Corrective Action Plans

Finding 1186637 (2025-001)

Material Weakness 2025

HI

Special Tests & Provisions Eligibility Significant Deficiency

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2025: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2025 Item 2025-001 - Specia...

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2025: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2025 Item 2025-001 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6, 2 H80CS00646-24-01, 1 H8LCS51923-01-00 for 2024 and 2025, 1 H8NCS54043-01- 00 for 2025 - (Significant Deficiency) During our audit, we noted that the Center did not properly determine the sliding fee discount for one eligible patient, based on information provided during the patient registration process. Recommendation We recommend that the Center provide training to all personnel involved in determining patients’ sliding fee discounts. In addition, we recommend that an internal audit of a sample of patient charts be conducted periodically to verify that sliding fee scale discounts or categories are properly and accurately determined based on the information provided by patients. Finally, we recommend that the results of such internal audits be formally documented. Action Taken Management agrees with the finding and will be establishing policies and procedures and conducting training for all personnel involved in determining patients' sliding fee discounts to help ensure the accuracy of the process. Management will also implement an internal audit of a sample of patient charts and will ensure that such audits are properly documented. Effectivity Date: June 30, 2026

View Audit 394336

Finding 1186634 (2025-001)

Material Weakness 2025

The New York Botanical Garden

NY

Subrecipient Monitoring § 200.303 § 200.332 § 200.521

2025-001 Monitoring of Subrecipients Agency: National Aeronautics & Space Administration Program Titles: Surviving a mass extinction: Lessons from the post K-Pg fern spike Grant Numbers: 80NSSC23K1013 Contact Person: Emily Schwarz, Chief Financial Officer (718) 817-8730 Corrective Action: Subsequent...

2025-001 Monitoring of Subrecipients Agency: National Aeronautics & Space Administration Program Titles: Surviving a mass extinction: Lessons from the post K-Pg fern spike Grant Numbers: 80NSSC23K1013 Contact Person: Emily Schwarz, Chief Financial Officer (718) 817-8730 Corrective Action: Subsequent to year end, the Garden obtained and reviewed Single Audit filings for all its Subrecipients from the Federal Audit Clearinghouse. In the Garden’s review of the Subrecipient Single Audit Reports, it did not note any findings related to its Federal programs. The Garden has implemented a control to continue to obtain and review the Single Audit filings for its Subrecipients on an annual basis. Anticipated Completion Date: Plan implemented immediately, and then continues on an ongoing basis.

View Audit 394332

Finding 1186633 (2025-002)

Material Weakness 2025

Mississippi Regional Housing Authority No. V

MS

HUD Housing Programs Subrecipient Monitoring Cash Management

To the Department of Housing and Urban Development, During the audit of the Housing Authority’s fiscal year ended June 30, 2025 financial statements, it was determined that the unaudited financial data schedule that is utilized as the Housing Authority’s underlying financial statements were not prop...

To the Department of Housing and Urban Development, During the audit of the Housing Authority’s fiscal year ended June 30, 2025 financial statements, it was determined that the unaudited financial data schedule that is utilized as the Housing Authority’s underlying financial statements were not properly stated. Significant errors existed regarding grant receivables, the allowance for doubtful accounts - tenants, capital assets, accounts payable, grant revenues and bad debt expense. Also, a desk review was performed by HUD and it was determined that the Housing Authority had not properly documented its calculation of monthly voucher leased amounts and it understated its Housing Assistance Payment expenses in its VMS reporting. The Housing Authority’s Executive Director, Ashiya Hawkins, is responsible for implementing the corrective action plan. Finding 2025-002 - VMS Reporting Deficiencies We concur with the recommendation and we will establish standard operating procedures that ensure that the HAP amounts and number of vouchers stated on the VMS report are both accurate and properly documented. We are working with our software provider to ensure that VMS reporting software is being fully and correctly utilized. We are also planning on additional training for HCV employees to make sure they are qualified to meet VMS reporting and documentation requirements.

View Audit 394328

Finding 1186615 (2025-002)

Material Weakness 2025

Valley Healthcare System, Inc.

GA

Sliding Fee Discount Supporting Documentation - Significant Deficiency 2025-002 Valley Healthcare System, Inc. acknowledges that supporting documentation used to determine sliding fee discounts should be consistenly maintained. Valley Healthcare System, Inc. will implement procedures and controls to...

Sliding Fee Discount Supporting Documentation - Significant Deficiency 2025-002 Valley Healthcare System, Inc. acknowledges that supporting documentation used to determine sliding fee discounts should be consistenly maintained. Valley Healthcare System, Inc. will implement procedures and controls to ensure that documentation is consistently maintained.

View Audit 394322

Finding 1186614 (2025-001)

Material Weakness 2025

Community Action Team, Inc.

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

3/20/2026 Community Action Team, Inc. respectfully submits the following corrective action plan for the year ending June 30, 2025. Kern & Thompson, LLC: Audit period: July 1, 2024 to June 30, 2025 The finding from the schedule of findings are discussed below. FINANCIAL STATEMENT FINDINGS 2025-001 Fe...

3/20/2026 Community Action Team, Inc. respectfully submits the following corrective action plan for the year ending June 30, 2025. Kern & Thompson, LLC: Audit period: July 1, 2024 to June 30, 2025 The finding from the schedule of findings are discussed below. FINANCIAL STATEMENT FINDINGS 2025-001 Federal Award Special Reporting Federal Funding Accountability and Transparency Act (FFATA) Material Non-Compliance and Material Weakness in Internal Controls over Compliance (Repeat of finding 2023-003, 2024-002) Recommendation: The Organization should establish written policies and procedures regarding review of grant agreements for compliance requirements along with written policies and procedures for first-tier subawards including tracking and proper internal control procedures. Action Taken: Management concurs with the finding and has defined corrective action to address it. We understand a material weakness is identified in the internal control over special reporting. We have identified gaps in our reporting processes and worked to implement changes to ensure compliance with special reporting requirements. The responsibility for reporting under the Federal Funding Accountability and Transparency Act (FFATA) will be within the Fiscal Department. Policies and procedures will be updated regarding special reporting requirements. The Fiscal department will also be responsible for reviewing all contracts to identify all compliance requirements. Tracking procedures will be implemented to ensure reports are filed timely. The above identified corrective action was implemented in July 2024 and subsequent filing for 2025 and 2026 are compliant. Stacey Wilson, Fiscal Director, has implemented a tracking system for the FFATA. Should you have any questions regarding this plan, please contact me at 503-366-6563. Sincerely, Daniel Brown Executive Director

View Audit 394320

Finding 1186613 (2025-001)

Material Weakness 2025

Rice Lake Housing Authority

WI

Internal Control / Segregation of Duties

Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...

Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing

View Audit 394318

Finding 1186611 (2025-003)

Material Weakness 2025

American Rivers, Inc.

DC

Reporting

Finding Number: 2025-003 – Untimely Submission of Federal Financial Report (SF-425) Planned Corrective Action: American Rivers hired a Grants Director in January 2026, and the required SF-425 reporting will be the director’s responsibility to ensure compliance with all required reporting. Anticipate...

Finding Number: 2025-003 – Untimely Submission of Federal Financial Report (SF-425) Planned Corrective Action: American Rivers hired a Grants Director in January 2026, and the required SF-425 reporting will be the director’s responsibility to ensure compliance with all required reporting. Anticipated Completion Date: 02/28/2026 Responsible Contact Person: Vickie Barrow-Klein, Chief Financial Officer

View Audit 394315

Finding 1186610 (2025-002)

Material Weakness 2025

American Rivers, Inc.

DC

Subrecipient Monitoring

Finding Number: 2025-002 – Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting Not Performed Planned Corrective Action: American Rivers hired a Grants Director in January 2026 and the FFATA reporting will be the director’s responsibility to ensure compliance with all FFATA...

Finding Number: 2025-002 – Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting Not Performed Planned Corrective Action: American Rivers hired a Grants Director in January 2026 and the FFATA reporting will be the director’s responsibility to ensure compliance with all FFATA and other required reporting. Anticipated Completion Date: 02/28/2026 Responsible Contact Person: Vickie Barrow-Klein, Chief Financial Officer

View Audit 394315

Finding 1186609 (2025-001)

Material Weakness 2025

Page Unified School District No. 8

AZ

Procurement, Suspension & Debarment Special Tests & Provisions Reporting

2025-001 Certified Payroll Reporting Federal Assistance Listing Number: 84.041 Program: Impact Aid Federal Agency: U.S. Department of Education Pass-Through Number: N/A Compliance Requirement: N. Special Tests and Provisions Award Period: July 1, 2024 – June 30, 2025 Type of Finding: Noncompliance (...

2025-001 Certified Payroll Reporting Federal Assistance Listing Number: 84.041 Program: Impact Aid Federal Agency: U.S. Department of Education Pass-Through Number: N/A Compliance Requirement: N. Special Tests and Provisions Award Period: July 1, 2024 – June 30, 2025 Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Questioned Costs: $-0- Repeat Finding: Similar to finding 2024-002. Condition/Context: The District did not retain documentation sufficient to determine the Davis-Bacon compliance clause was included in advertised specifications for construction projects paid with federal Impact Aid monies. In addition, for nine of 10 vendors selected weekly certified payrolls were not collected and maintained for any relevant weeks during the fiscal year. Corrective Action: The District will implement monitoring procedures over the procurement process to ensure provisions of the Davis-Bacon Act are implemented into contracts and that certified payrolls are obtained, when necessary. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Lori Wilson, Business Manager

View Audit 394314

Finding 1186608 (2025-001)

Material Weakness 2025

1260 Housing Development Corporation

PA

HUD Housing Programs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

It is the goal of the Corporation to maintain compliance with regulatory requirements. Where hardships are encountered, the Corporation remains in ongoing communication with respective regulatory agencies to promote transparency and mitigate risk of loss in funding or default.

View Audit 394308

Finding 1186607 (2025-002)

Material Weakness 2025

Randolph School District

WI

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties

Finding #2025-002: #84.184X – Wisconsin Well Be’s School-Based Mental Health Consortium Federal Grantor Agency: U.S. Department of Education Compliance Requirement: Cash Management Condition: During our audit procedures, it was determined that there was miscommunication between the grant manager and...

Finding #2025-002: #84.184X – Wisconsin Well Be’s School-Based Mental Health Consortium Federal Grantor Agency: U.S. Department of Education Compliance Requirement: Cash Management Condition: During our audit procedures, it was determined that there was miscommunication between the grant manager and the business manager. Therefore, an additional claim was made which resulted in the District receiving federal funds in excess of immediate needs. Effect: The District received federal funds in excess of immediate needs and before disbursement for allowable program costs. Cause: The District’s internal controls failed to identify a duplicate claim submitted for federal funds. Criteria: It is necessary under U.S. Office of Management and Budget (OMB) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (commonly called "Uniform Guidance") and under most federal grant agreements that the recipient must implement financial management system that provide proper fund control, which ensures funds used in a timely fashion. Recommendation: We recommend that the District implement a pre-submission check to verify that invoices have not been previously claimed. Response: The funds were fully used up in the following fiscal year as expenditures were incurred. The grant funding has been cut as of December 31, 2025. This finding has been resolved.

View Audit 394302

Finding 1186606 (2025-001)

Material Weakness 2025

Randolph School District

WI

Subrecipient Monitoring Allowable Costs / Cost Principles

Finding #2025-001: #84.184X – Wisconsin Well Be’s School-Based Mental Health Consortium Federal Grantor Agency: U.S. Department of Education Compliance Requirement: Subrecipient Monitoring Condition: During our audit procedures, it was determined that the District did not review supporting documenta...

Finding #2025-001: #84.184X – Wisconsin Well Be’s School-Based Mental Health Consortium Federal Grantor Agency: U.S. Department of Education Compliance Requirement: Subrecipient Monitoring Condition: During our audit procedures, it was determined that the District did not review supporting documentation such as invoices or pay records from subrecipient schools claiming funds. Although there is a Google shared document that summarizes expenditures claimed, subrecipient schools did not submit invoices to the grant manager for review and approval. Additionally, there was no formal written agreement between the District and the subrecipient to document the terms and conditions of the subrecipient awards. Effect: The District’s system of monitoring is not sufficient, formal, or uniform which could result in unallowable expenditures and misunderstandings between the District and the subrecipients. Cause: The District does not have adequate review and approval processes and formal written agreements for the subrecipients. Criteria: It is necessary under U.S. Office of Management and Budget (OMB) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (commonly called "Uniform Guidance") and under most federal grant agreements that any federal funds passed through to a subrecipient be appropriately monitored and that the subrecipient is properly informed of the grant requirements. Recommendation: We recommend that the District review invoices from the subrecipient schools and have written agreements signed by all parties that fully explain the federal grant requirements and include other appropriate language to protect the District and to further document the District’s compliance regarding subrecipient monitoring. Response: The grant funding has been cut as of December 31, 2025. The District did not implement the recommended procedures above as there are currently no other subrecipient relationships.

View Audit 394302

Finding 1186605 (2025-005)

Material Weakness 2025

Summit Academy Oic

MN

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the Academy implemented a process to ensure credit balances are returned timely based on the regulations set forth by the Department of Education. Explanation of disagreement with audit finding: T...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend that the Academy implemented a process to ensure credit balances are returned timely based on the regulations set forth by the Department of Education. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Financial Aid Coordinators have been instructed to run the credit balance report more frequently after aid has been posted to identify students with a credit balance. Also, once a request has been made to rectify the credit balance, it will become top priority to ensure its completion is within 10 days. Name(s) of the contact person(s) responsible for corrective action: Rachael Farnell Planned completion date for corrective action plan: 07/01/2025 If the Department of Education has questions regarding this plan, please call Rachael Farnell at (612-278-5271)

View Audit 394300

Finding 1186604 (2025-004)

Material Weakness 2025

Summit Academy Oic

MN

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy reevaluate its policies around accurate R2T4 calculations as well as timely return of funds to COD. Explanation of disagreement with audit finding: There is no disagreement with the audit f...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy reevaluate its policies around accurate R2T4 calculations as well as timely return of funds to COD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: R2T4 calculations will now be handled by the Financial Aid Manager & to ensure timely refunds; the Financial Aid Manager will process R2T4’s every two weeks to ensure the timeliness of any refunds. Name(s) of the contact person(s) responsible for corrective action: Rachael Farnell Planned completion date for corrective action plan: 07/01/2025

View Audit 394300

Finding 1186603 (2025-003)

Material Weakness 2025

Summit Academy Oic

MN

Student Financial Aid Eligibility Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy implement a process to ensure student is being properly awarded based on their SAI and enrollment status. Explanation of disagreement with audit finding: There is no disagreement with the a...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy implement a process to ensure student is being properly awarded based on their SAI and enrollment status. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Coordinators now have a corrected calculator to use when determining the student’s Pell eligibility based on their SAI. The Financial Aid Manager will also look over the award to ensure proper funding has been put into place. Name(s) of the contact person(s) responsible for corrective action: Rachael Farnell Planned completion date for corrective action plan: 07/01/2025

View Audit 394300

Finding 1186602 (2025-002)

Material Weakness 2025

Summit Academy Oic

MN

Student Financial Aid Reporting Significant Deficiency § 200.303

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Explanation of disagreement with audit finding: There is no disagreement with the audit find...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy reevaluate its procedures and review policies surrounding controls implemented for Title IV Aid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Per finding 2025-002, Summit Academy has been completing the control piece when processing Title IV aid. To further the control of this process, the Financial Aid Manager will provide initials to show evidence of review. Name(s) of the contact person(s) responsible for corrective action: Rachael Farnell Planned completion date for corrective action plan: 07/01/2025

View Audit 394300

Finding 1186601 (2025-001)

Material Weakness 2025

Summit Academy Oic

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explana...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the Academy reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to put a process in place to ensure the student status changes are being reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Manager will run reports every thirty days and students will be certified in NSLDS every 30 days to ensure their enrollment status is reported in a timely manner. The Financial Aid Manager is also tracking the NSLDS changes on a spreadsheet. Name(s) of the contact person(s) responsible for corrective action: Rachael Farnell Planned completion date for corrective action plan: 07/01/2025

View Audit 394300

Finding 1186589 (2025-001)

Material Weakness 2025

Women in Safe Homes, Inc.

AK

Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs

Federal Single Audit Finding: 2025-001 Reporting - Significant Deficiency in Internal Control over Compliance Name of Contact Person: Adrienne Gaines, Executive Director Corrective Action: WISH will reinforce existing policies requiring documented evidence of review and approval for all key reports....

Federal Single Audit Finding: 2025-001 Reporting - Significant Deficiency in Internal Control over Compliance Name of Contact Person: Adrienne Gaines, Executive Director Corrective Action: WISH will reinforce existing policies requiring documented evidence of review and approval for all key reports. These controls will ensure approval via physical signature or electronic approval via email correspondence of each key report. Periodic monitoring will be performed to ensure compliance with documentation requirements. Proposed Completion Date: June 30, 2026

View Audit 394292

Finding 1186588 (2025-003)

Material Weakness 2025

Housing for Rockdale Elders, Inc.

MA

Eligibility Subrecipient Monitoring HUD Housing Programs

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 2025-003 - Eligibility - Material Weakness Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that the determination of tenant eligibility and the maintenance of lease files are in accordance with guidelines specified by HUD. Action Taken: Management agrees with the finding and is in the process of revising internal controls to address this issue.

View Audit 394285

Finding 1186587 (2025-002)

Material Weakness 2025

Housing for Rockdale Elders, Inc.

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

View Audit 394279

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

View Audit 394279

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

View Audit 394279

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

View Audit 394279

Corrective Action Plans

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