Corrective Action Plans

Finding 563796 (2024-002)

Significant Deficiency 2024

WA

Questioned Costs Allowable Costs / Cost Principles § 200.403

Activities Allowed or Unallowed; Allowable Costs and Cost Principles Auditor's Recommendations: We recommend that the Organization obtains a better understanding of allowable and unallowable costs for federal awards. We also recommend that the Organization implement a system of internal control tha...

Activities Allowed or Unallowed; Allowable Costs and Cost Principles Auditor's Recommendations: We recommend that the Organization obtains a better understanding of allowable and unallowable costs for federal awards. We also recommend that the Organization implement a system of internal control that can detect noncompliance prior to charging costs to the federal award. Corrective Action: Executive Director, Faith Brown, will develop a process for checking and charging costs to federal awards as required per the compliance policy. The Executive Director will be responsible for verifying that all internal controls are operating and will have been checked for unallowable prior to disbursing future federal funds. Timing of remediation completion: Executive Director, Faith Brown, will complete by September 29, 2025.

View Audit 358009 Questioned Costs: $1

Finding 563792 (2024-002)

Significant Deficiency 2024

Herzing University, Ltd.

WI

Student Financial Aid Subrecipient Monitoring Eligibility § 200.303

Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-002 – Eligibility - Pell Finding: Herzing University did not properly award Pell funding to an eligible student in the Spring 2024 semeste...

Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-002 – Eligibility - Pell Finding: Herzing University did not properly award Pell funding to an eligible student in the Spring 2024 semester. Condition: A student was eligible to receive Pell funding but did not receive Pell funds due to an employee error. For one out of 40 students tested for eligibility, we noted 1 student (2.5%) who was eligible to receive Pell funding but did not receive Pell funds due to an employee error. Action Taken: The identified student withdrew from the University on May 8, 2023. The student’s 2023-24 Pell award was cancelled during the required R2T4 process that was completed on May 23, 2023. The 2023-24 Pell award for the Spring 2024 semester was not manually reinstated upon the student’s return to an Active status on June 28, 2023. The employee who was responsible for updating the student’s financial aid package upon the student’s return to an Active status erroneously neglected to reinstate the 2023-24 Pell award for the Spring 2024 semester. This finding is attributed to human error. In April 2025, Herzing University created an internal compliance checkpoint for Pell awarding. This checkpoint will identify any students with a Pell eligible SAI for the Federal Award year that do not have Pell packaged for the semester. This checkpoint was completed for the Spring 2025 semester on April 7, 2025, and will be completed each semester going forward. Any affected students identified during the completion of this semester-based checkpoint will have their financial aid package revised to include Pell funding for the applicable semester, prior to the end of the semester. Herzing University’s Policy Manual was updated in April 2025 to reflect the addition of the Pell Awarding compliance checkpoint. For the identified student, Herzing University has provided a tuition waiver for the amount of the Pell funds that the student was eligible for and should have received for the Spring 2024 semester. The required corrective action for Finding 2024-002 listed in the SFA audit for the period 1/1/2024 – 12/31/2024 was completed on 5/7/2025. The person responsible for completion of the corrective action was Kevin McShane, Vice President of Financial Aid & Compliance. ____________________________________ _______________________ Kevin McShane Date Vice President of Financial Aid & Compliance Herzing University 275 W. Wisconsin Ave., Ste. 210, Milwaukee, WI 53203 Email Address: kmcshane@herzing.edu

View Audit 358003

Finding 563791 (2024-001)

Significant Deficiency 2024

Herzing University, Ltd.

WI

Student Financial Aid Subrecipient Monitoring Eligibility § 200.303

Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-001 – Eligibility - SEOG Finding: Herzing University did not properly award SEOG funding to an eligible student in the Fall 2024 semester....

Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2024 – 12/31/2024 Comments on Findings and Recommendations: Finding 2024-001 – Eligibility - SEOG Finding: Herzing University did not properly award SEOG funding to an eligible student in the Fall 2024 semester. Condition: A student was eligible to receive SEOG funding but did not receive SEOG funds due to an employee error. For one out of 40 students tested for eligibility, we noted 1 student (2.5%) who was eligible to receive SEOG funding but did not receive SEOG funds due to an employee error. Action Taken: On May 1, 2024, a Financial Aid Advisor manually cancelled the identified student’s 2024-25 SEOG award in Regent (Herzing University’s Financial Aid Management Software), with a notation that the student had an ineligible Student Aid Index (SAI). The student had an SAI of -117 on their 2024-25 ISIR, and in accordance with Herzing University’s FSEOG policy were eligible for 2024-25 SEOG in the Fall 2024 semester. The award was incorrectly manually canceled by the advisor because of human error. In April 2025, Herzing University created an internal compliance checkpoint for FSEOG awarding. This checkpoint will serve as a safety net to identify any students who have a Pell award for the Federal Award year, have an SAI that is FSEOG eligible according to Herzing University’s FSEOG policy, and do not correctly have FSEOG packaged for the semester. Any affected students identified during the completion of this semester-based checkpoint will have their financial aid package reviewed and if necessary revised to include FSEOG funding for the applicable semester, prior to the end of the semester. This checkpoint was completed for the Spring 2025 semester on April 4, 2025, and will be completed each semester going forward. Herzing University’s Policy Manual was updated in April 2025 to reflect the addition of the FSEOG Awarding compliance checkpoint. For the identified student, Herzing University has provided a tuition waiver for the amount of the FSEOG funds that the student was eligible for and should have received for the Fall 2024 semester. The required corrective action for Finding 2024-001 listed in the SFA audit for the period 1/1/2024 – 12/31/2024 was completed on 5/7/2025. The person responsible for completion of the corrective action was Kevin McShane, Vice President of Financial Aid & Compliance. ____________________________________ _______________________ Kevin McShane Date Vice President of Financial Aid & Compliance Herzing University 275 W. Wisconsin Ave., Ste. 210, Milwaukee, WI 53203 Email Address: kmcshane@herzing.edu

View Audit 358003

Finding 563693 (2024-002)

Material Weakness 2024

Toole County

MT

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.

View Audit 357988

Finding 563684 (2024-001)

None 2024

Auburn University

AL

Procurement, Suspension & Debarment Questioned Costs Allowable Costs / Cost Principles § 200.324

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, SNAP, and also applies to COVID-19 – Coronavirus State and Local Fisca...

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, SNAP, and also applies to COVID-19 – Coronavirus State and Local Fiscal Recovery Funds, which is not a cluster Sponsoring Agency: Various agencies Award Names: DE-CR0000033, USDA-58-6010-9-011, WICHITA ST UN-23-01534, AL DHR-AGREE 4153-FY24, and ADF-RURAL HLTH INITIATIVE-OPS Award Numbers: 212514, 204805, 245195, 376563, and 223331 Assistance Listing Title: Cybersecurity, Energy Security & Emergency Response (CESER), Agricultural Research Basic and Applied Research, Other Financial Assistance, State Administrative Matching Grants for the Supplemental Nutrition Assistance Program, and COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 81.008, 10.001, 12.RD, 10.561, and 21.027 Award Year: 2023 – 2024 To ensure Auburn University is in compliance with 2CFR 200.324, Auburn University will implement the following corrective action plan: In addition to our current policies that require three quotes for purchases between $15,000-$75,000 and a formal competitive bid for purchases greater than $75,000, Auburn University will revise our policies to require a cost or price analysis for items greater than $250,000, documenting that the purchase is reasonable. The items identified within the audit were either a Professional Service Contract, advertising services (which are both exempt from State of Alabama Bid Law) or a sole source purchase. For items greater than $250,000, we will include a certification on the Professional Services Contracts and the Sole Source request forms indicating an analysis of cost or price has occurred and that the purchase is reasonable. As part of the cost or price analysis, we will utilize available data points. In addition to our analysis, we will ensure that our reviews have been appropriately documented and included in our files. Prior to the implementation date noted below, we will review any purchases greater than $250,000 in fiscal year 2025 and ensure proper cost or price analysis is completed and documented. Contact: Missty Kennedy Chief Procurement Officer and Executive Director Procurement and Payment Services Amy Douglas Associate VP Financial Services/Controller Anticipated Completion Date: October 1, 2025

View Audit 357977

Finding 563671 (2024-003)

Significant Deficiency 2024

Wilmington Community Clinic

CA

Questioned Costs Reporting

Views of responsible officials and planned corrective actions: The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be c...

Views of responsible officials and planned corrective actions: The Clinic will be retraining front office staff to ensure a thorough understanding of the Sliding Fee Scale policy and its proper application. The training will be led by the Revenue Cycle Manager. Additionally, monthly audits will be conducted on Sliding Fee Scale patients to verify that discounts are applied correctly and that completed applications with appropriate proof of income are collected. These efforts will be overseen by the Revenue Cycle Manager. Personnel responsible for implementation: Veronica Rodarte, Revenue Cycle Manager Date of implementation: June 1, 2025

View Audit 357973 Questioned Costs: $1

Finding 563666 (2024-002)

None 2024

California Institute of Technology

CA

Student Financial Aid Reporting Questioned Costs

Finding 2024-002: Common Origination and Disbursement (COD) Reporting Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Pell Grant Program, Federal Direct Loans Award Number: Various Award Year: 10/1/2023-9/30/2024 Assistance Listing Tit...

Finding 2024-002: Common Origination and Disbursement (COD) Reporting Cluster Name: Student Financial Assistance Federal Awarding Agency: Department of Education Award Name: Federal Pell Grant Program, Federal Direct Loans Award Number: Various Award Year: 10/1/2023-9/30/2024 Assistance Listing Title: Federal Pell Grant Program, Federal Direct Student Loans Assistance Listing Number: 84.063, 84.268 Pass-Through Entities: Not applicable As described in finding 2024-002, 1 of the 25 selections was not reported to the COD system within 15 calendar days of the disbursement to the student. The noted disbursement was reported 5 calendar days late. Caltech confirmed it had additional instances of late reporting beyond the audit selection. To address this finding, Caltech created a Disbursement Checklist to ensure that all steps in the process are followed, including generating common record files of disbursement information and transmitting those files to COD the same day as the funds are disbursed to the student accounts. The checklist was created in May 2025. Malina Chang, Director, Financial Aid Office, is responsible for this corrective action plan. Caltech also performs Pell monthly reconciliations to capture discrepancies between internal information and that which is reported by COD. Any discrepancies are investigated via this monthly reconciliation process, and errors are corrected. In addition, Caltech requests Pell funds from the Department of Education on a quarterly basis (quarterly EDCAPS draws), significantly reducing the risk of the Institute needing to return funds.

View Audit 357971

Finding 563644 (2024-001)

Significant Deficiency 2024

The Community Action Agency of Western Connecticut, Inc.

CT

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties § 200.414

Internal Control Over Compliance Recommendation: We recommend that the organization implement additional review process over the rate determination to ensure it is being calculated correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action t...

Internal Control Over Compliance Recommendation: We recommend that the organization implement additional review process over the rate determination to ensure it is being calculated correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Daycare Director will review all parent fee calculations with signed approval, beginning upon enrollment of the student and, annually, for as long as they remain enrolled at AELC. Name(s) of the contact person(s) responsible for corrective action: Michelle James Planned completion date for corrective action plan: May 23, 2025 f the State has questions regarding this plan, please call Michelle James at (203) 744-4700.

View Audit 357957

Finding 563618 (2024-002)

None 2024

Civil Air Patrol

AL

Equipment & Real Property Management Questioned Costs Reporting § 200.312

We concur with the finding and are implementing procedures to address all issues. The SF-428 is completed by Logistics utilizing data from ORMS. The report is meant to include only federally owned assets. Assets purchased by CAP with federal funds are not federally owned and should not be included i...

We concur with the finding and are implementing procedures to address all issues. The SF-428 is completed by Logistics utilizing data from ORMS. The report is meant to include only federally owned assets. Assets purchased by CAP with federal funds are not federally owned and should not be included in the report. Items are entered into ORMS manually and the funding source is chosen from a drop-down menu. Two vehicles were entered in fiscal year 2024, and the incorrect funding source was chosen from the drop-down menu. The correct option was right below the option chosen. The items were corrected when found during the audit. FM will work with Logistics to ensure all capitalized assets added during the fiscal year are reviewed for the correct funding source. We will review this as part of the cost review throughout the year. We will also request that a pop up or some other messaging be added to ORMS to alert the individual entering items to double check that the correct fund source has been chosen. We will implement the reviews in May 2025.

View Audit 357905

Finding 563613 (2024-002)

Material Weakness 2024

Council of Spanish Speaking Organizations, Inc.

PA

Allowable Costs / Cost Principles Questioned Costs Student Financial Aid

2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of H...

2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services (DHS). Our review found missing documents, time gaps between submissions, or untimely paperwork, including the following: (a) 29 CUA Safety Assessments, (b) 30 CUA Safety Plans, (c) 7 CUA PA Model Risk Assessments, (d) 3 CUA Documented Client Visits (Structure Case Notes), (e) FAST Family Advocacy Forms, (f) 17 Life Skills Assessment/ Biopsychosocial Evaluation/ IEP or Ages & Stages Questionnaire (ASQ), (g) 11 School Aged Report Cards, (h) 6 CUA Authorization to Release Information, (i) 9 CUA Immunizations, (j) 3 DHS Court Order Sheets, (k) 14 Child’s Photo, (l) 10 Initial CUA Single Case Plan, (m) 7 Monthly Updates to CUA Single Case Plan, (n) 17 Initial CUA Case Service Conference Summary Report, and (o) 16 Six Month Ongoing CUA Services Conference Summary Report. Furthermore, each child's file needed to contain specific documents from the DHS, which had to be supplied by the department or shown evidence of request by the CUA. Missing documents consisted of: (a) 34 DHS Service Authorization Forms, (b) 21 DHS CUA Provider Referral Forms, and (c) 30 DHS CUA In-Home Services Referral Forms. Recommendation: We recommend that management continue to develop policies and procedures in order to properly include all pertinent documentation within each client file as required by the City of Philadelphia, Department of Human Services. In addition, we recommend that program leadership and/or quality control department performs periodic audits of the client files to ensure all required documentation is included. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. FINDINGS – FEDERAL AWARD PROGRAM AUDITS (CONTINUED) Action taken in response to finding: 1. Hiring of Chief Compliance Officer to oversee Concilio Quality Assurance and Compliance process 2. Staffing of Quality Assurance department 3. Monthly review of client files for accuracy and completeness 4. Additional training of staff to review audit findings and implement corrective action Name of the contact person responsible for corrective action: Albert Essilfie, Chief Financial Officer albert.essilfie@elconcilio.net (215) 627-3100 Planned completion date for corrective action plan: June 30, 2025

View Audit 357894

Finding 563601 (2024-002)

Material Weakness 2024

Gadsden City Board of Education

AL

Questioned Costs Procurement, Suspension & Debarment Special Tests & Provisions

Funds from COVID-19 Education Stabilization Fund (ESF) were used to fund construction contracts in excess of $2,000 without the inclusion of prevailing wage rate clauses as required by Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedur...

Funds from COVID-19 Education Stabilization Fund (ESF) were used to fund construction contracts in excess of $2,000 without the inclusion of prevailing wage rate clauses as required by Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the “Davis-Bacon Act”). The Board did not have controls in place to ensure the Davis-Bacon Act wage rate requirements were included in construction contracts. Therefore, the construction project contract awarded during the fiscal year did not include prevailing wage rate clauses nor did the contractors submit weekly certified payrolls to the Board. Response: Management will implement controls to ensure future contracts funded with COVID-19 Education Stabilization Funds (ESF) in excess of $2,000 specify applicability of wage rate requirements.

View Audit 357874 Questioned Costs: $1

Finding 563600 (2024-002)

Material Weakness 2024

Chariton Community School District

IA

Questioned Costs Internal Control / Segregation of Duties Reporting

The office staff is currently working to segregate duties.

View Audit 357869 Questioned Costs: $1

Finding 563599 (2024-001)

Material Weakness 2024

Redevelopment Authority of Allegheny County

PA

Questioned Costs Reporting Internal Control / Segregation of Duties

Financial Statement Finds: Accounting Records Criteria: The accounts of the Authority should include all significant transactions in the period of benefit. Contion: During the audit, certain audit adjustments were required to record transactions in the period of benefit for the General Fund, Spe...

Financial Statement Finds: Accounting Records Criteria: The accounts of the Authority should include all significant transactions in the period of benefit. Contion: During the audit, certain audit adjustments were required to record transactions in the period of benefit for the General Fund, Special Projects Fund, IMPAC, and CITF Fund. Effect: The financial records for the General Fund, Special Projects Fund, IMPAC, and CITF Fund did not reflect the financial activity in the period of benefit, which could result in a material misstatement of the financial statements. This is a repeat finding from a previous year – Finding 2023-001. Recommendation: The Authority should ensure that internal control procedures over financial reporting are sufficient to identify and record all transactions in the period of benefit. Management Response: The Authority has initiated additional levels of review in order to sufficiently identify and record all transactions in the period of benefit. Anticipated Completion Date: Immediate

View Audit 357867 Questioned Costs: $1

Finding 563597 (2024-001)

Significant Deficiency 2024

Chatham Park South Cooperative

IL

Questioned Costs HUD Housing Programs

Recommendation: It is recommended that the Cooperative ensures the replacement reserve is appropriately funded each month to avoid future underfunding. Response: As of March 2025, the Cooperative has transferred the necessary funds to adequately cover the replacement reserve shortfall.

View Audit 357858 Questioned Costs: $1

Finding 563596 (2024-001)

Significant Deficiency 2024

Naomi and Sylvester Smith Senior Living Center

IL

Questioned Costs HUD Housing Programs Eligibility

Recommendation: We recommend that management and those charge with governance to improve internal controls to ensure that all required EIV reports are included in tenant files. View of Responsible Officials: Management agrees with the finding.

View Audit 357856 Questioned Costs: $1

Finding 563594 (2024-003)

None 2024

Western Maine Community Action, Inc.

ME

Special Tests & Provisions Questioned Costs

To address the finding related to noncompliance with the required tri-partite board composition, our organization has taken several steps to move toward full compliance. A board recuitment committee has been formally established to lead ongoing efforts to identify and engage qualified candidates to ...

To address the finding related to noncompliance with the required tri-partite board composition, our organization has taken several steps to move toward full compliance. A board recuitment committee has been formally established to lead ongoing efforts to identify and engage qualified candidates to fill board vacancies. Additionally, our new CEO has made board development a top priority and has already successfully added two new members. Two additional members are expected to join in the coming months. These actions reflect our continued commitment to meeting the tri-partite composition requirements and ensuring our board structure aligns with all applicable regulations.

View Audit 357850

Finding 563581 (2024-004)

Significant Deficiency 2024

City of La Habra

CA

Questioned Costs Subrecipient Monitoring

A tracking system (Kidkare) has been established to ensure day care homes are reviewed at least every six months, as required. The City also creates a spreadsheet to help track day care homes monitoring status during staff turnover/ transition.

View Audit 357845

Finding 563580 (2024-003)

Significant Deficiency 2024

City of La Habra

CA

Questioned Costs Cash Management

The City will update its procedures to ensure the most current school enrollment data is used when determining tier status for day care homes. Before completing any of the provider’s determinations upon enrollment or updating tier determination, the Site Director will double-check the Department of ...

The City will update its procedures to ensure the most current school enrollment data is used when determining tier status for day care homes. Before completing any of the provider’s determinations upon enrollment or updating tier determination, the Site Director will double-check the Department of Education website to ensure the City uses the most updated data.

View Audit 357845

Finding 563573 (2024-001)

Material Weakness 2024

Teton Youth and Family Services, Inc.

WY

Questioned Costs Procurement, Suspension & Debarment

Corrective Action Plan: 2024-001 Procurement of Capital Projects - Material Weakness Issue Summary A material weakness has been identified in the procurement process for capital projects, specifically regarding non-compliance with established procurement policies, insufficient documentation, and ina...

Corrective Action Plan: 2024-001 Procurement of Capital Projects - Material Weakness Issue Summary A material weakness has been identified in the procurement process for capital projects, specifically regarding non-compliance with established procurement policies, insufficient documentation, and inadequate oversight and segregation of duties. Root Cause Analysis - Lack of formalized and consistently enforced procurement procedures. - Insufficient internal controls and monitoring mechanisms. Corrective Actions Expected Outcome - Strengthened internal control environment. - Improved compliance with procurement policies. - Reduction in risk of misappropriation, waste, or fraud. - Enhanced transparency and accountability in contracted project spending. Monitoring and Reporting The Finance Committee, the Executive Director, and the Director of Finance will monitor progress on the corrective actions and report monthly updates to the Executive Leadership Team and Audit Committee until full resolution is achieved.

View Audit 357840 Questioned Costs: $1

Finding 563033 (2024-027)

Material Weakness 2024

City of Baltimore, Maryland

MD

Reporting Questioned Costs Material Weakness § 200.302 § 200.303

Finding 2024-027 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-023 Auditee’s Corrective Action Plan: BCHD fiscal department contin...

Finding 2024-027 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-023 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562904 (2024-023)

Material Weakness 2024

City of Baltimore, Maryland

MD

Questioned Costs Subrecipient Monitoring Eligibility § 200.302 § 200.303

Finding 2024-023 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-019 Auditee’s Corrective Action Plan: BCHD fiscal department continues to rev...

Finding 2024-023 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-019 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562864 (2024-021)

Material Weakness 2024

City of Baltimore, Maryland

MD

Reporting Questioned Costs Subrecipient Monitoring § 200.302 § 200.303

Finding 2024-021 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-016 Auditee’s Corrective Action Plan: The Federal Financial Report (FFR) is a cumu...

Finding 2024-021 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-016 Auditee’s Corrective Action Plan: The Federal Financial Report (FFR) is a cumulative report covering the entire project or award period, which for this grant spans from March 1, 2020, to February 28, 2025. As a result, the cumulative amounts reported on the FFR will not align with the amounts recorded in the general ledger for fiscal year 2024. BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established the Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562863 (2024-020)

Significant Deficiency 2024

City of Baltimore, Maryland

MD

Matching / Level of Effort / Earmarking Questioned Costs § 200.302 § 200.303

Finding 2024-020 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Significant Deficiency in Internal Controls and Noncompliance over Earmarking Repeat Finding: No Auditee’s Corrective Action Plan: BCHD fiscal will revise its internal processes to...

Finding 2024-020 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Significant Deficiency in Internal Controls and Noncompliance over Earmarking Repeat Finding: No Auditee’s Corrective Action Plan: BCHD fiscal will revise its internal processes to ensure compliance with 2 CFR 200 and the OMB compliance supplement (Part IV) by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include training on earmarking requirements. B. Established a Contract and Compliance Unit which responsibilities include ensuring program and fiscal staff are informed of all grant compliance requirements. C. Establish a process for periodic review by BCHD Fiscal internal audit team of grant expenditure reports and general ledger details to ensure compliance with the earmarking requirements. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562858 (2024-017)

Significant Deficiency 2024

City of Baltimore, Maryland

MD

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Finding 2024-017 U.S. Department of Health and Human Services AL No. 93.600 Head Start Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: MOCFS has noted the requirement to complete the FFATA report on the annual Baltimor...

Finding 2024-017 U.S. Department of Health and Human Services AL No. 93.600 Head Start Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: No Auditee’s Corrective Action Plan: MOCFS has noted the requirement to complete the FFATA report on the annual Baltimore City Head Start Administrative Calendar and will put an alert in the Workday system. Filing the FFATA for each sub-recipient will be completed once the entire contract is approved by the BOE. Contact Person: Shannon Burroughs-Campbell, Executive Director of Baltimore City Head Start Lisa Dooley, Head Start Accountant Completion Date: June 30, 2025

View Audit 357839

Finding 562453 (2024-013)

Significant Deficiency 2024

City of Baltimore, Maryland

MD

Questioned Costs Subrecipient Monitoring HUD Housing Programs § 200.303

Finding 2024-013 U.S. Department of Housing and Urban Development AL No. 14.241 Housing Opportunities for Persons with AIDS Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-010 Auditee’s Corrective Action Plan: Condition #1 Response MOHS acknowle...

Finding 2024-013 U.S. Department of Housing and Urban Development AL No. 14.241 Housing Opportunities for Persons with AIDS Significant Deficiency in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-010 Auditee’s Corrective Action Plan: Condition #1 Response MOHS acknowledges that evidence that the Federal Funding Accountability and Transparency Act (FFATA) report was prepared and submitted, was not provided. Corrective Action: MOHS will follow the City’s Grant Management office’s established process of establishing and maintaining a hardcopy audit file. This file will include: a. Federal System Registrations: SAM, DUNS #s, Grants.gov information; b. Federal Financial Accountability and Transparency (FFATA) information; c. FFR Submissions (SF-425 Federal Financial Report); d. Grant Agreements; and, e. Prior Year Single Audits/Monitoring Reports. Contact Person: Lakeysha Williams, Director of Programs, Mayor’s Office of Homeless Services Completion Date: April 7, 2025

View Audit 357839

Corrective Action Plans

Filters