issues with Medical Status codes prior to the beginning of the audit. DMS directed the Enrollment & Eligibility System vendor to identify and implement a system correction. Concurrently, the LAB identified the issue as part of their current year audit fieldwork. The correction was included in the February 2026 system update which is expected to address the concerns underlying this finding. Additionally, DMS will complete an assessment of potential effects on required federal reporting and make any adjustments. Anticipated Completion Date: June 30, 2026 Persons responsible for corrective action: Hannah Stephens, Section Manager Bureau of Fiscal Accountability and Management, Division of Medicaid Services, hannah.stephens@dhs.wisconsin.gov

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Finding 1182962 (2025-302)

Material Weakness 2025

State of Wisconsin

WI

Reporting Internal Control / Segregation of Duties Cash Management § 200.303

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-302: Grants to States for Medicaid and Children’s Health Insurance Program – Agency Directives. This is the department’s Corrective Action Plan.  Recommendation (2025-302): Grants to States for Me...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-302: Grants to States for Medicaid and Children’s Health Insurance Program – Agency Directives. This is the department’s Corrective Action Plan.  Recommendation (2025-302): Grants to States for Medicaid and Children’s Health Insurance Program – Agency Directives. We recommend the Wisconsin Department of Health Services: • Enforce with the fiscal agent that directives require appropriate approval and that the fiscal agent should confirm any directive where the approver may not be authorized; • Ensure that the listings of authorized directive approvers provided to the fiscal agent are updated at least quarterly; • Review policies related to directives, updated the policies to identify those directives that require an approver other than the creator, and document justifications for any directives for which the creator and approver may be the same employee; and • Access the feasibility of changes to the PRISM system that would enforce an approval from a user other than the creator of a directive. Wisconsin Department of Health Services Planned Corrective Action: DMS will ensure that the fiscal agent follows DHS policy to confirm directive approvals. In addition, DHS will update the authorized approvers list at least quarterly, define in policy when an approver other than the creator is needed, and consider changes to the PRISM system to enforce separation of duties between creator and approver. If system changes are feasible, the corrective actions will require additional time to complete beyond what is needed for the policy and procedure changes. Anticipated Completion Date: June 30, 2026 Persons responsible for corrective action: Carrie Kahn, Section Manager Systems Infrastructure Accountability Section, Bureau of Fiscal Accountability and Management, Division of Medicaid Services CarriePKahn@dhs.wisconsin.gov

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Finding 1182961 (2025-301)

Material Weakness 2025

State of Wisconsin

WI

Cash Management Eligibility Significant Deficiency

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-301: Grants to States for Medicaid and Children’s Health Insurance Program – Computer Data Matches. This is the department’s Corrective Action Plan.  Recommendation (2025-301): Grants to States fo...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-301: Grants to States for Medicaid and Children’s Health Insurance Program – Computer Data Matches. This is the department’s Corrective Action Plan.  Recommendation (2025-301): Grants to States for Medicaid and Children’s Health Insurance Program – Computer Data Matches. We recommend the Wisconsin Department of Health Services: • Identify and implement procedures to monitor the timeliness with which data match discrepancies are resolved and perform follow-up with local agencies as needed; and • Continue efforts to assess solutions for resolving state wage information collection agency data match discrepancies in a timely manner to determine if system or policy changes are needed. Wisconsin Department of Health Services Planned Corrective Action: Beginning in February 2026, the Medicaid Eligibility Quality Control Unit will include State Wage Information Collection Agency (SWICA) discrepancies in the monthly report that is available to Income Maintenance (IM) agencies through SharePoint. IM workers are expected to address the discrepancies. The Medicaid Eligibility Quality Control Unit will monitor the agencies to ensure they are completing the SWICA work. Prior to receipt of this finding in the fall of 2025, DHS initiated a project to assess the current state of SWICA discrepancy processing, develop solutions to improve the process, and consider automation options. The Bureau of Eligibility Operations and Training and the Bureau of Eligibility Enrollment and Policy are currently weighing several proposed solutions. If it is determined that changes to CARES are required, the project completion will depend on prioritization and coordination of CARES updates. Anticipated Completion Date: November 2027 Persons responsible for corrective action: Jonelle Brom, Director Bureau of Eligibility Operations and Training, Division of Medicaid Services Jonellem.Brom@dhs.wisconsin.gov

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Finding 1182960 (2025-306)

Material Weakness 2025

State of Wisconsin

WI

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Cash Management § 200.403 § 200.406

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-306: Children’s Health Insurance Program – Reconciliation of Vaccine Purchases. This is the department’s Corrective Action Plan.  Recommendation (2025-306): Children’s Health Insurance Program – R...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-306: Children’s Health Insurance Program – Reconciliation of Vaccine Purchases. This is the department’s Corrective Action Plan.  Recommendation (2025-306): Children’s Health Insurance Program – Reconciliation of Vaccine Purchases We recommend the Wisconsin Department of Health Services comply with federal regulations and ensure it performs annual reconciliations to calculate any differences between the estimated cost and the actual cost of vaccines for SCHIP participants and then adjusts the estimate for vaccine purchases funded from the Children’s Health Insurance Program (CHIP). Wisconsin Department of Health Services Planned Corrective Action: The Division of Enterprise Services and the Division of Public Health worked together to complete the reconciliation and adjust the estimate for FFY 2026. However, this work was done after the end of the audit period. This work effectively returned the $2.6 million in unallowable costs included in the memo to the federal government. The divisions will continue to work together to perform an annual reconciliation and adjust the estimate going forward. Anticipated Completion Date: September 1, 2026 Persons responsible for corrective action Becky Mogensen, Section Chief Managerial Accounting Section, Bureau of Fiscal Services, Division of Enterprise Services rebeccaj.mogensen@dhs.wisconsin.gov Elizabeth Brotheridge, Section Manager Communicable Disease Administration Section, Bureau of Communicable Diseases, Division of Public Health elizabeth.brotheridge@dhs.wisconsin.gov

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Finding 1182956 (2025-300)

Material Weakness 2025

State of Wisconsin

WI

Eligibility Cash Management Significant Deficiency

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan.  Recommendation (2025-300): Eligibility for the Children’s Health Insurance Program W...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-300: Eligibility for the Children’s Health Insurance Program. This is the department’s Corrective Action Plan.  Recommendation (2025-300): Eligibility for the Children’s Health Insurance Program We recommend the Wisconsin Department of Health Services continue its efforts to monitor for Children’s Health Insurance Program participants who exceed the age requirement to ensure they are identified and removed in a timely manner. Wisconsin Department of Health Services Planned Corrective Action: On August 1, 2025, a CARES Coordinator Notice was sent to Income Maintenance agencies to emphasize the Monthly BC CHIP Report, which provides a list of individuals aging out of the program in the following month. Beginning with this notification, agencies were required to work the cases on the list and notify DHS of completion on or before the 10th of each month. Since August 2025, agencies have followed the directives in the notice and are informing DHS when work is completed on each case. Anticipated Completion Date: August 2025 Persons responsible for corrective action: Jonelle Brom, Director Bureau of Eligibility Operations and Training, Division of Medicaid Services Jonellem.Brom@dhs.wisconsin.gov

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Finding 1182952 (2025-500)

Material Weakness 2025

State of Wisconsin

WI

Reporting

This letter is the Wisconsin Department of Transportation's response and corrective action plan for the finding and recommendations made by the State of Wisconsin Legislative Audit Bureau (LAB) in the interim memo dated February 11, 2026. Finding 2025-500: Motor Carrier Safety Assistance Program—Fin...

This letter is the Wisconsin Department of Transportation's response and corrective action plan for the finding and recommendations made by the State of Wisconsin Legislative Audit Bureau (LAB) in the interim memo dated February 11, 2026. Finding 2025-500: Motor Carrier Safety Assistance Program—Financial Reporting The Wisconsin Department of Transportation (WisDOT) agrees with the audit finding. Planned Corrective Action: WisDOT processes are now established to ensure that SF-270 and SF425 reports are submitted in a timely manner per the terms and conditions of federal grant agreements governing Motor Carrier Safety Assistance Program awards. These processes have been implemented by the WisDOT Division of State Patrol and Division of Business Management in FY 2025-2026 and will be maintained as required. Anticipated Completion Date: this corrective action has been completed and implemented. Person responsible for corrective action: Captain Karl L. Mittelstadt Wisconsin State Patrol Motor Carrier Enforcement Section Karl.Mittelstadt@dot.wi.gov

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Finding 1182951 (2025-503)

Material Weakness 2025

State of Wisconsin

WI

Significant Deficiency

This letter is the Wisconsin Department of Transportation's response and corrective action plan for the finding and recommendations made by the State of Wisconsin Legislative Audit Bureau (LAB) in the interim memo dated February 19, 2026. Finding 2025-503: Airport Improvement Program, Infrastructure...

This letter is the Wisconsin Department of Transportation's response and corrective action plan for the finding and recommendations made by the State of Wisconsin Legislative Audit Bureau (LAB) in the interim memo dated February 19, 2026. Finding 2025-503: Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs—Wage Rate Requirements The Wisconsin Department of Transportation (WisDOT) agrees with the audit finding. Planned Corrective Action: • The WisDOT Bureau of Aeronautics (BOA) will establish procedures to ensure timely and accurate certified payroll reporting for Airport Improvement Program (AIP) projects. This includes contractor reporting in the Civil Rights Compliance System (CRCS); onsite activity reporting by contractors, engineers, and BOA project managers; and enforcement by the BOA Aeronautical and Technical Services Section Labor Compliance Team. • BOA will update AES-43 Airport Engineering Procedures to strengthen Davis-Bacon Act compliance, including comprehensive project activity reporting through project completion and final payment. BOA project managers will verify reporting and coordinate with the Labor Compliance Section using weekly progress updates. • BOA will maintain project completion documentation to support proper closeout of airport development projects subject to Davis-Bacon requirements. Anticipated Completion Date: May 2026 Person responsible for corrective action: Shannon Clary, Labor Compliance and DBE Program Manager Airport Technical Services Section WisDOT- Division of Transportation Investment Management, Bureau of Aeronautics Shannon.Clary@dot.wi.gov

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Finding 1182950 (2025-502)

Material Weakness 2025

State of Wisconsin

WI

Subrecipient Monitoring

This letter is the Wisconsin Department of Transportation's response and corrective action plan for the finding and recommendations made by the State of Wisconsin Legislative Audit Bureau (LAB) in the interim memo dated February 18, 2026. Finding 2025-502: Airport Improvement Program, Infrastructure...

This letter is the Wisconsin Department of Transportation's response and corrective action plan for the finding and recommendations made by the State of Wisconsin Legislative Audit Bureau (LAB) in the interim memo dated February 18, 2026. Finding 2025-502: Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs—FFATA Reporting The Wisconsin Department of Transportation (WisDOT) agrees with the audit finding. Planned Corrective Action: • The WisDOT Bureau of Aeronautics (BOA) will develop written procedures to ensure all suballotments are appropriately reflected in Federal Funding Accountability and Transparency Act (FFATA) reporting. These procedures will include accurate and timely reporting. o Any sub-allotment of $30,000 or more, including any amendments and modifications to the sub-allotment, will be reported no later than the last day of the month following the month in which the sub-allotment was made. • BOA will work with the Federal Aviation Administration (FAA) to obtain clarification on the reporting of the public health emergency sub-allotments. o If it is determined these are exempt from reporting, BOA will obtain written confirmation of such from FAA. o If these funds should be reported, BOA will complete the reporting as soon as practicable after receiving guidance from FAA. Anticipated Completion Date: May 2026 Person responsible for corrective action: Tami Weaver, Section Chief Airport Program Section WisDOT- Division of Transportation Investment Management, Bureau of Aeronautics tamera.weaver@dot.wi.gov

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Finding 1182949 (2025-501)

Material Weakness 2025

State of Wisconsin

WI

Reporting § 200.303 § 200.344

This letter is the Wisconsin Department of Transportation's response and corrective action plan for the finding and recommendations made by the State of Wisconsin Legislative Audit Bureau (LAB) in the interim memo dated February 18, 2026. Finding 2025-501: Airport Improvement Program, Infrastructure...

This letter is the Wisconsin Department of Transportation's response and corrective action plan for the finding and recommendations made by the State of Wisconsin Legislative Audit Bureau (LAB) in the interim memo dated February 18, 2026. Finding 2025-501: Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs—Financial Reporting The Wisconsin Department of Transportation (WisDOT) agrees with the audit finding. Planned Corrective Action: • The Bureau of Aeronautics (BOA) will update the current APS-30 BOA Airport Improvement Program Reporting (Grant Reporting) policy and procedures to include a secondary review by the Bureau of Financial Management (BFM). This update will include how corrections will be documented and handled prior to reporting submission to the federal government. • BOA and BFM will develop and implement written procedures for a coordinated internal secondary review of the final SF-271 and SF-270 forms, and the annual and final SF-425 reports, including procedures for maintaining sufficient documentation of the internal review. • BOA will obtain and maintain documentation of the project completion information to be used to initiate the closeout of a grant and/or airport development project. Anticipated Completion Date: May 2026 Person responsible for corrective action: Tami Weaver, Section Chief Airport Program Section WisDOT- Division of Transportation Investment Management, Bureau of Aeronautics tamera.weaver@dot.wi.gov

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Finding 1182945 (2025-400)

Material Weakness 2025

State of Wisconsin

WI

School Nutrition Programs Subrecipient Monitoring Reporting

Finding 2025-400: Child Nutrition Cluster—Federal Funding Accountability and Transparency Act Reporting: Planned Corrective Action: The Department of Public Instruction (DPI) will complete and submit reports for subaward information in the FFATA Subaward Reporting System (FSRS) for the Child Nutriti...

Finding 2025-400: Child Nutrition Cluster—Federal Funding Accountability and Transparency Act Reporting: Planned Corrective Action: The Department of Public Instruction (DPI) will complete and submit reports for subaward information in the FFATA Subaward Reporting System (FSRS) for the Child Nutrition Cluster (CNC) beginning in June 2025. Beginning with June 2025 awards reporting has been completed by the applicable due date (June 2025 awards, reported by July 31, 2025, etc) The internal processes established to ensure proper reporting of subaward has been updated to include payments made for Child Nutrition Cluster grants. Upon completion of the required reporting, a summary of all Child Nutrition Cluster awards is submitted to the Department of Administration, providing the FAIN, Amount, and Date Reported. Anticipated Completion Date: July 2025. Person responsible for corrective action: Michael Brendel, Section Leader Bureau of School Financial Services Division for Libraries & Technology (working title: Division of School & Library Operations) Department of Public Instruction michael.brendel@dpi.wi.gov

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Finding 1182943 (2025-303)

Material Weakness 2025

State of Wisconsin

WI

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-303: WIC Supplemental Nutrition Program for Women, Infants, and Children – Service Organization Controls. This is the department’s Corrective Action Plan.  Recommendation (2025-303): WIC Supplemen...

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2025-303: WIC Supplemental Nutrition Program for Women, Infants, and Children – Service Organization Controls. This is the department’s Corrective Action Plan.  Recommendation (2025-303): WIC Supplemental Nutrition Program for Women, Infants, and Children – Service Organization Controls. We recommend the Wisconsin Department of Health Services: • Develop and document procedures to complete an annual assessment of the controls in place by each contractor that provides support and security for an IT system used in administering the WIC Special Supplemental Nutrition Program for Women, Infants, and Children program, including the support provider, the cloud provider, and the EBT provider; • Obtain annually available service organization controls audit reports and perform an annual review that includes an assessment of the identified internal control deficiencies and a determination of whether the relevant complementary user entity controls are implemented; and • Prepare and maintain documentation of its annual review and assessment. Wisconsin Department of Health Services Planned Corrective Action: In partnership with DHS’s Information Security Section (ISS), the WIC Program will develop and document procedures to complete an annual assessment of security controls. The WIC Program will annually request SOC reports from all vendors. ISS will review SOC reports identifying deficiencies and risks and ensuring the user entity controls are addressed. DHS will then prepare and maintain documentation of its annual SOC reviews and assessments. Anticipated Completion Date: June 1, 2026 Persons responsible for corrective action: Kari Malone, Section Manager WIC and Nutrition Section, Division of Public Health kari.malone@dhs.wisconsin.gov

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Finding 1182936 (2025-700)

Material Weakness 2025

State of Wisconsin

WI

Cash Management Subrecipient Monitoring § 200.305

Finding 2025-700: Dairy Business Innovation Initiatives—Cash Management Planned Corrective Action: To comply with federal cash management requirements, Research and Sponsored Programs (RSP) revised all contracts with WCMA to be standard cost-reimbursement only agreements. RSP developed a cash manage...

Finding 2025-700: Dairy Business Innovation Initiatives—Cash Management Planned Corrective Action: To comply with federal cash management requirements, Research and Sponsored Programs (RSP) revised all contracts with WCMA to be standard cost-reimbursement only agreements. RSP developed a cash management guidance that specifies the circumstance and requisites in which a cash advance may be suitable with department and RSP Director approval. The guidance has been shared with pre- and post- award RSP staff. Anticipated Completion Date: April 1, 2026 Person responsible for corrective action: Liz Bevins-Smith, Director of Research Financial Services Research and Sponsored Programs bivinssmith@rsp.wisc.edu

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Finding 1182935 (2025-047)

Material Weakness 2025

State of South Carolina

SC

Equipment & Real Property Management Subrecipient Monitoring § 200.303 § 200.313

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-047] (Equipment and Real Property Management) Public Health Emergency Preparedness and Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Assistance Listing: 93.069 and 93.354 Disposition of Audit Finding: The Department of Public Health concurs with the audit finding. Corrective Action: At the time of the agency restructuring and transfer of assets from the Department of Health and Environmental Control (DHEC) to the Department of Public Health (DPH) and the Department of Environmental Services (DES), the DHEC Asset Manager oversaw the asset transfers to both successor agencies (J060 and P500). During this transition, we were advised by the SCEIS team to temporarily move all agency assets into a single generic fund for each new agency to ensure the transfer process could be completed without system errors. Specifically, one generic funding stream was established for J060 and one for P500 to facilitate the transfer of assets from the previous J040 designations. We gave the auditors an email from the SCEIS team that provided this guidance. To complete the transition, the assets were placed on large transfer documents that were uploaded into SCEIS in bulk. This process was facilitated by the SCEIS team, and we followed their direction throughout the entire transfer process. Due to the complexity and volume of assets involved, it ultimately took close to a year after the agency split for all assets to be successfully moved from their original J040 designations to the new agency structures. Following the transition, our Budget team developed a crosswalk identifying which former J040 grants would correspond to the new J060 grant designations. Based on the information you shared, it appears that the updated grant designations for certain assets were not fully applied or uploaded into SCEIS after the initial transfer into the generic funding stream. As a result, those assets are still present in the system under DPH but are not currently associated with the applicable federal program when reports are generated. To address this, we will work with the SCEIS Asset Management team to determine why the grant designations were not updated as expected and to ensure the affected assets are reassigned to the appropriate grant funding sources in the system. We are unsure how long the correction process will take. If the adjustments must be made individually at the asset level, the updates will be completed by October. Anticipated Completion Date: October 31, 2026 The contact persons responsible for corrective action: . Trey Reed, Director, Bureau of Business Management at 803-898-3522 . Ryan Sims, Director, Support Services, Bureau of Business Management 803-898-3523

View Audit 394274

Finding 1182933 (2025-046)

Material Weakness 2025

State of South Carolina

SC

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-046] (Suspension and Debarment) Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health Assistance Listing: 93.967 Disposition of Audit Finding: The Department of Public Health concurs with the audit finding. Corrective Action: In this case, one of the six contracts tested did not have documentation on file to show that a SAM check was done. It is standard practice that when the SAM check is performed, a copy of the results is printed from the SAM.gov website. This is typically a page showing "no exclusions" or, frequently, if the vendor has no Federal contracting history, a screen showing "no results found." If the purchase is the result of a formal written solicitation, the solicitation contains the standard Compendium clause, “Certification Regarding Debarment and Other Responsibility Matters”. To strengthen compliance, the agency procurement director created an instructional video on March 15, 2024, guiding staff through the SAM check process, which is complex and lacks clear federal instructions, and distributed it to procurement staff. On January 27, 2025, this requirement was reinforced again in an email to all buyers, which included the video link and a detailed explanation of when SAM checks are necessary. The importance of, and process for, the SAM check is also a frequent topic at our monthly staff meetings. Most recently, it was a "Reminder" topic at both our January and February 2026 staff meetings. Moving forward, we will continue reminding staff of this requirement and incorporate it as a checkpoint in our quality assurance review before issuing purchase orders. Anticipated Completion Date: June 30, 2026 The contact persons responsible for corrective action: . Trey Reed, Director, Bureau of Business Management at 803-898-3522 . Tripp Clark, Director, Procurement, Bureau of Business Management at 803-898-3485

View Audit 394274

Finding 1182930 (2025-045)

Material Weakness 2025

State of South Carolina

SC

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-045] (Activities Allowed or Unallowed and Allowable Costs/Cost Principles) Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health Assistance Listings: 93.967 Disposition of Audit Finding: The Department of Public Health concurs with the audit finding. Corrective Action: In this case, 1 of 70 transactions tested did not contain a supervisory review and approval of a journal entry. The agency has implemented additional procedures to ensure that all applicable documents receive the required second-level review and signature prior to final processing. These processes include reinforcing review requirements with staff and incorporating additional verification steps to confirm that a second signature is obtained and documented. The agency will continue to monitor this control to ensure compliance going forward. Anticipated Completion Date: June 30, 2026 The contact person responsible for corrective action: . Katie Tillman, Director, Grant Compliance at 803-898-4103

View Audit 394274

Finding 1182929 (2025-044)

Material Weakness 2025

State of South Carolina

SC

Subrecipient Monitoring Special Tests & Provisions § 200.303

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-044] (Special Tests and Provisions) Immunization Cooperative Agreements Assistance Listing: 93.268 Disposition of Audit Finding: Management understands and respects the audit process, while maintaining our disagreement with this finding. The tardiness of the data entry was due to staff turnover and overburdening of remaining staff, not due to lack of oversite or "falling through the cracks". Internal email communication forwarded to the audit team evidences that the specific item in question was being tracked and followed up on to ensure completion. Corrective Action: The 1 of the 60 site visit follow-ups was completed within the appropriate timeframe for this site. However, due to loss of staff, the documentation was not completely done in a timely manner. The documentation has since been updated by the Lowcountry Compliance Unit Manager in lieu of the former staff member, and the site visit reviewed by VFC Coordinator in Secured Access Management Services. VFC Coordinator continues to monitor and track site visit data and communicates to compliance unit managers to stay ahead of upcoming due dates and assist in supporting teams as needed. These communications will be increased to occur monthly in the last week of the month. Anticipated Completion Date: Ongoing The contact person(s) responsible for corrective action and phone number(s): McColloch Salehi - 803-587-1537

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Finding 1182927 (2025-043)

Material Weakness 2025

State of South Carolina

SC

Cash Management Subrecipient Monitoring § 200.303

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-043] (Cash Management) Immunization Cooperative Agreements and Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health Assistance Listings: 93.268 and 93.967 Disposition of Audit Finding: The Department of Public Health concurs with the audit finding. Corrective Action: The agency has implemented additional procedures to ensure that all applicable documents receive the required second-level review and signature prior to final processing. These processes include reinforcing review requirements with staff and incorporating additional verification steps to confirm that a second signature is obtained and documented. The agency will continue to monitor this control to ensure compliance going forward. The overdraw observed for Immunizations was the result of a timing issue. A draw was processed based on the cash balance at that time, and a subsequent journal entry reclassified revenue. This sequence temporarily created an overstated cash balance; however, the balance was then applied to payroll and other eligible expenses. Regarding the Collaboration with Academia grants, these discrepancies occurred during a period when the agency was utilizing the draw database, which at that time was not pulling accurate data. The agency has since corrected the process used to perform federal draws to ensure accuracy and proper reconciliation. Any remaining balance was applied to allowable program expenses, and the grant has since been properly closed out with no remaining balance. Anticipated Completion Date: June 30, 2026 The contact person responsible for corrective action: . Katie Tillman, Director, Grant Compliance at 803-898-4103

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Finding 1182924 (2025-042)

Material Weakness 2025

State of South Carolina

SC

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-042] (Reporting) Maternal and Child Health Services Block Grant to the States Assistance Listings: 93.994 Disposition of Audit Finding: The Department of Public Health concurs with the audit finding. Corrective Action: The variance identified occurred because the amounts reported were compiled from internal supporting documentation rather than directly from SCEIS. While reported totals met the minimum required thresholds for Matching and Earmarking, the department recognizes the importance of alignment with the official accounting system. Going forward, the budget analyst will prioritize using SCEIS data when preparing reports, and the department will continue to monitor reporting procedures to ensure accuracy and consistency. Anticipated Completion Date: June 30, 2026 The contact persons responsible for corrective action: . Meredith Murphy, Director, Budgets & Financial Planning at 803-898-4222

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Finding 1182923 (2025-041)

Material Weakness 2025

State of South Carolina

SC

Subrecipient Monitoring Period of Performance Significant Deficiency § 200.303 § 200.403

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-041] (Period of Performance) Maternal and Child Health Services Block Grant to the States Assistance Listings: 93.994 Disposition of Audit Finding: The Department of Public Health concurs with the audit finding. Corrective Action: For 5 of the 60 transactions tested, 1 had costs incurred before the period of performance date and 4 had program expenditures not obligated and expended in accordance with program requirements. This was the result of human error/misclassification during processing. We are reinforcing guidance with both program and budget staff to prevent similar errors in future reporting periods. Anticipated Completion Date: June 30, 2026 The contact persons responsible for corrective action: . Meredith Murphy, Director, Budgets & Financial Planning at 803-898-4222 . Danielle Wingo, Director, MCH Bureau at 640-649-9292

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Finding 1182922 (2025-040)

Material Weakness 2025

State of South Carolina

SC

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-040] (Earmarking and Level of Effort) Maternal and Child Health Services Block Grant to the States Assistance Listings: 93.994 Disposition of Audit Finding: The Department of Public Health concurs with the audit finding. Corrective Action: We acknowledge that the level of effort amount reflected in the electronic signature approval for the FY26 Application/FY24 Annual Report was understated by $279,390. This variance resulted from a data extraction issue and does not reflect unallowable expenditures or misallocation of funds. The overall level of effort for the grant remains supported and exceeds the minimum required, and the impact of the discrepancy is immaterial relative to the total grant award. Controls are in place to review and validate level of effort allocations during report preparation, and any updates identified during this process will be accurately reflected in the submitted documentation. The agency has had ongoing discussions with the Grantor regarding our methodology for allocating administrative costs. During those discussions, we were informed that states have flexibility in how the calculation is prepared and we were provided with examples of methodologies used by several other states. While our administrative percentage for the current reporting period slightly exceeded the 10 percent, we have been actively working with the Grantor to evaluate alternative approaches for calculating these costs. Due to the recent agency split, HPS reorganization, and bureau management transitions, we have continued using our current methodology while considering potential adjustments. While reviewing these methodologies, we will assess administrative costs to ensure compliance with the 10 percent cap in future periods. Anticipated Completion Date: June 30, 2026 The contact person responsible for corrective action: . Meredith Murphy, Director, Budgets & Financial Planning at 803-898-4222

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Finding 1182921 (2025-039)

Material Weakness 2025

State of South Carolina

SC

Reporting Subrecipient Monitoring § 200.303

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers a...

Department of Public Health respectfully submits the following corrective action plan for the year ended June 30, 2025, on behalf of the State of South Carolina. The findings from the schedule of findings and questioned costs are discussed below. The findings numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAM AUDIT Department of Health and Human Services [2025-039] (Reporting and Matching) Maternal and Child Health Services Block Grant to the States Assistance Listings: 93.994 Disposition of Audit Finding: The Department of Public Health concurs with the audit finding. Corrective Action: We provided a reconciliation for the MCH Block Grant that shows that the expenditures reconcile to the amounts reported on the Federal Financial Report (FFR). This report was generated using the KSB1 report in the SC Enterprise Information System (SCEIS). The indirect cost (IDC) amount may not fully align because an incorrect rate was entered on the FFR. The applicable rates should have been applied as follows: . 19.40% for the period 10/1/2022 – 6/30/2023 . 20.30% for the period 7/1/2023 – 6/30/2024 . 24.00% for the period 7/1/2024 – 9/30/2024 Additionally, in the Payment Management System (PMS) the IDC calculation requires entry of the rate and the base amount, and the system automatically calculates the federal share. Because the system performs this calculation, minor rounding differences may occur. At the time of submission, the employee responsible for preparing and submitting the FFR was new to the role and relied on the matching requirement as presented in the Notice of Award (NOA) that was in effect at that time. The NOA included an incorrect matching amount, which was not removed until an amendment was issued after the FFR was submitted and approved in PMS. For the matching and indirect cost, we will have a more detailed second level of review. We will also require that the Cost Accountant obtains any matching information from the Budget Analyst assigned to the grant. Anticipated Completion Date: June 30, 2026 The contact person responsible for corrective action: . Katie Tillman, Director, Grant Compliance at 803-898-4103

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