Corrective Action Plans

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 1182487 (2025-002)

Material Weakness 2025

Homestead Homes of Greensboro INC

NC

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

2. Finding 2025-002: a. Comments on the findings and Recommendation: At the time of the Audit, we agree with the findings. b. Action (s) Taken or planned on the finding: Work orders had fallen behind due to staff changes, and unit turns. Regional Asset Manager has advised the staff that this cannot ...

2. Finding 2025-002: a. Comments on the findings and Recommendation: At the time of the Audit, we agree with the findings. b. Action (s) Taken or planned on the finding: Work orders had fallen behind due to staff changes, and unit turns. Regional Asset Manager has advised the staff that this cannot continue, and all work orders must be completed within less than (30) days from date of receipt. Since completion of Audit, maintenance has been working to get all work orders completed and caught up and to make sure they will continue to be completed in a timely manner. Regional Asset Manager will also check to make sure this is being accomplished at each quarterly site visit.

View Audit 393911

Finding 1182486 (2025-001)

Material Weakness 2025

Homestead Homes of Greensboro INC

NC

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

1. Finding 2025-001: a. Comments on the findings and Recommendation: At the time of the audit, we agree with the findings. b. Action (s)Taken or planned on the finding: The preventative maintenance and painting schedules were started to be maintained by management as of May 2025. Regional Asset Mana...

1. Finding 2025-001: a. Comments on the findings and Recommendation: At the time of the audit, we agree with the findings. b. Action (s)Taken or planned on the finding: The preventative maintenance and painting schedules were started to be maintained by management as of May 2025. Regional Asset Manager has advised staff of the importance of these tasks and schedules to be maintained and carried out on a routine basis. Moving forward they will be maintained properly and kept current throughout the year. Regional Asset Manager will continue to check these schedules at each quarterly site visit.

View Audit 393911

Finding 1182485 (2025-001)

Material Weakness 2025

University of Denver

CO

Student Financial Aid

Federal Agency: Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Numbers: • 84.063 – Federal Pell Grant Program • 84.268 – Federal Direct Student Loans Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matter Recommenda...

Federal Agency: Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Numbers: • 84.063 – Federal Pell Grant Program • 84.268 – Federal Direct Student Loans Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matter Recommendation: We recommend that the University strengthen its internal controls over reporting student enrollment changes to NSLDS to ensure that enrollment effective dates are reported to NSLDS within 60 days of an enrollment status change and that enrollment is being properly certified every 60 days. Explanation of Disagreement with Audit Finding: The University agrees with the audit finding. Action in Response to Finding: To prevent recurrence, the Office of the Registrar has implemented the following controls effective immediately: 1. Procedural Update: A mandatory coordination meeting between the College of Law and the Office of the Registrar is now scheduled to occur four weeks post-term to finalize degree verification. 2. Role Assignment: The Student Systems Analyst (Office of the Registrar) has been assigned ownership of this submission. They are responsible for proactively verifying the completion of Law awarding and executing the subsequent data submission to the Clearinghouse. Name of the Contact Person Responsible for Corrective Action: Nathan Bauer, Associate Vice Chancellor for Enrollment, Director of Financial Aid. Planned Completion Date for Corrective Action Plan: January 2026

View Audit 393900

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 1182481 (2025-004)

Material Weakness 2025

Eastern Oregon University

OR

Questioned Costs Student Financial Aid Subrecipient Monitoring

Recommendation: We recommend the University review the GLBA Safeguards Rule and implement appropriate processes and controls to ensure compliance with all applicable provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response ...

Recommendation: We recommend the University review the GLBA Safeguards Rule and implement appropriate processes and controls to ensure compliance with all applicable provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT Department, in conjunction with Human Resources and individual directors and department heads, will institute an annual system inventory of data classification and owner, ensuring job roles and position descriptions are mapped to access profiles. The CIO will review the current classification process for assigning role-based access and the related IT ticketing process for access to ensure existence of documented approvals for provisioning and role changes through a defined access request and approval workflow. IT will also work with HR to establish onboarding/position change/separation controls and timelines triggered by HR provisioning with same-day termination (within 24-hours) upon termination and role change reviews with transfers. IT will also enforce multi-factor authentication (MFA) administrative access where feasible. The relevant Policy and Procedure Manuals will be updated to define access privileges and approval processes, and staff will be trained annually and with onboarding. Name(s) of the contact person(s) responsible for corrective action: Russ Fagan, Chief Information Officer Planned completion date for corrective action plan: March 31, 2026

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

Finding 1182464 (2025-001)

Material Weakness 2025

Frank B. Peers Senior Housing Ml-93

IL

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Views of Responsible Officials and Planned Corrective Action Management agrees with the finding and is committed to strengthening our internal controls. We will review and enhance our invoice coding and approval procedures to ensure expenses are properly allocated to the correct property and to prev...

Views of Responsible Officials and Planned Corrective Action Management agrees with the finding and is committed to strengthening our internal controls. We will review and enhance our invoice coding and approval procedures to ensure expenses are properly allocated to the correct property and to prevent similar issues from occurring in the future. We believe the improvements underway will further support accurate financial reporting and continued compliance with HUD requirements.

View Audit 393876

Finding 1182463 (2025-002)

Material Weakness 2025

Ruby Valley Hospital District Dba Ruby Valley Medical Center

MT

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking

The District will work to establish and review policies and procedures to ensure adequate funding is reserved for debt service during the year and at fiscal year end.

View Audit 393871

Finding 1182462 (2025-002)

Material Weakness 2025

Heritage Behavioral Health Center, Inc.

IL

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.308 § 200.309 § 200.403

Finding 2025-002: Noncompliance with OMB Compliance Supplement; Period of Performance (H) for Assistance Listing Number (ALN) 93.958 Block Grants for Community Mental Health Services Criteria: The Code of Federal Regulations (CFR) Sections 200.308, 200.309, and 200.403(h) states “a non-Federal entit...

Finding 2025-002: Noncompliance with OMB Compliance Supplement; Period of Performance (H) for Assistance Listing Number (ALN) 93.958 Block Grants for Community Mental Health Services Criteria: The Code of Federal Regulations (CFR) Sections 200.308, 200.309, and 200.403(h) states “a non-Federal entity may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the Federal awarding agency or pass-through entity made the Federal award that were authorized by the Federal awarding agency or pass-through entities.” Costs incurred before or after the period of performance are unallowable unless explicitly approved. Condition: During our testing of expenditures charged to ALN 93.958, we identified 2 transactions out of a total sample of 15 totaling $192 that were incurred outside of the award’s period of performance. Corrective Action Plan: To ensure compliance and accurate reporting, we established internal control protocols for the formal review of service dates, verifying that all expenditures correspond to the appropriate period of performance. The Controller's signature on formal, documented month end checklists will serve as confirmation that all year-end invoices have been checked for appropriate period distribution. Responsible Person for Corrective Action Plan: Addy Hiles (Controller) Implementation Date for Corrective Action Plan: September 2025

View Audit 393858

Finding 1182457 (2025-002)

Material Weakness 2025

Eastern Carver County Schools Independent School District No. 112

MN

Procurement, Suspension & Debarment § 200.303

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

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

View Audit 393848

Finding 1182455 (2025-001)

Material Weakness 2025

Eastern Carver County Schools Independent School District No. 112

MN

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

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

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

View Audit 393848

Finding 1182452 (2025-001)

Material Weakness 2025

Alliance Apartments Housing Development Fund Co., Inc.

NY

Questioned Costs Cash Management HUD Housing Programs

Budget Based Rent increase has been submitted to HUD and is in queue for approval. The request includes funding for the reimbursement of the Replacement Reserve. We anticipate that this will be approved.

View Audit 393847

Finding 1182451 (2025-001)

Material Weakness 2025

New Hampton Community School District

IA

Internal Control / Segregation of Duties

Management is cognizant of this limitaiton and will implement additional procedures where possible.

View Audit 393846

Finding 1182448 (2025-008)

Material Weakness 2025

Plymouth Community School Corporation

IN

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

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

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

View Audit 393841

Finding 1182445 (2025-007)

Material Weakness 2025

Plymouth Community School Corporation

IN

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

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

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

View Audit 393841

Finding 1182443 (2025-006)

Material Weakness 2025

Plymouth Community School Corporation

IN

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

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

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

View Audit 393841

Corrective Action Plans

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