Corrective Action Plans

Finding 1206458 (2024-005)

Material Weakness 2024

ME

Reporting HUD Housing Programs

Management Response/Corrective Action Plan: Management is in the process of reviewing current meal count procedures to identify gaps and inconsistencies in documentation and reporting practices. The goal is to strengthen internal controls and ensure that the meal counting process is both accurate an...

Management Response/Corrective Action Plan: Management is in the process of reviewing current meal count procedures to identify gaps and inconsistencies in documentation and reporting practices. The goal is to strengthen internal controls and ensure that the meal counting process is both accurate and auditable.

View Audit 398467

Finding 1206391 (2024-002)

Material Weakness 2024

Hollywood West Tenant Action Committee

CA

Subrecipient Monitoring Reporting § 200.512

Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number...

Name of auditee: Hollywood West Tenant Action Committee HUD auditee identification number: 122-44641 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2024 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2024-002: The Corporation has not submitted audited financial statements to the Federal Audit Clearinghouse after the receipt of the auditor's reports. Recommendation: The Corporation should submit audited financial statements to the Federal Audit Clearinghouse within the time frames required. Action(s) taken or planned on the finding: The audited financial statements will be submitted to the Federal Audit Clearinghouse on a go forward basis.

View Audit 398397

Finding 1206279 (2024-002)

Material Weakness 2024

Nebraska Children's Home Society

NE

Subrecipient Monitoring Material Weakness Reporting

Management acknowledges that this finding was also reported in the prior fiscal year. Due to staffing changes within the finance department and competing operational priorities, the corrective actions previously planned were not fully implemented in time to ensure timely filing of the required repor...

Management acknowledges that this finding was also reported in the prior fiscal year. Due to staffing changes within the finance department and competing operational priorities, the corrective actions previously planned were not fully implemented in time to ensure timely filing of the required reports. Management recognized the importance of timely regulatory filings and has taken additional steps to strengthen internal processes and oversight. Significant staff turnover within the finance department during and after the audit period resulted in delays in preparing audit schedules and supporting documentation required for the completion of the related regulatory filings. In addition, formalized procedures and a compliance calendar for regulatory reporting deadlines were not fully implemented during the prior year. Finance Management will implement a financial compliance calendar to track all required regulatory reporting deadlines, including IRS Form 990, single audit and other financial reports. The calendar will include preparation, review, and submission deadlines to ensure reports are completed and filed in time. Finance management will coordinate with external auditors and tax preparers to support timely completion of filings. Responsible party: Finance Management Target Completion Date: June 30, 2026 Monitoring: The Finance Director will maintain and review the compliance calendar monthly to monitor upcoming deadlines and filing status. The CFDO will periodically review compliance with reporting requirements to ensure filings are completed within required timeframes.

View Audit 398306

Finding 1206278 (2024-001)

Material Weakness 2024

Nebraska Children's Home Society

NE

Subrecipient Monitoring Reporting Material Weakness

Management acknowledges this finding and recognizes the importance of maintaining adequate internal control over the preparation and review of accounting records. This finding was also reported in the prior fiscal year, however due to turnover within key finance leadership roles and limited staff ca...

Management acknowledges this finding and recognizes the importance of maintaining adequate internal control over the preparation and review of accounting records. This finding was also reported in the prior fiscal year, however due to turnover within key finance leadership roles and limited staff capacity and expertise during the audit period, the previously planned corrective actions were not fully implemented. While improvement began toward the end of Fiscal Year 2025 (FY25), management acknowledges that the implementation of strengthened internal control procedures will continue into Fiscal Year 2026 (FY26), as the newly established finance team further develops and formalizes these processes. The Finance Department experienced turnover within key finance leadership roles, which limited the department's capacity and expertise necessary to implement the corrective actions and process improvements identified in the prior year audit. The organization has since strengthened the finance department by hiring additional staff to support the implementation of improved internal controls, formalized procedures, and regulatory reporting processes. Finance leadership has implemented additional review procedures over the preparation of the accounting records including supervisory review of journal entries, documented monthly account reconciliations and a standardized month-end checklist. These procedures will help ensure accounting records are accurate, complete and reviewed timely. While improvements begin during the end of FY25, full implementation of these process improvements will continue into FY26 to ensure sustainable internal control practices and timely regulator reporting. Responsible party: Finance Management Target Completion Date: June 30, 2026 Monitoring: Management reviews the month end close calendar monthly to ensure all reconciliation, journal entries, and reporting are completed and documented. Finance management also reviews monthly financials with the program leaders during soft close.

View Audit 398306

Finding 1206271 (2024-005)

Material Weakness 2024

Cherrywood Village 094-Ee009-Np-Wah

ND

Internal Control / Segregation of Duties Material Weakness Reporting § 200.512

2024-005 – Reporting Contact Person Terry Hanson Corrective Action Plan Management recognizes the delayed submission of the 2024 audit to the Federal Audit Clearinghouse. To prevent recurrence, management is developing a compliance calendar and assigning responsibility for federal filing deadlines t...

2024-005 – Reporting Contact Person Terry Hanson Corrective Action Plan Management recognizes the delayed submission of the 2024 audit to the Federal Audit Clearinghouse. To prevent recurrence, management is developing a compliance calendar and assigning responsibility for federal filing deadlines to the Director of Finance. Regular progress reviews will ensure all audit deliverables are completed and submitted within the required ninemonth period. This corrective measure will improve accountability and ensure timely compliance with federal reporting standards. Planned Completion Date for CAP Immediately

View Audit 398304

Finding 1206259 (2024-002)

Material Weakness 2024

County of Monroe, Pennsylvania

PA

Reporting

Completion and Submission of Annual Single Audit – Significant Deficiency/Noncompliance · All Federal Programs Condition/Context: The County's Single Audit and reporting package was delayed for the year ended December 31, 2024, beyond the 9-month due date. As part of the County's year-end close, the...

Completion and Submission of Annual Single Audit – Significant Deficiency/Noncompliance · All Federal Programs Condition/Context: The County's Single Audit and reporting package was delayed for the year ended December 31, 2024, beyond the 9-month due date. As part of the County's year-end close, the Children and Youth federal revenues and expenditures were not timely reconciled between the programmatic reports and the general ledger leading to incomplete and inaccurate information being included in the County's general ledger system and incomplete information for the County’s Schedule of Expenditures of Federal Awards. The June 30, 2024 reconciliation was not completed until June 2025 and the December 31, 2024 reconciliation and necessary adjustments were not completed until October 2025. Cause: The Children and Youth fund reconciliations were not completed timely due to staffing limitations, which delayed the completion and filing of the County's December 31, 2024 Single audit and reporting package. Corrective Action Planned: In response to Finding 2024-002, the County is taking the following steps to ensure that these issues are rectified going forward. The issues regarding Children and Youth have been ongoing. The delay in the filing of the Single Audit was solely due to their lack of staffing and inability to complete their reconciliations and reporting timely. The Commissioners and Children & Youth Administration are well aware of the lack of staff and are working towards hiring individuals to complete the necessary tasks. The County continues to work with a sub-contractor in an effort to free up time of the full-time staff and assist with preparation and submission of monthly and quarterly reporting. Controller, Erik Diemer, Fiscal Director, Jennifer Barclay, County Commissioners and Director of C & Y are providing all available resources to assist the Fiscal Department of Children and Youth. Vacant positions in the Department have been filled, and future reconciliations will be timely.

View Audit 398236

Finding 1206239 (2024-002)

Material Weakness 2024

Ramsey County

MN

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

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

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

View Audit 398206

Finding 1206234 (2024-003)

Material Weakness 2024

City of Wilkes-Barre, Pennsylvania

PA

Reporting Special Tests & Provisions

The City plans to have information ready for the auditors to get 2025 done in a reasonable time frame. This finding will likely carry to 2025 but between staffing and priorities, the City hopes to have clear this finding following its December 31, 2025 audit.

View Audit 398198

Finding 1206107 (2024-002)

Material Weakness 2024

Bowling Green Warren County Regional AIR

KY

Reporting § 200.512

March 6, 2026 - Bowling Green – Warren County Regional Airport Board respectfully submits the following corrective action plan for the year end June 30, 2024. Name and address of independent public accounting firm: Kirby & Moore, LLP, 1020 College Street, Bowling Green, Kentucky. Audit period: Fisca...

March 6, 2026 - Bowling Green – Warren County Regional Airport Board respectfully submits the following corrective action plan for the year end June 30, 2024. Name and address of independent public accounting firm: Kirby & Moore, LLP, 1020 College Street, Bowling Green, Kentucky. Audit period: Fiscal year ending June 30, 2024. The findings from the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT: 2024-001 Material Weakness: Adjusting Journal Entries. Recommendation: The accounts of the organization should be reviewed each reporting period to ensure balances are reported in accordance with accrual basis accounting principles generally accepted in the United States of America (U.S. GAAP). Action Taken: Airport management will ensure accounts are reviewed each reporting period to ensure balances are reported in accordance with U.S. GAAP. FINDINGS – FEDERAL AWARD PROGRAM AUDIT: DEPARTMENT OF TRANSPORTATION - 2024-002 Airport Improvement Program – 20.106. Recommendation: Procedures should be put in place to ensure the data collection form is submitted to the FAC timely. Action Taken: Airport management will ensure the data collection form is submitted to the FAC timely. If the Federal Aviation Administration has questions regarding this plan, please call Susan Harmon at 270-842-1101.

View Audit 398076

Finding 1206060 (2024-003)

Material Weakness 2024

City of Menomonie

WI

Procurement, Suspension & Debarment Reporting § 200.512

Finding 2024-003: Late Submission Corrective Action: The City of Menomonie is developing policies and procedures to ensure that financial records are maintained on a more current basis, reconciled timely and audited within nine months after year-end. Persons Responsible: Eric Atkinson Anticipated Co...

Finding 2024-003: Late Submission Corrective Action: The City of Menomonie is developing policies and procedures to ensure that financial records are maintained on a more current basis, reconciled timely and audited within nine months after year-end. Persons Responsible: Eric Atkinson Anticipated Completion Date: Ongoing

View Audit 397944

Finding 1205908 (2024-007)

Material Weakness 2024

Cardiovascular Center Corporation of Puerto Rico and the Caribbean

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.334

The Corporation will take the following corrective actions: • Compliance Calendar Implementation - Develop a formal compliance calendar including all Uniform Guidance reporting deadlines. • Designated Reporting Oversight - Assign a responsible management-level individual to monitor timely submission...

The Corporation will take the following corrective actions: • Compliance Calendar Implementation - Develop a formal compliance calendar including all Uniform Guidance reporting deadlines. • Designated Reporting Oversight - Assign a responsible management-level individual to monitor timely submission of federal reporting requirements. • Financial Close Acceleration - Improve internal financial close timelines to meet audit deadlines. • Monitoring and Reporting - Provide periodic updates to executive management regarding compliance status. • Staffing Structure Enhancement – Continue strengthening the finance and budget department structure to improve compliance. Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date June 30, 2026

View Audit 397711

Finding 1205907 (2024-006)

Material Weakness 2024

Cardiovascular Center Corporation of Puerto Rico and the Caribbean

PR

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.334

Corrective Action Plan • Policies and Procedures Reinforcement – Review and reinforce procurement policies to ensure all purchases are supported by approved requisitions and required quotations. • Documentation Retention Controls - Implement controls to ensure all procurement documentation is proper...

Corrective Action Plan • Policies and Procedures Reinforcement – Review and reinforce procurement policies to ensure all purchases are supported by approved requisitions and required quotations. • Documentation Retention Controls - Implement controls to ensure all procurement documentation is properly filed and retrievable. • Staff Training and Development – Provide training on procurement requirements under uniform guidance. This training will focus on compliance with policies and procedures and emphasize the importance of require documentation for each process and best practices. • Monitoring and Compliance Review - Establish periodic internal review procedures to ensure adherence to procurement policies. Name of the contact person responsible for corrective action plan Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date June 30, 2025

View Audit 397711

Finding 1205906 (2024-005)

Material Weakness 2024

Cardiovascular Center Corporation of Puerto Rico and the Caribbean

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

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

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

View Audit 397711

Finding 1205814 (2024-007)

Material Weakness 2024

City of Tower, Minnesota

MN

Reporting

There is now a new Clerk/Treasurer in place who is aware of the federal award tracking requirements and will keep a current listing of federal award information.

View Audit 397558

Finding 1205810 (2024-003)

Material Weakness 2024

City of Tower, Minnesota

MN

Reporting Internal Control / Segregation of Duties

Management will evaluate the cost benefit of making cash to accrual adjusting entries on an annual basis.

View Audit 397558

Finding 1205797 (2024-017)

Material Weakness 2024

City of Mission

TX

Cash Management Reporting Significant Deficiency

The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Officials: Michael Elizalde, Grants & Strategic Initiatives Director / Vidal Roman, Finance Director ...

The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Officials: Michael Elizalde, Grants & Strategic Initiatives Director / Vidal Roman, Finance Director Timeline to Complete: Estimated June 2026

View Audit 397522

Finding 1205793 (2024-018)

Material Weakness 2024

City of Mission

TX

Eligibility Reporting Significant Deficiency

The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into formal grant management policy. Responsible Officials: Michael Elizalde, Grants &...

The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into formal grant management policy. Responsible Officials: Michael Elizalde, Grants & Strategic Initiatives Director Timeline to Complete: Estimated June 2026.

View Audit 397522

Finding 1205774 (2024-003)

Material Weakness 2024

City of Chickasha, Oklahoma

OK

Procurement, Suspension & Debarment Eligibility Reporting § 200.512

Views of Responsive Officials of Auditee: Management recognizes that the City’s audits have not been completed within the required statutory deadlines in recent years, including the reporting delay noted in this finding. These delays were primarily the result of turnover and transition in key financ...

Views of Responsive Officials of Auditee: Management recognizes that the City’s audits have not been completed within the required statutory deadlines in recent years, including the reporting delay noted in this finding. These delays were primarily the result of turnover and transition in key financial staff positions, which impacted continuity and the timely completion of audit-related activities. At the same time, management would like to highlight the significant progress that has been made in addressing this issue. Over the past six months, the City has successfully completed two fiscal year audits, representing meaningful advancement toward eliminating the audit backlog. Management is committed to continuing this progress and has established a plan to return to full compliance with reporting deadlines. The City anticipates being fully current beginning with the FY-2027 audit cycle and will continue implementing process improvements and ensuring staffing stability to support timely audit completion. Management understands the importance of timely reporting, particularly as it relates to maintaining eligibility for federal funding and will prioritize adherence to all applicable deadlines moving forward.

View Audit 397519

Finding 1205772 (2024-004)

Material Weakness 2024

Midwest Organic Association Inc

WI

Reporting

Agency: U.S. Department of Agriculture Responsible Person, Title: Cori Skolaski, ED Completion date: 2026 Agency Response: Concur Corrective Action Plan: The Association will file reports timely for the year ended December 31, 2025 and any future years.

View Audit 397509

Finding 1205763 (2024-002)

Material Weakness 2024

Missoula County

MT

Reporting

Corrective Action Plan In the audit schedule of findings for the year ended June 30, 2024, the auditors identified the following item in the financial statements. The County’s corrective action plan for this item is addressed below. Finding 2024-001 – Internal Control Over Financial Reporting and Ac...

Corrective Action Plan In the audit schedule of findings for the year ended June 30, 2024, the auditors identified the following item in the financial statements. The County’s corrective action plan for this item is addressed below. Finding 2024-001 – Internal Control Over Financial Reporting and Account Adjustments including the Schedule of Expenditures of Federal Awards Missoula County will begin with FY25 year-end financial reporting to provide additional training to all staff related to Financial Statement reporting. Due to staffing issues, an accounting firm will continue to support Missoula County staff in meeting deadlines with accurate information. A thorough review of all practices, policies and procedures will continue over the next fiscal year to ensure key control activities are in place. Each staff person involved with Financial Reporting will be trained on the key control activities and their importance. This information has been used in implementing a new Financial Software application which allows for business process workflows to aid departments in completing financial transactions accurately. The business process workflows include appropriate internal controls and review steps to ensure accuracy of entries. In addition, a new process for tracking monthly, quarterly and year end adjustments will be implemented. This process includes a second individual to review the year end reports for completeness, adherence to GAAP and monitoring of information reported on the Schedule of Expenditures of Federal Awards. Contact Person Responsible for Corrective Action: Michelle Denman, Financial Services Director Anticipated Completion Date of the Corrective Action: June 30, 2026 Finding 2024-002 – U.S. Department of Treasury COVID 19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)-ALN 21.027 Reporting Missoula County has implemented a dual control process over CSLFRF reporting. Prior to quarterly reporting, the accountant in finance will review all expenditures related to obligated ARPA programs and reconcile this activity with each department expenditures. At the end of the quarter, after all months have closed and prior to Treasury reporting, an additional review of prior quarter activity will occur to ensure any reclassification journals have been noted to ensure prior quarter reports can be updated. Contact Person Responsible for Corrective Action: Michelle Denman, Financial Services Director Anticipated Completion Date of the Corrective Action: June 30, 2026

View Audit 397500

Finding 1205742 (2024-005)

Material Weakness 2024

Excelsior Springs Hospital

MO

Reporting Internal Control / Segregation of Duties

Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.

View Audit 397466

Finding 1205735 (2024-001)

Material Weakness 2024

County of Coos, New Hampshire

NH

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

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

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

View Audit 397440

Finding 1205409 (2024-005)

Material Weakness 2024

City of Dunkirk Housing Authority

NY

HUD Housing Programs Reporting

2023-005 Material Weakness: See finding 2024-005. Recommendation: We recommend that management of the Authority review the deadlines for FDS submission and the financial statement submission and work with the newly retained fee accountant to ensure that these deadlines are met in the future. Managem...

2023-005 Material Weakness: See finding 2024-005. Recommendation: We recommend that management of the Authority review the deadlines for FDS submission and the financial statement submission and work with the newly retained fee accountant to ensure that these deadlines are met in the future. Management’s response: The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that its submissions were not timely. Management engaged the services of a fee-accountant subsequent to year-end who will assist with these submission going forward. In order to submit and ensure integrity of the unaudited financial statements, the bank accounts reconciliations needed to be completed and account analysis performed. Management will continue to prioritize and remediate outstanding compliance obligations and develop a compliance catch-up plan to ensure timely account reconciliation and account analysis in the future. The fee accountant was not re-engaged to perform bank reconciliations and account analysis for the year ended June 30, 2025 until after June 30, 2025 year end. As a result, management expects this to be a repeat finding in the June 30, 2025 audit.

View Audit 397084

Finding 1205398 (2024-004)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Reporting § 200.303 § 200.502 § 200.510

Other finding – SEFA Preparation Preparation of Schedule of Expenditures of Federal Awards Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its policies and procedures and i...

Other finding – SEFA Preparation Preparation of Schedule of Expenditures of Federal Awards Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its policies and procedures and internal controls to ensure accurate reporting of the Schedule as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. The ORSPA department created a standard pre-award approval process for all sponsored proposals prior to submission or award acceptance. The pre-award approval process applies to all federal, state, local, private and commercial funding opportunities across all UMMS entities and covers new, renewal, resubmission and supplemental proposals. The establishment of a central intake process through one department, for all grants across the Corporation, enhances the controls to ensure complete and accurate reporting of the Schedule as required by the Uniform Guidance. Additionally, ORSPA and Corporate Financial Reporting implemented the following controls to ensure all expenditures of federal awards are included on the Schedule. These controls include:  Reconciliation of the grants from the pre-award approval process to the grants tagged in the accounting system;  Use of a specific grant identifier within the accounting system to track expenditures and revenue recognition and tag grants as federal, state or private funded;  Comparison of grant expenditures per the accounting system to the grant agreement;  Comparison of grant expenditures per the accounting system to the financial reporting submissions made to the federal agencies;  Certification from legal entity Finance Executives that the draft Schedule is complete and accurate;  Comparison of the prior year Schedule to the current year Schedule with further investigation around changes in grants and agencies included, and significant changes in the expenditures. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397083

Finding 1205395 (2024-002)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles Cash Management Reporting

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

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

View Audit 397083

Corrective Action Plans

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