Corrective Action Plans

Finding 1159687 (2024-001)

Material Weakness 2024

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

Finding 1158306 (2024-006)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Student Financial Aid Allowable Costs / Cost Principles Reporting

Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not c...

Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not correctly populated. Management has since corrected the data and submitted a revised FISAP. Management notes there was turnover in the PSON’s Office of Student Financial Aid during the year and an employee was not properly trained on the FISAP preparation. Training has since been implemented and new employees in the department will be trained accordingly. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158301 (2024-005)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Student Financial Aid

Finding 2024-005 N. Special Tests and Provisions - Disbursement to or on Behalf of Students Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective ac...

Finding 2024-005 N. Special Tests and Provisions - Disbursement to or on Behalf of Students Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that certain credit refunds were not issued timely. PSON and ISMMS’ Offices of Student Financial will implement a control that ensures communication related to refunds is enhanced when a student withdraws. ISMMS has ensured compliance with the Department of Education’s 14-day credit balance requirement by contracting with Nelnet, an external financial management vendor, to administer the credit refund process, supported by ongoing monitoring and periodic internal reviews. The control will ensure that all credit refunds are issued timely. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org LaVerne Walker Director of Student Financial Services, Icahn School of Medicine at Mount Sinai Laverne.walker@mssm.edu Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158296 (2024-004)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions

Finding 2024-004 N. Special Tests and Provisions - Enrollment Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management ag...

Finding 2024-004 N. Special Tests and Provisions - Enrollment Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON and ISSMS’ Offices of Student Financial will ensure that all NSLDS submissions are made timely and with the correct status of each student. The respective Offices are implementing enhanced monitoring, staff training, and periodic internal reviews to confirm compliance. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org LaVerne Walker Director of Student Financial Services, Icahn School of Medicine at Mount Sinai Laverne.walker@mssm.edu Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158291 (2024-003)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Student Financial Aid

Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees wit...

Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON’s Office of Student Financial Aid will implement a process that ensures all required documentation is retained. Employees of the Student Financial Aid Office will be trained and PSON will be in compliance with the requirements in the Federal Student Aid Handbook. Name of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158248 (2024-002)

Material Weakness 2024

Providence St. Joseph Health

WA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying an...

Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying and documenting disbursement and enrollment dates, academic year parameters, and cost of attendance calculations prior to COD submission. This will include additional layers of review to ensure timely and accurate reporting. These policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158246 (2024-001)

Material Weakness 2024

Providence St. Joseph Health

WA

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

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158232 (2024-003)

Material Weakness 2024

New York College of Traditional Chinese Medicine

NY

Special Tests & Provisions Student Financial Aid Significant Deficiency

Finding 2025-003: Campus Crime Awareness Requirements Not Met Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of 1. a burglary crime was reported in the Annual Security Report when it should have been reported as a motor vehicle theft. The issue was du...

Finding 2025-003: Campus Crime Awareness Requirements Not Met Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of 1. a burglary crime was reported in the Annual Security Report when it should have been reported as a motor vehicle theft. The issue was due to error entry, neighboring lines. 2. motor vehicle theft and a weapons violation was not reported to the Department of Education. The issue was due to carelessness. These were correctly reported in the Annual Security Report. Usually, the Annual Security Report and report to the Department of Education is prepared and completed by the Student Services Coordinator and the Administrative Dean based on the statistic report from the school and the Police Department in August/September. Because the college was engaged in the self-study for accreditation, everyone was extremely busy at that time. Errors might occur when doing things in a hassle way. Actions Taken or Planned: 1. Corrections were made in the Annual Security Report and in the report to the Department of Education. Two corrections were made in the DOE website: Criminal Offenses - Public Property: For 2023, line J (motor vehicle theft) was changed from 0 to 1. Arrests - Public Property: For 2023, line a (weapon) was changed from 0 to 2 2. New Hire: The college is in the process of hiring a new Student Services Coordinator. This individual will work with the Administrative Dean for ensuring the accuracy and timelines of reporting moving forward. 3. A strengthen double-check system will be established to ensure the accuracy of all reporting. Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu

View Audit 370123

Finding 1158227 (2024-002)

Material Weakness 2024

Native Sun Community Power Development

MN

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

Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to b...

Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to be Completed by October 1, 2025

View Audit 370119

Finding 1158202 (2024-002)

Material Weakness 2024

National Council for Community Development, Inc.

NY

Subrecipient Monitoring Reporting Significant Deficiency

Finding No. 2024-002 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-t...

Finding No. 2024-002 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-through Entity (if applicable): Nassau County Condition: During our testing, we noted that the Organization did not provide the required monthly reports to Nassau County. Recommendation: We recommend that the Organization establish policies, procedures, and controls to ensure that the required information is submitted on a timely basis. Action Taken: Management has incorporated procedures into our grant compliance and administration policies and procedures to ensure that a Project Director reviews, understands and takes the necessary steps to comply with reporting requirements or other, as set forth by the client agreements. This step includes but is not limited to the Project Director completing a Grant Award File Checklist. Anticipated completion date: Immediately.

View Audit 370110

Finding 1158192 (2024-006)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Cash Management Period of Performance

Corrective Action Plan: Atrium Health CMHA management in the future will ensure that all correspondence, including notes from review meetings and approvals of key decisions, will be documented and retained as part of the support records for FEMA related awards. Proposed Completion Date: No further a...

Corrective Action Plan: Atrium Health CMHA management in the future will ensure that all correspondence, including notes from review meetings and approvals of key decisions, will be documented and retained as part of the support records for FEMA related awards. Proposed Completion Date: No further action is required until future needs arise for Atrium Health CMHA to obtain FEMA funding awards at which time management will ensure all documentation supporting the process and key decisions are retained.

View Audit 370096

Finding 1158191 (2024-005)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that appropriate training and process design for Jenzabar Financial Aid (JFA) system are implemented to accurately capture and retain all data required for FISAP report...

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that appropriate training and process design for Jenzabar Financial Aid (JFA) system are implemented to accurately capture and retain all data required for FISAP reporting. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

View Audit 370096

Finding 1158190 (2024-004)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT sys...

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

View Audit 370096

Finding 1158189 (2024-003)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are ma...

Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are maintained. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

View Audit 370096

Finding 1158188 (2024-002)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign various processes and w...

Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign various processes and work flows. This project is expected to address the gap in SFA transactional review and approval internal controls that are arising due to the SFA program size, limited number of subject matter experts, and the management turn; and result in mitigating controls and policies being implemented to ensure the accuracy and completeness of all SFA transactions. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.

View Audit 370096

Finding 1158187 (2024-001)

Material Weakness 2024

Atrium Health, Inc.

NC

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign the reporting structure...

Corrective Action Plan: Due to operational management turnover and restructuring experienced in 2024 and 2025, this corrective action plan has been delayed. Atrium Health CMHA management has engaged with outside consultants in the third quarter of 2025 to examine and redesign the reporting structures, process work flows, and procedures within the Student Financial Aid (SFA) office, the Business office, and Student Services specifically as those areas relate to student status and records. It is expected this engagement will ensure that the internal controls within the entire SFA office will improve, including that the SFA IT Systems are documented and tested and that any compensating controls identified as needed are implemented. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action plan. .

View Audit 370096

Finding 1158176 (2024-002)

Material Weakness 2024

Philadelphia Industrial Development Corporation

PA

Internal Control / Segregation of Duties Material Weakness Reporting

2024-002 – Incorrect Filing of Form ED-209 to the EDA Management inaccurately reported balances on Form ED-209 to the EDA. This inaccurate reporting is due to a lack of management review over the reported amounts. Per the ED-209 report, PIDC had $6,048,775 of principal outstanding on loans as of Dec...

2024-002 – Incorrect Filing of Form ED-209 to the EDA Management inaccurately reported balances on Form ED-209 to the EDA. This inaccurate reporting is due to a lack of management review over the reported amounts. Per the ED-209 report, PIDC had $6,048,775 of principal outstanding on loans as of December 31, 2024; however, per the supporting documentation only $5,048,775 of principal outstanding on loans was recorded within the financial statements as of December 31, 2024. Corrective Action During 2024, PIDC initiated an EDA loan to a borrower in the amount of $1,000,000. While the loan was committed at December 31, 2024, the loan was never disbursed. We will establish a dedicated oversight team of existing personnel to monitor the reporting process and to ensure reconciliation of our loan portfolio system. Furthermore, we will streamline our reporting processes by conducting a thorough review and implementing necessary changes. Ongoing training for portfolio management staff on new techniques and software tools will be initiated and continue on a regular basis. Regular progress reviews will be conducted to address quality issues promptly. By implementing these corrective actions, we aim to prevent inaccurate reporting Individual Responsible for Corrective Action Plan Lawrence McComie SVP & Chief Credit Officer 215-496-8145 Anticipated Completion Date: 30 days from issuance, management will file an updated ED-209 report to the EDA.

View Audit 370094

Corrective Action Plans

Filters