Corrective Action Plans

Finding 1207002 (2024-016)

Material Weakness 2024

State of Illinois

IL

Allowable Costs / Cost Principles Eligibility Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2024-016 Finding Name: Failure to Discontinue CHIP Benefits for Ineligible Individuals Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) improperly continued providing benefits under the Children’s Health Insurance Program (CHIP) program to indivi...

Finding Number: 2024-016 Finding Name: Failure to Discontinue CHIP Benefits for Ineligible Individuals Finding Condition(s): The Illinois Department of Healthcare and Family Services (DHFS) improperly continued providing benefits under the Children’s Health Insurance Program (CHIP) program to individuals who were over the age of 18. In addition, the auditors noted that the DHFS has not established adequate controls to identify and remove individuals over the age of 18 from the CHIP program and to determine if they are eligible for benefits under the Medicaid Cluster program. Name of Contact Person(s): • Katherine A. Yager, Administrator, Illinois Department of Healthcare and Family Servies, Division of Eligibility • George Jacaway, Deputy Administrator - Illinois Department of Healthcare and Family Services, Eligibility Operations • Jacqueline Myers, Interim Deputy Administrator - Illinois Department of Healthcare and Family Services, Eligibility Data and Systems Corrective Action(s): Currently, the DHFS identifies and redetermines eligibility for this population each month. Each month, DHFS systemically identifies this population and provides a report to both DHFS and DHS to redetermine eligibility. Previously, this population was not being systematically identified. The amount of medical payments have decreased by 85% from fiscal year 2024 to 2025. A review of FY26 data indicates a continual decrease, currently at 93%. The DHFS will continue to identity and redetermine eligibility for this population group on a monthly basis. Proposed Completion Date: April 30, 2025 - Completed

View Audit 398893

Finding 1206967 (2024-011)

Material Weakness 2024

State of Illinois

IL

Allowable Costs / Cost Principles § 200.303 § 200.403

Finding Number: 2024-011 Finding Name: Unallowable Costs Charged to the TANF and CCDF Cluster Programs Finding Condition(s): The Illinois Department of Human Services (IDHS) could not provide documentation to support payments made on behalf of beneficiaries of the Temporary Assistance for Needy Fami...

Finding Number: 2024-011 Finding Name: Unallowable Costs Charged to the TANF and CCDF Cluster Programs Finding Condition(s): The Illinois Department of Human Services (IDHS) could not provide documentation to support payments made on behalf of beneficiaries of the Temporary Assistance for Needy Families (TANF) and Child Care and Development Fund (CCDF) Cluster programs. Additionally, the auditors noted that the IDHS does not have adequate controls in place to ensure information provided by providers is accurate and the related child care payments made were appropriate. Name of Contact Person(s): Maureen Bilek, Audit Compliance and Programmatic Monitoring Administrator – Illinois Department of Human Services, Division of Early Childhood (DEC) Corrective Action(s): The IDHS will (1) develop and implement internal procedures to conduct quarterly reviews of billing certificates for payments entered through the Interactive Voice Response (IVR) system, (2) assess existing deliverables, its Child Care Assistance Program (CCAP) policy and its CCDF State Plan responses related to IVR payments and determine and implement any necessary revisions, (3) develop external guidance for providers and Child Care Resource & Referral (CCR&R) agencies outlining IVR payment requirements, documentation standards, record-retention expectations, and the review process, (4) initiate and continue implementation of a communication plan to announce upcoming reviews, including the Service Employees International Union (SEIU), the Division of Early Childhood (DEC), CCR&Rs, and all providers utilizing IVR (additional communications will be issued as the process is refined), (5) commence IVR payment reviews in June 2026 and continue on a quarterly basis, and (6) Establish and maintain a master tracking log of provider reviews by year, subject to management review and oversight. Proposed Completion Date: June 30, 2026

View Audit 398893

Finding 1206962 (2024-010)

Material Weakness 2024

State of Illinois

IL

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Eligibility § 200.303 § 200.403

Finding Number: 2024-010 Finding Name: Improper TANF Beneficiary Payments Finding Condition(s): The Illinois Department of Human Services (IDHS) made improper payments to beneficiaries of the Temporary Assistance for Needy Families (TANF) program. In addition, the IDHS identified a system error in J...

Finding Number: 2024-010 Finding Name: Improper TANF Beneficiary Payments Finding Condition(s): The Illinois Department of Human Services (IDHS) made improper payments to beneficiaries of the Temporary Assistance for Needy Families (TANF) program. In addition, the IDHS identified a system error in June 2025 impacting beneficiaries whose benefit payments were calculated using diverted income. Finally, the IDHS did not establish control procedures at an adequate level of precision to ensure TANF program benefits were accurately calculated based on the beneficiary’s case file supporting documentation. Name of Contact Person(s): Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services Corrective Action(s): The IDHS has submitted a repair ticket to repair the system it uses to calculate its diverted income. Additionally, the cases affected by the diverted income error are being reviewed and referend to the Bureau of Collections for overpayment, as needed. The cases with incorrect beneficiary payments, outside of the diverted income errors, have been corrected and overpayment/supplements have been completed. Finally, the IDHS will require its TANF managers to conduct a monthly review of TANF cases to include all components of the cases. Proposed Completion Date: June 30, 2026

View Audit 398893

Finding 1206960 (2024-009)

Material Weakness 2024

State of Illinois

IL

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

Finding Number: 2024-009 Finding Name: Missing Documentation in Beneficiary Files Finding Condition(s): The Illinois Department of Human Services (IDHS) could not locate case file documentation supporting certain eligibility and special test requirements for beneficiaries of the Temporary Assistance...

Finding Number: 2024-009 Finding Name: Missing Documentation in Beneficiary Files Finding Condition(s): The Illinois Department of Human Services (IDHS) could not locate case file documentation supporting certain eligibility and special test requirements for beneficiaries of the Temporary Assistance for Needy Families (TANF) program. Also, the auditors noted that the IDHS does not have adequate resources to perform and document eligibility determinations. Additionally, the auditors noted that the IDHS has not established appropriate monitoring procedures to ensure eligibility determinations are properly documented in accordance with program requirements. Name of Contact Person(s): Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services (FCS) Corrective Action(s): The IDHS’ TANF Managers will conduct a monthly review of TANF cases to include all components of the TANF cases. Additionally, an Integrated Eligibility System (IES) enhancement will be implemented to allow telephonic signatures for TANF Responsibility and Service Plans. This will eliminate the need to use a paper process. Proposed Completion Date: March 21, 2027

View Audit 398893

Finding 1206947 (2024-007)

Material Weakness 2024

State of Illinois

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.332

Finding Number: 2024-007 Finding Name: Failure to Follow Established Program Subrecipient Monitoring Procedures Finding Condition(s): The Illinois Department of Human Services (IDHS) did not follow its established program monitoring policies and procedures for subrecipients of the Temporary Assistan...

Finding Number: 2024-007 Finding Name: Failure to Follow Established Program Subrecipient Monitoring Procedures Finding Condition(s): The Illinois Department of Human Services (IDHS) did not follow its established program monitoring policies and procedures for subrecipients of the Temporary Assistance for Needy Families (TANF), Child Care Development Fund Cluster (CCDF), Social Services Block Grant (SSBG), and Block Grants for Prevention and Treatment of Substance Abuse (SAPT) programs. Further, the auditors noted that the IDHS did not have adequate policies or procedures to ensure fiscal and administrative reviews were completed timely to detect potential non-compliance. Name of Contact Person(s): • Kasey Reagan, Interim Director – Illinois Department of Human Services, Division of Family and Community Services (FCS) • Christina Miller, Fund Disbursement Manager – Illinois Department of Human Services, Division of Behavioral Health and Recovery (IDHS-SAPT-Program) • Maureen Bilek, Audit Compliance and Programmatic Monitoring Administrator – Illinois Department of Human Services, Division of Early Childhood (DEC) • Brian Bond, Director – Illinois Department of Human Services, Office of Contract Administration (OCA) Corrective Action(s): The IDHS has completed or will take the following actions within four of its divisions/offices: Division of Family and Community Services (FCS) The FCS (1) has worked to identify the late subrecipient monitoring reviews and created a plan to address the backlog, (2) will utilize the plan to eliminate the back log of subrecipient monitoring reviews, (3) will meet with staff to reinforce the importance of adhering to the agreed upon monitoring processes and timeframes, (4) will update and circulate to staff the revised monitoring standard operating procedure, and (5) will review staff adherence to monitoring SOP timeframes during weekly meetings with staff who conduct monitoring. Division of Behavioral Health and Recovery (IDHS-SAPT PROGRAM) The IDHS-SAPT PROGRAM will (1) hire an administrative assistant to assist with compliance monitoring tracking activities to maintain communication about important deadlines, (2) hire compliance monitors to engage in conducting compliance reviews, (3) meet weekly to track monitoring activities to ensure deadlines are met, (4) review policy and procedures to assess timelines associated with the monitoring process, and (5) train all monitors to use the updated tool, templates and updated policies and procedures and the new electronic system. Division of Early Childhood (DEC) The DEC will (1) develop and implement a standardized deadline tracking tool to monitor review completion dates and required subrecipient notifications, including documented supervisory review and management oversight to ensure timeliness, (2) establish and implement internal Corrective Action Plan (CAP) procedures that outline standardized processes for CAP tracking, documentation, and escalation efforts and define protocols when subrecipients fail to submit required CAPs within established timeframes, (3) initiate and implement a CAP tracking tool to monitor review dates, findings issuance, subrecipient notification dates, CAP receipt, and implementation follow-up activities, with documented management oversight and approval to ensure timeliness, accountability, and consistent monitoring, and (4) conduct formal staff training on procedures for accurately completing and maintaining the CAP tracking tool, including documentation standards, required data elements, and supervisory review expectations to ensure consistent and compliant use. Office of Contract Administration (OCA) The OCA (1) has formally briefed leadership and management the issues noted in the finding and initiated a cross-division review of current subrecipient monitoring execution to identify gaps, inconsistencies, and needed revisions, (2) will complete a structured validation of monitoring expectations to ensure programmatic on-site reviews and expenditure/performance report reviews are occurring at the required frequency and depth, consistent with pass-through monitoring responsibilities, (3) will review minimum documentation standards and supervisory quality control checkpoints for review workpapers, expenditure/performance report review evidence, and monitoring report issuance, to strengthen internal controls over compliance, (4) will standardize and revise the data tracking definitions to ensure program findings from subrecipient monitoring are issued, tracked, and followed through to corrective action completion, including defined escalation steps when responses are delinquent or incomplete, (5) will align enforcement actions with the Statewide Grantee Compliance Enforcement System (GCES) framework (e.g., stop-payment status triggers, notices, objection windows, and resolution and closure steps), and ensure staff understand how and when to apply GCES in response to unresolved monitoring deficiencies, (6) finalize recommendations to streamline Fiscal Administrative Review (FAR) production triggers (pre-draft and post-draft), clarify program engagement in special condition processing post-FAR, and reduce reliance on informal technical assistance in CAP in favor of documented compliance correction and closure, (7) revised procedures and controls will be implemented for FARs scheduled on/after August 1, 2026 (target), with interim guidance applied as feasible to active cases prior to that date, and (8) will conduct structured database integrity review and update process aligned with official guidance and source documentation to ensure accuracy, completeness, consistency, and reliability of all FAR database records. Proposed Completion Date: December 31, 2026

View Audit 398893

Finding 1206939 (2024-006)

Material Weakness 2024

State of Illinois

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303 § 200.502 § 200.510

Finding Number: 2024-006 Finding Name: Inadequate Process for Monitoring Interagency Program Expenditures Finding Condition(s): The Illinois Department of Human Services (IDHS) does not have an adequate process for monitoring interagency expenditures claimed under or used to meet maintenance of effo...

Finding Number: 2024-006 Finding Name: Inadequate Process for Monitoring Interagency Program Expenditures Finding Condition(s): The Illinois Department of Human Services (IDHS) does not have an adequate process for monitoring interagency expenditures claimed under or used to meet maintenance of effort (MOE) requirements of the Temporary Assistance for Needy Families (TANF) and Child Care Development Fund (CCDF) Cluster programs. Name of Contact Person(s): Sarah Eves, Deputy Chief Financial Officer – Illinois Department of Human Services Corrective Action(s): The IDHS will request quarterly certifications, control assessments, and program expenditure questionnaires for those agencies receiving funds from federal awards. Additionally, the IDHS will sample interagency expenditures and request that the agency provide supporting documentation for the expenses. This documentation will be reviewed by the IDHS to ensure that the expenditures meet federal program requirements. Proposed Completion Date: October 1, 2026

View Audit 398893

Finding 1206600 (2024-002)

Material Weakness 2024

Urban League of Greater Pittsburgh

PA

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

Executive Committee Actions and Finance Next Steps The Urban League of Greater Pittsburgh’s Executive Committee convened to identify key areas of significance and outline the next steps for the organization’s financial operations. The primary focus of the discussion was on empowering individuals to ...

Executive Committee Actions and Finance Next Steps The Urban League of Greater Pittsburgh’s Executive Committee convened to identify key areas of significance and outline the next steps for the organization’s financial operations. The primary focus of the discussion was on empowering individuals to lead the organization and establishing modernized, well-managed financial systems, procedures, and practices. Policies and Procedures The Committee recognized that the Urban League of Greater Pittsburgh of Greater Pittsburgh maintains a long-established Policies and Procedures Manual, which incorporates controls mandated under the Uniform Guidance. This manual serves as the foundation for the organization’s financial management and ensures compliance with regulatory requirements. Leadership and Staffing To strengthen financial oversight, the Committee recommended recruiting a full-time Vice President of Finance. This position has been successfully filled, bringing dedicated leadership to the finance department. Strengthening Internal Controls Immediate next steps include a thorough review and enhancement of internal controls to ensure that financial risks are appropriately managed. These measures are being implemented with the aim of safeguarding the organization's assets and maintaining the integrity of financial reporting. Third-Party Involvement The Urban League of Greater Pittsburgh has engaged a third-party provider to assist with documenting key deliverables, organizing and convening meetings, and overseeing daily executions. This partnership is designed to enable more timely financial reporting and the development of a comprehensive plan that documents roles, responsibilities, procedures, and practices—including necessary approvals—for managing billings, receivables, cash flow, and other critical accounting and finance functions. Role of the Treasurer The Treasurer of the Urban League of Greater Pittsburgh has played a vital role in the implementation of these initiatives. The Treasurer actively participates in regularly scheduled weekly meetings, helping to ensure ongoing oversight and the effective execution of improvements to the organization’s financial management practices. Staff Roles and Responsibilities In Order to improve performance, collaboration, and to distribute the workload effectively. The Urban League has defined individuals and their role to strengthen Internal Controls. The staff responsible for the administration and oversight include: President/CEO Responsible for signing checks, authorizing payroll, approving transfers between bank accounts, and endorsing all Account Clearing House transactions. VP/Finance Reviews bank reconciliations and co-signs check with a second signatory. Approves Positive Pay transactions, initiates and completes transfers between accounts, reviews and authorizes payroll, enters Automatic Clearing House transactions, and oversees Accounts Payable approvals. This position will provide internal oversight to ensure financial reporting is timely and accurate. Accountant Records transactions in the accounting software. All payment requests to vendors require approval from both the Vice President of Finance and Program Managers. Prepares checks, inputs them into Positive Pay, requests Automated Clearing House payments, reconciles bank statements, and processes payroll. The accountant also initials inter-account bank transfers, manages deposit entries (stamps, records, and distributes check copies), and ensures proper authorization for Accounts Payable entries in the software. Executive Assistant Opens and logs checks into a tracking spreadsheet.

View Audit 398676

Finding 1206574 (2024-003)

Material Weakness 2024

Town of Natick, Massachusetts

MA

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

2024-003 Document Policies and Procedures Over Federal Awards Cluster/Program: All federal programs Type of Finding Compliance – Other Matters Internal Control over Compliance – Significant Deficiency Condition: The Town has not formalized written policies and procedures related to federal awards re...

2024-003 Document Policies and Procedures Over Federal Awards Cluster/Program: All federal programs Type of Finding Compliance – Other Matters Internal Control over Compliance – Significant Deficiency Condition: The Town has not formalized written policies and procedures related to federal awards required under the Uniform Guidance. Criteria: OMB’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (UG) requirements stipulate that federal award recipients must document their policies and procedures over certain aspects of financial and program management. Specifically, written policies are required for the following: • Cash management • Determination of allowable costs • Employee travel • Procurement • Conflicts of interest • Subrecipient monitoring and management Cause: The Town has not developed written formal documentation of internal controls to encompass all required areas per the Uniform Guidance. Effect: The Town is not in compliance with the requirements of the Uniform Guidance as it relates to the requirement to have documented policies and procedures pertaining to the management of federal awards. No questioned costs are reported as this requirement is procedural in nature. Recommendation: Written policies and procedures should be implemented in accordance with the Uniform Guidance. Views of Responsible Official: The reconciliations of retirement board accounts were handled through a third party prior to January 2024. There have been delays in obtaining the files from the third party. With the hiring of the new director in January 2024, the reconciliations are now performed in the Retirement office, by the retirement staff. We anticipate that the records will be available upon request in the future.

View Audit 398631

Finding 1206534 (2024-001)

Material Weakness 2024

Housing Authority of the City of Michigan City, Indiana

IN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.400

The Authority concurs with the Auditor’s recommendation. The Authority has made a number of employee changes as well as administrative and accounting-related improvements. The Authority will continue its efforts to further strengthen its administration of the federal programs/funds. The Executive Di...

The Authority concurs with the Auditor’s recommendation. The Authority has made a number of employee changes as well as administrative and accounting-related improvements. The Authority will continue its efforts to further strengthen its administration of the federal programs/funds. The Executive Director will continue to oversee the process of updating the Authority’s policies and procedures. The Executive Director will oversee the correction by September 30, 2025.

View Audit 398610

Finding 1206462 (2024-006)

Material Weakness 2024

Regional School Unit #54 - Msad #54

ME

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Management Response/Corrective Action Plan: Management agrees with the recommendation and acknowledges the importance of implementing stronger internal controls to ensure that all wage rates charged are properly documented and approved. The District is currently reviewing its written policies and pr...

Management Response/Corrective Action Plan: Management agrees with the recommendation and acknowledges the importance of implementing stronger internal controls to ensure that all wage rates charged are properly documented and approved. The District is currently reviewing its written policies and procedures to strengthen its internal controls. These updates will be communicated to the staff involved. Targeted training will be provided to reinforce federal compliance requirements, the importance of accurate documentation, and the roles and responsibilities in the review and approval process.

View Audit 398467

Finding 1206446 (2024-003)

Material Weakness 2024

Regional School Unit #54 - Msad #54

ME

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Management’s Response/Corrective Action Plan: Management has communicated directly with all staff responsible for student recordkeeping and cohort tracking at the high school level. The District procedural form for documenting student removals will be required in all cases. This form will serve as t...

Management’s Response/Corrective Action Plan: Management has communicated directly with all staff responsible for student recordkeeping and cohort tracking at the high school level. The District procedural form for documenting student removals will be required in all cases. This form will serve as the official record and must be completed, signed, and retained in accordance with district policy and audit requirements. No student will be removed from the cohort without completed and verifiable documentation.

View Audit 398467

Finding 1206387 (2024-006)

Material Weakness 2024

Association for Energy Affordability, Inc.

NY

Allowable Costs / Cost Principles § 200.405

1. Document formal allocation methodologies for shared non-personnel costs using rational and supportable bases such as square footage, FTEs, usage, or other proportional benefit measures depending on the cost. 2. Review and approve methodologies by management and update them when operational realit...

1. Document formal allocation methodologies for shared non-personnel costs using rational and supportable bases such as square footage, FTEs, usage, or other proportional benefit measures depending on the cost. 2. Review and approve methodologies by management and update them when operational realities change. 3. Maintain allocation schedules and supporting documentation for audit and grant compliance purposes. 4. Incorporate the methodology into policy and periodic review procedures.

View Audit 398386

Finding 1206386 (2024-005)

Material Weakness 2024

Association for Energy Affordability, Inc.

NY

Allowable Costs / Cost Principles § 200.430

1. Implement and maintain a formal time and effort process for payroll charged to Federal and other restricted awards. 2. Require approved time records or other compliant personnel activity documentation that accurately reflects work performed and is incorporated into payroll allocations. 3. Train p...

1. Implement and maintain a formal time and effort process for payroll charged to Federal and other restricted awards. 2. Require approved time records or other compliant personnel activity documentation that accurately reflects work performed and is incorporated into payroll allocations. 3. Train program and finance staff on requirements for payroll allocation support under 2 CFR 200.430. 4. Retain supporting records in the grant file and review payroll allocation support as part of monthly close and grant reporting.

View Audit 398386

Finding 1206296 (2024-002)

Material Weakness 2024

Town of Livermore Falls

ME

Allowable Costs / Cost Principles § 200.303

CORRECTIVE ACTION PLAN (Concerning Finding 2024-002) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer and Town Manager will take the following actions to address finding 2023-002 The current Town Manager was appointed by the Select Bo...

CORRECTIVE ACTION PLAN (Concerning Finding 2024-002) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer and Town Manager will take the following actions to address finding 2023-002 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for clerks, the Treasurer, and the Select Board. She has corrected items such as abatements being posted to a revenue account and LRAP funds being posted to an expense account. The prior Town Manager processed pay requisitions herself and approved disbursements without select board approval or signatures. There was one instance of checks being distributed with only two select board signatures, but has been addressed between the treasurer and town manager. Additionally, Department Heads are required to turn in no later than Thursday by 9 am, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. RHR Smith has been contracted to provide training with the Town’s Treasurer on using TRIO for journal entries from RHR Smith personnel. Additionally, the Town has implemented on July 1, 2025, a new chart of accounts using the Maine Model Chart of Accounts for Municipal and County Budgets. RHE Smith facilitated the transition to the new chart of accounts. Anticipated Completion Date: On-going training on journal entries and adjustments through Fiscal Year 2027 as the town is reliant on the intermittent availability of RHR Smith staff for training purposes. The new chart of account is in use as of July 1, 2024.

View Audit 398361

Finding 1206239 (2024-002)

Material Weakness 2024

Ramsey County

MN

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303 § 200.403

Finding Number: 2024-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Daniel Rahkola, Division Director Finance Corrective Acti...

Finding Number: 2024-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Daniel Rahkola, Division Director Finance Corrective Action Planned: The County will review program-related costs to ensure compliance with applicable grant requirements and to confirm that all costs are allowable, allocable, and properly supported. Supporting documentation must sufficiently demonstrate the allowability of each cost. This review will include the following: • Submitted payroll reports that detail individual hours worked, descriptions of work performed, and a clear link between the work performed and allowable grant program activities. • General ledger reports that support each cost and clearly document the relationship between the expenditure and allowable grant program expenses. Anticipated Completion Date: June 30, 2026

View Audit 398206

Finding 1206105 (2024-001)

Material Weakness 2024

Delaware Academy of Medicine, Inc.

DE

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance

The Academy learned of deficiencies pertaining to allowable indirect costs during the 2024 calendar year, at which time, after consultation with the funder, changes were made to the policies for calculation of indirect costs for the grant.

View Audit 398057

Finding 1205906 (2024-005)

Material Weakness 2024

Cardiovascular Center Corporation of Puerto Rico and the Caribbean

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Corrective Action Plan The Corporation will take the following corrective actions: • Financial Close Acceleration – The Corporation is aligning its accounting closing expectations for the issuance of its financial statements according to the Secretary of the Department of Treasury deadlines. Therefo...

Corrective Action Plan The Corporation will take the following corrective actions: • Financial Close Acceleration – The Corporation is aligning its accounting closing expectations for the issuance of its financial statements according to the Secretary of the Department of Treasury deadlines. Therefore, the accounting close processes are being improved in order to be completed by September of each fiscal year and issue the Single Audit on or before March 31 of the following fiscal year (nine months after each year end). • Compliance Calendar Implementation – Develop a formal compliance calendar to close its accounting books on September 30 and issuing the financial statements by March 31. Name of the contact person responsible for corrective action plan Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date March 31, 2027

View Audit 397711

Finding 1205735 (2024-001)

Material Weakness 2024

County of Coos, New Hampshire

NH

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303

The county will implement a formal reconciliation process between grant tracking spreadsheets and the General Ledger. This reconciliation will be performed at minimum quarterly (when most grants are submitted) and shall include: 1. Documented Comparison: A side-by-side verification of total expendit...

The county will implement a formal reconciliation process between grant tracking spreadsheets and the General Ledger. This reconciliation will be performed at minimum quarterly (when most grants are submitted) and shall include: 1. Documented Comparison: A side-by-side verification of total expenditures and revenues per grant on amounts reported within the general ledger and amounts included on subsidiary tracking spreadsheets. This verification (crosswalk) should include specific general ledger account numbers used for tracking revenues and expenditures. 2. Supervisory Review: Reconciliations should be reviewed and signed off by a person independent of the spreadsheet preparation 3. System Integration: In January 2025, the County implemented a new ERP software system, which offers a grant module and features to identify grant items to help eliminate reliance on manual “shadow” systems or spreadsheets.

View Audit 397440

Finding 1205400 (2024-005)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles

A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: Manageme...

A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: Management should reassess the design of its controls to ensure documentation is retained that evidences the review and approval of expenditures submitted to the Department of Treasury for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. ORSPA and Corporate Financial Reporting are developing standard operating procedures for the required review and reconciliation of grant expenditures per the accounting system to the financial submissions to the granting agency, including requirements for maintaining evidence of the review(s). Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397083

Finding 1205395 (2024-002)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles Cash Management Reporting

C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: M...

C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should reassess the design of its controls to ensure submissions to BHSB are made timely within the required 15-day period and that documentation is retained that evidences the review and approval of expenditures submitted to BHSB for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. Additionally, management is developing standard operating procedures and policies that include the requirements for compliance and internal controls for federal grants. The policies will acknowledge that for controls to be designed and operate effectively, there must always be a segregation of duties between the preparer of the control vs. reviewer and that clear documentation must be retained to evidence the execution of the controls. Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397083

Finding 1205394 (2024-001)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles

A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Purchase Orders Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management shou...

A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Purchase Orders Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should obtain documentation that evidences the review and approval of expenditures submitted to Behavioral Health System Baltimore (BHSB). Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on system capabilities that can be utilized in the execution of review and approval of grant expenditures prior to submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as retain their review and approval evidence. For the specific vendor noted in Finding 2024-001, a grant input field was added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants. Additionally, management worked with the vendor to ensure the requisition and approval configuration is properly maintained to prevent an approver from approving their own requisitions. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397083

Finding 1205047 (2024-001)

Material Weakness 2024

Detroit Police Athletic League, Inc.

MI

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management is committed to strengthening how we track and allocate hours to grant-funded projects to ensure full compliance with 2 CFR 200.430. Going forward, the organization will implement a time study approach to support the allocation of personnel costs to federal grants. Employees working across multiple funding sources will participate in periodic time studies designed to reasonably estimate the distribution of their time based on actual activities performed. The results of these time studies will be used as the basis for allocating payroll costs to the appropriate grants, and will be supported by documentation and supervisory review. We will also implement consistent tools and processes to ensure allocations are applied systematically across all funding sources. On a monthly basis, the finance team will review and reconcile payroll allocations to ensure they align with the established methodology. In addition, we will provide training and ongoing oversight to reinforce compliance and prevent similar Issues In the future.

View Audit 396692

Finding 1204998 (2024-008)

Material Weakness 2024

The City of Frederick, Maryland

MD

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding reference: 2024-008 - 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for...

Finding reference: 2024-008 - 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Action taken: The City has moved to personnel activity reports (PARS) for timesheet reporting to ensure the allocation of the number of hours performed on each program is accurate. The only exception is an employee that works 100% on one grant. Total working hours are recorded to the grant for this individual.

View Audit 396662

Finding 1204988 (2024-003)

Material Weakness 2024

The City of Frederick, Maryland

MD

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding reference: 2024-003 - 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for emp...

Finding reference: 2024-003 - 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Action taken: The City has moved to personnel activity reports (PARS) for timesheet reporting to ensure the allocation of the number of hours performed on each program is accurate. The only exception is when an employee works 100% on one grant. Then all working hours are recorded to the grant.

View Audit 396662

Finding 1203104 (2024-001)

Material Weakness 2024

Town of Oak Bluffs

MA

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C....

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C. 53 State Street, 17th Floor Boston, MA 02109 Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Financial Statement Finding 2024-001 – Document Policies and Procedures Over Federal Awards Condition: During our audit, we noted that the Town did not have formal policies and procedures in place covering the requirements of Uniform Guidance as specified in 2 CFR Part 200. Certain elements, such as procurement standards, subrecipient monitoring, internal control, and other compliance areas, were not addressed in written policies or documented procedures. Criteria: Uniform Guidance (2 CFR Part 200) requires non-federal entities administering federal awards to establish and maintain written policies and procedures to address all requirements specified in the regulations, including but not limited to internal controls, determination of allowable costs, procurement, subrecipient monitoring, financial management, and reporting. Cause: The Town has not developed comprehensive written policies and procedures to address all compliance requirements under Uniform Guidance. Effect: The absence of written policies and procedures increases the risk of noncompliance with federal requirements, reduces consistency in federal program administration, and limits transparency and accountability. Recommendation The Town should develop and implement comprehensive written policies and procedures that address all major compliance requirements under Uniform Guidance (2 CFR Part 200). Periodic review and updates should be performed to ensure ongoing compliance. Views of Responsible Officials: We have been reviewing existing workflows, and unwritten procedures, relative to our management and oversight of federal awards either received directly from the federal or from another intermediary pass-through agency. Once our review is complete, we will commit those procedures to writing and present them to the Select Boad for approval. The anticipation is that we will have documented policies and procedures, that are compliant with the Uniform Guidance, in time for the FY2026 audit.

View Audit 396313

Corrective Action Plans

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