Corrective Action Plans

Finding 1160120 (2024-002)

Material Weakness 2024

CT

HUD Housing Programs Matching / Level of Effort / Earmarking

Major Federal Award Programs Audit Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid payroll xpenses in the amount of $76 on behalf of an affiliate from project cash without HUD approval. The amount due to the project as of December 31, 2024 is $76....

Major Federal Award Programs Audit Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid payroll xpenses in the amount of $76 on behalf of an affiliate from project cash without HUD approval. The amount due to the project as of December 31, 2024 is $76. Action(s) Taken or Planned on the Finding As of December 31, 2024 the $76 of payroll expenses was not reimbursed from the affiliate project account. This has been processed in the current year on September 5,2025.

View Audit 370520

Finding 1160119 (2024-001)

Material Weakness 2024

Shiloh Manor, Inc.

CT

HUD Housing Programs Special Tests & Provisions Matching / Level of Effort / Earmarking

Major Federal Award Programs Audit Comments on the Finding and Recommendation We concur with the auditors finding as follows: On December 31, 2017, HUD had approved a loan to operations from the reserve for replacement of $40,239 to be repaid upon receipt of the past due subsidy. When the past due s...

Major Federal Award Programs Audit Comments on the Finding and Recommendation We concur with the auditors finding as follows: On December 31, 2017, HUD had approved a loan to operations from the reserve for replacement of $40,239 to be repaid upon receipt of the past due subsidy. When the past due subsidy was received, the property was unable to repay the loan because of an unexpected increase in vacancies as a result of tenant turnover. As of December 31, 2024, management had not repaid $40,239 due to reserve for replacement Action(s) Taken or Planned on the Finding As of December 31, 2024, management has not repaid $40,239 due to reserve for replacement. Additionally, no deposits were made into the reserve for replacement. The owner and agent met with HUD on September 15, 2022 to discuss the loan repayment. It was determined that the loan payment would be deferred and absorbed into the budget-based increase submitted lo HUD and currently in review. This would cover the loan repayment that has been impossible to repay because the property has not operated efficiently since the Residual Receipt swipe of $241,000 in 2017. The finding is repeated as Finding No. 2024-001

View Audit 370520

Finding 1159998 (2024-004)

Material Weakness 2024

City of Princeton

IN

Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2024-004 Finding Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Contact Person Responsible for Corrective Action: David M. Kennard Contact Phone Number and Email Address: 812-677-3959 clerk@princetoncity.com Views of Responsible Officials: We concur with the find...

FINDING 2024-004 Finding Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Contact Person Responsible for Corrective Action: David M. Kennard Contact Phone Number and Email Address: 812-677-3959 clerk@princetoncity.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Clerk-Treasurer will prepare the annual data report and someone else, who is knowledgeable about the awards and the reporting compliance requirement, will review the report prior to submission. Documentation of the review will be retained with the City’s records. Anticipated Completion Date: The corrective action plan will go into effect immediately.

View Audit 370481

Finding 1159894 (2024-002)

Material Weakness 2024

City of Nashua

NH

Questioned Costs Period of Performance Subrecipient Monitoring § 200.308 § 200.309 § 200.403

Corrective Action Plan – Federal Funds Review and Processing Audit Finding Reference: Response to Finding 2024-002: Improvement Control Over Period of Performance for Federal Awards Name of Contact Person and Completion Date: Krystal De Gray, COO of Nashua School District 09-22-2025 Planned Correcti...

Corrective Action Plan – Federal Funds Review and Processing Audit Finding Reference: Response to Finding 2024-002: Improvement Control Over Period of Performance for Federal Awards Name of Contact Person and Completion Date: Krystal De Gray, COO of Nashua School District 09-22-2025 Planned Corrective Action: The Nashua School District acknowledges the finding related to the control over the period of performance for federal awards (Finding 2024-002). In response, the district will develop and implement a formal internal procedure to ensure that all purchases funded by federal awards are both placed and received within the established period of performance. This procedure will include appropriate review, documentation, and oversight to maintain compliance with federal grant regulations. To further strengthen internal controls, the Nashua School District will implement a procedure limiting purchases to occur no later than 15 days prior to the grant’s end date. Additionally, all necessary services must be received and completed prior to the expiration of the grant period. Mario Andrade Krystal De Gray Superintendent Chief Operating Officer

View Audit 370436 Questioned Costs: $1

Finding 1159875 (2024-002)

Material Weakness 2024

County of York, Pennsylvania

PA

Student Financial Aid Cash Management Matching / Level of Effort / Earmarking

We concur with this finding. The County of York has hired a Human Services Director of Finance to assist with improving systems and financial processes within the Human Services (HS) divisions. The HS Executive Director and Director of Finance are recommending engaging an expert Consultant to assist...

We concur with this finding. The County of York has hired a Human Services Director of Finance to assist with improving systems and financial processes within the Human Services (HS) divisions. The HS Executive Director and Director of Finance are recommending engaging an expert Consultant to assist the County’s Children & Youth Fiscal team in getting caught up on internal system timelines, as well as delayed reporting. The Consulting company will also be working to adequately train the Children & Youth Fiscal team for development purposes.

View Audit 370417

Finding 1159865 (2024-001)

Material Weakness 2024

Allenstown School District

NH

Questioned Costs Matching / Level of Effort / Earmarking

The LEA funding that was budgeted and expended was consistent with expectations, as a worksheet was completed and submitted to the State for approval of the original allotment. The issued identified in the finding appears to relate specifically to the ARP IDEA funding an additional allocation provid...

The LEA funding that was budgeted and expended was consistent with expectations, as a worksheet was completed and submitted to the State for approval of the original allotment. The issued identified in the finding appears to relate specifically to the ARP IDEA funding an additional allocation provided to the district well after the FY23/24 IDEA award. At no point did the State require our district to revise the MOE or resubmit the worksheet, which is why a revised version was not submitted. The district continued to receive grant approval without the ARP IDEA portion included in the worksheet. This was not due to staff inexperience or lack of training, but rather the direct result of the State’s guidance and approval process. In fact, the District has received multiple commendations from the State for the effective management of the IDEA funds. Moving forward, if additional funding is allocated, we will proactively submit a revised worksheet, regardless of whether the State requests it, to ensure full compliance with audit requirements and all grant fund related funding is captured.

View Audit 370405 Questioned Costs: $1

Finding 1159856 (2024-001)

Material Weakness 2024

Imec USA Nanoelectronics Design Center, INC

FL

Cash Management Matching / Level of Effort / Earmarking § 200.303 § 200.305

For all grant reimbursement requests we will now have an addtional person to review and sign off on the reimbursement request.

View Audit 370393

Finding 1159852 (2024-006)

Material Weakness 2024

Second Harvest Northern Lakes Food Bank

MN

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

The Accountant prepares reimbursement requests and the Contracted Controller reviews and approves reimbursement before submission is submitted.

View Audit 370389

Finding 1159836 (2024-007)

Material Weakness 2024

Second Harvest Northern Lakes Food Bank

MN

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking § 200.303

The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.

View Audit 370389

Finding 1159800 (2024-003)

Material Weakness 2024

City of Akron, Ohio

OH

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.

View Audit 370339 Questioned Costs: $1

Finding 1159797 (2024-005)

Material Weakness 2024

Program of Academic Exchange

NY

Matching / Level of Effort / Earmarking

Based upon current auditor’s recommendation, PAX has revised its effort verification reporting system. The previous system recommended by the last auditor was launched in FY23, however, current auditor points out the need to track all efforts rather than only the federal grants in order to provide s...

Based upon current auditor’s recommendation, PAX has revised its effort verification reporting system. The previous system recommended by the last auditor was launched in FY23, however, current auditor points out the need to track all efforts rather than only the federal grants in order to provide support for the full effort of each employee. Our latest revised system will accurately capture 100% of the effort spent by each employee on specific grants, other programs, and general and administrative functions, ensuring complete documentation of allocation of wages and salaries to the respective federal awards.

View Audit 370336

Finding 1159737 (2024-001)

Material Weakness 2024

End Domestic Abuse Wisconsin: the Wisconsin Coalition Against Domestic

WI

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Comments on findings and recommendations The organization agrees with the finding and the auditor’s recommendation. Actions taken or planned The organization reinstated the practice of preparing monthly financial statements to be reviewed by management and those charged with governance. Completion d...

Comments on findings and recommendations The organization agrees with the finding and the auditor’s recommendation. Actions taken or planned The organization reinstated the practice of preparing monthly financial statements to be reviewed by management and those charged with governance. Completion date September 30, 2024

View Audit 370321

Finding 1159736 (2024-002)

Material Weakness 2024

Okaloosa Aids Support and Informational Services INC Dba Oasis Florida

FL

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creati...

Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creating a temporary strain on resources. The few instances of noncompliance noted in the finding were missed during this influx. Management is actively reviewing intake procedures to ensure capacity adjustments are made in response to future changes in referral patterns.

View Audit 370319

Finding 1159731 (2024-002)

Material Weakness 2024

Seward Association for the Advancement of Marine Science

AK

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.430

To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness...

To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness and consistency of information. In addition, SAAMS will update its policies to clearly describe the review objectives and responsibilities of staff conducting payroll reviews. Training will be provided to relevant staff to ensure proper understanding and execution of the updated procedures. These measures will ensure payroll reviews are accurate, effective, and aligned with best practices. Completion Date: September 30, 2026 Responsible Person: Dr. Wei Ying Wong, CEO, SAAMS

View Audit 370314

Finding 1159706 (2024-004)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25

View Audit 370288

Finding 1159698 (2024-003)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Reporting HUD Housing Programs Significant Deficiency § 200.303

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25

View Audit 370288

Finding 1159687 (2024-001)

Material Weakness 2024

Mount Horeb Area Joint Fire Department

WI

Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking

Finding 2024-001 Program Federal Assistance Listing and Title: 10.766 Community Facilities Loans and Grants Award Numbers: Unknown Federal Grantor: U.S. Department of Agriculture Pass-Through Agency: N/A Criteria: 2 CRF 200.303 Internal Controls requires that non-federal entities receiving federal a...

Finding 2024-001 Program Federal Assistance Listing and Title: 10.766 Community Facilities Loans and Grants Award Numbers: Unknown Federal Grantor: U.S. Department of Agriculture Pass-Through Agency: N/A Criteria: 2 CRF 200.303 Internal Controls requires that non-federal entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with federal laws, regulations and program compliance requirements. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and deposits of loan and reserve payments, which should be reviewed and approved by a responsible party other than the original preparer. Condition/Context: There was not a review/approval performed of the annual reserve deposit tested and its entry for the loan. The sample was not statistically valid. Cause: There are not controls in place for a review and approval process of journal entries and deposits for the loan and reserve payments. Effect: Accounting software and/or reports could contain errors. Recommendation: The fire department should review its internal control procedures to ensure there is proper review and approval processes over completeness and accuracy of deposits and reserve payments, including documentation of that review. Corrective Action Plan: Controls for review and approval of journal entries and deposits Corrective Action Planned: The control deficiency has been discussed with the Department’s management and we acknowledge our responsibility for a review and approval process. The Board was aware that this condition existed and realizes that the concentration of duties and responsibilities in a limited number of individuals is not desirable from a control point of view. The Department is onboarding a Business Manager in a new position that will allow more segregation of duties. The Department has met with our Accountant to prioritize those duties that are important for segregation of accounting responsibilities. Name(s) of Contact Person(s) Responsible for Corrective Action: Jenny Minter Anticipated Completion Date: December 31, 2025

View Audit 370279

Finding 1159585 (2024-002)

Material Weakness 2024

Westward Heights

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.327

Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate...

Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate time to prepare quarterly reports for submission to the USDA. Once the quarterly financials are finalized, the USDA report will be submitted no later than the last day of the month. This plan will also be added to the calendar with reminders set for the Administor to ensure timely review and submission.

View Audit 370235

Finding 1159584 (2024-001)

Material Weakness 2024

Franklin County Technical School District

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assess...

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assessment of existing procedures to identify gaps that led to noncompliance with grant regulations. • Ensure timely submission of grant applications. • Implement enhanced oversight and monitoring processes for all grant-related expenditures to ensure alignment with policy 2 CFR 200.1. • Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. • Ensure all documentation is easily accessible and systematically organized for audit purposes. • Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and only with written approval from the Federal awarding agency (as per 2 CFR 200.458). • Establish a process for obtaining and documenting written approval for pre-award costs. • Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. • Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. • Assign accountability for monitoring and reporting compliance to specific roles within the organization. The Business Manager, Elizabeth Bouchard, will be responsible for implementing this plan beginning with the Fiscal Year 2026 grant cycle. As of September 2025, non-compliance issues have been identified and addressed, documentation has been maintained to track award dates, and training has been provided to designated roles within the District. In addition, procedures to maintain detailed documentation of all award dates and expenditures to ensure a clear compliance record have been shared with all District Administrators utilizing grant funds.

View Audit 370226 Questioned Costs: $1

Finding 1159462 (2024-002)

Material Weakness 2024

City of Aledo

IL

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Period of Performance § 200.302

City of Aledo Program Specific Audit Recommendation 2024-001 We recommend that the Organization review the requirements of 2 CFR Section 200.302 to develop allowable cost, activity, and period of performance activities to be followed. Management Response: The organization recognizes the importance o...

City of Aledo Program Specific Audit Recommendation 2024-001 We recommend that the Organization review the requirements of 2 CFR Section 200.302 to develop allowable cost, activity, and period of performance activities to be followed. Management Response: The organization recognizes the importance of having written policies and procedures to ensure cost are allowed and reasonable for the federal program. To address this finding, the agency has implemented the following corrective actions:  Review requirements of 2 CFR Section 200.302 as it relates to internal controls and financial management  Create documented policies and procedures that details how the grantee will review and approve invoices, cost allocation, efforts of personnel, fringe benefits and indirect charges for allowability, adherence to cost principles, accuracy, and completeness  Create documented policies and procedures that details how the grantee will review and approve invoices, cost allocations, efforts of personnel, fringe benefits and indirect charges to ensure they were incurred during the period of performance Responsible Staff: City Official Implementation Date: October 1,2025 90

View Audit 370207

Finding 1159439 (2024-001)

Material Weakness 2024

Montefiore Health System, Inc.

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice...

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.

View Audit 370177

Finding 1159426 (2024-003)

Material Weakness 2024

Capital Region Minority Supplier Development Council

MD

Questioned Costs Matching / Level of Effort / Earmarking § 200.306

Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the ...

Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the support and documentation we provided we captured $191,000 (25% non-federal match) of in-kind to meet our obligation of $189,250 for grant award Year 1, 2023. And although we met our in-kind obligation, we experienced several delays which were recognized by our grantee, MBDA. The delay in funding the grant award took place from July 2023 to September 2023 and subsequently after funding was released an additional black-out period from September 2023 to October 2023 was experienced due to a system transition from BAS to GEMS/era Commons. Acknowledgement of these delays was addressed by an official during an MBDA All Equities call on October 18, 2023. During that call awardees were advised to continue focusing on our program activities and clients as the situation was being addressed. To account for the delays, we later submitted a budget revision request through the new system, eRA Commons on 12.09.2024 asking for a budget carryover of $337,825.00 which also outlines how the funds will be expended. Additionally, it is noted in your finding that the allowable in-kind contribution is being reduced given that budget categories were not met by line item. However, our interpretation of MBDA Capital Readiness NOFO (pg.14), we are directed to Section CFR200.306 [https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-D/section-200.306] which does not cap in-kind by line-item. Lastly, the MBDA organization has changed dramatically since the inception of the Capital Readiness grant in 2023, yet we have been in communication with an MBDA government official who acknowledges the delays during the time outlined above and ask that flexibility for this non-federal share requirement be re-considered. Supporting documentation has been sent to support the statements. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: We plan to continue to seek validation of our position from our grantor and grant management entity – 4th Quarter 2025.

View Audit 370152 Questioned Costs: $1

Finding 1159416 (2024-002)

Material Weakness 2024

Gowest Foundation

WA

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303 § 200.518

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

View Audit 370140 Questioned Costs: $1

Finding 1159415 (2024-001)

Material Weakness 2024

Gowest Foundation

WA

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

View Audit 370140 Questioned Costs: $1

Finding 1159410 (2024-001)

Material Weakness 2024

Grady Memorial Hospital Corporation

GA

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting

View Audit 370132

Corrective Action Plans

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