Corrective Action Plans

Finding 544459 (2024-002)

Significant Deficiency 2024

HI

Special Tests & Provisions Subrecipient Monitoring Eligibility

Federal Award Findings and Questioned Costs: Finding 2024.002 - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Mana...

Federal Award Findings and Questioned Costs: Finding 2024.002 - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Management recently migrated their electronic health records from AthenaPractice and Dentrix to EPIC. EPIC is programmed to calculate the sliding fee discount based upon the Family Size and Income that is entered into the system, unlike Dentrix which did not have this capability. In addition, monthly audits are conducted by the Billing Department to ensure that the supporting documentation matches the information entered into EPIC. If there are any question regarding this plan, please e-mail Monique van der Aa at monique@ccmaui.org. Sincerely, Monique van der Aa Chief Financial Officer

View Audit 351137

Finding 544452 (2024-003)

Material Weakness 2024

Ivy Tech Community College of Indiana

IN

Subrecipient Monitoring Eligibility Material Weakness § 200.303 § 200.329

FINDING 2024-003 (Auditor Assigned Reference Number) Finding Subject: TRIO - Reporting Contact Person Responsible for Corrective Action: Nichole Stitt, AVP Sponsored Programs Contact Phone Number and Email Address: 317-921-4800 ext. 084987 and nstitt@ivytech.edu Views of Responsible Officials: We co...

FINDING 2024-003 (Auditor Assigned Reference Number) Finding Subject: TRIO - Reporting Contact Person Responsible for Corrective Action: Nichole Stitt, AVP Sponsored Programs Contact Phone Number and Email Address: 317-921-4800 ext. 084987 and nstitt@ivytech.edu Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The college will develop an internal control system to ensure compliance with the requirement related to the TRIO reporting compliance requirement. Anticipated Completion Date: The projected date of completion for the CAP mentioned above is June 30, 2025. The Student Support Services APR process was corrected in April 2024, a query interfacing with Banner to identify errors in the APRs submitted by each campus, was created.

View Audit 351125

Finding 544448 (2024-001)

Significant Deficiency 2024

Ivy Tech Community College of Indiana

IN

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency § 200.303

FINDING 2024-001 (Auditor Assigned Reference Number) Finding Subject: Economic Adjustment Assistance - Special Tests and Provisions – Wage Rate Requirements Contact Person Responsible for Corrective Action: Nichole Stitt, AVP Sponsored Programs Contact Phone Number and Email Address: 317-921-4800 ex...

FINDING 2024-001 (Auditor Assigned Reference Number) Finding Subject: Economic Adjustment Assistance - Special Tests and Provisions – Wage Rate Requirements Contact Person Responsible for Corrective Action: Nichole Stitt, AVP Sponsored Programs Contact Phone Number and Email Address: 317-921-4800 ext. 084987 and nstitt@ivytech.edu Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The college will develop an internal control that is documented for the Special Tests and Provisions - Wage Rate Requirement. Anticipated Completion Date: The projected date of completion for the CAP mentioned above is June 30, 2025.

View Audit 351125

Finding 544445 (2024-002)

Significant Deficiency 2024

Rice Lake Housing Authority

WI

Subrecipient Monitoring HUD Housing Programs Internal Control / Segregation of Duties

Corrective Action Planned: The Authority will closely monitor all deposits to make sure that the amount of funds on deposit are protected by federal deposit insurance, corporate surety bond, or collateral. Completion Date: June 30, 2025

View Audit 351122

Finding 544437 (2024-005)

Significant Deficiency 2024

City of Portsmouth

OH

Questioned Costs Period of Performance Subrecipient Monitoring § 200.303 § 200.344

Period of Performance Recommendation: We recommend that the City of Portsmouth review its procedures to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: NO Action taken in response to finding: Rev...

Period of Performance Recommendation: We recommend that the City of Portsmouth review its procedures to ensure that expenditures charged to the program are incurred within the grant’s period of performance. Explanation of disagreement with audit finding: NO Action taken in response to finding: Review grant related procedures to ensure all expenditures take place during the grant period. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Crimer, Patrick Fletcher, & Kyera Pope. Planned completion date for corrective action plan: 6/30/25

View Audit 351108 Questioned Costs: $1

Finding 544433 (2024-004)

Significant Deficiency 2024

City of Portsmouth

OH

Questioned Costs Subrecipient Monitoring Significant Deficiency § 200.303

Allowable Activities – Gift Card Recommendation: We recommend that the City develop and distribute clear guidelines on the documentation requirements for the assistance program and provide training for staff on the importance of obtaining and maintaining proper documentation and adhering to interna...

Allowable Activities – Gift Card Recommendation: We recommend that the City develop and distribute clear guidelines on the documentation requirements for the assistance program and provide training for staff on the importance of obtaining and maintaining proper documentation and adhering to internal controls. Explanation of disagreement with audit finding: NO Action taken in response to finding: Review and evaluate the policies for safeguarding assets and maintaining better records and reconciliation procedures. Name(s) of the contact person(s) responsible for corrective action: Temeka Mayes, Trey Burke Planned completion date for corrective action plan: 6/30/25

View Audit 351108 Questioned Costs: $1

Finding 544429 (2024-003)

Significant Deficiency 2024

City of Portsmouth

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Significant Deficiency § 200.303

Allowable Activities – Gift Card Controls Recommendation: We recommend that the City review and evaluate procedures to ensure that the procedures over safeguarding assets, maintenance of records, and reconciliation of activity are consistently performed. Explanation of disagreement with audit find...

Allowable Activities – Gift Card Controls Recommendation: We recommend that the City review and evaluate procedures to ensure that the procedures over safeguarding assets, maintenance of records, and reconciliation of activity are consistently performed. Explanation of disagreement with audit finding: NO Action taken in response to finding: Review and evaluate the policies for safeguarding assets and maintaining better records and reconciliation procedures. Name(s) of the contact person(s) responsible for corrective action: Temeka Mayes, Trey Burke Planned completion date for corrective action plan: 6/30/25

View Audit 351108

Finding 544424 (2024-002)

Material Weakness 2024

City of Portsmouth

OH

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

FFATA Reporting Prior Year Finding: 2023-004 Recommendation: We recommend the City establish procedures and internal controls to ensure that all required sub awards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each sub award. Exp...

FFATA Reporting Prior Year Finding: 2023-004 Recommendation: We recommend the City establish procedures and internal controls to ensure that all required sub awards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each sub award. Explanation of disagreement with audit finding: NO Action taken in response to finding: Review City’s policy, procedures, and internal controls to ensure the required sub awards and reported timely and accurately to FSRS. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Crimer, Patrick Fletcher, & Kyera Pope. Planned completion date for corrective action plan: 06/30/25

View Audit 351108

Finding 544420 (2024-002)

Significant Deficiency 2024

City of Oxnard

CA

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting

The City will improve its internal controls by implementing a new policy and procedures that will: (1) require staff to annually participate in HUD trainings related to federal grant reporting, (2) require management and staff to meet monthly to discuss and track federal reporting requirements and r...

The City will improve its internal controls by implementing a new policy and procedures that will: (1) require staff to annually participate in HUD trainings related to federal grant reporting, (2) require management and staff to meet monthly to discuss and track federal reporting requirements and review a listing of subaward agreements and (3) require staff to submit the Cash on Hand Report quarterly and the FFATA Report monthly.

View Audit 351106

Finding 544404 (2024-002)

Material Weakness 2024

Philadelphia Youth Basketball, Inc.

PA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.213 § 200.319

Finding No. 2024-002: Procurement – Material Weakness in Internal Control Over Compliance Contact for Corrective Action: Jayson Tischler, Chief Operating Officer The Organization needed to sole source its architectural firm because it was mission-critical on a compressed timeline with the New Mar...

Finding No. 2024-002: Procurement – Material Weakness in Internal Control Over Compliance Contact for Corrective Action: Jayson Tischler, Chief Operating Officer The Organization needed to sole source its architectural firm because it was mission-critical on a compressed timeline with the New Markets Tax Credit financing process. The Organization’s construction owner’s representative firm, D3 Development, LLC, undertook a market review that confirmed fair and reasonable pricing and service for the selected architectural services. The Organization then subsequently received a federal grant after the construction project began, which allowed the Organization to reimburse for architectural expenses. The Organization was able to reimburse through budget approval from HUD for those retroactive expenses, where competitive bidding had not been a requirement for the organization for any existing federal grants or awards. To ensure future compliance with federal procurement requirements, the Organization will revise its procurement policy to require a competitive bidding process, and proper documentation and record keeping of such, for all vendors eligible for reimbursement under federal programs. Additionally, the Organization will include suspension and debarment confirmation through the System for Award Management (SAM) in its procurement policy for all contractors. The Organization believes that these steps outlined above address this corrective action. Expected Completion Date: April 2025

View Audit 351077

Finding 544363 (2024-003)

Significant Deficiency 2024

Ontrack Inc.

OR

Subrecipient Monitoring Reporting Significant Deficiency

Contact Person Mark Bell Director of Finance vcc.m.bell@ontrackroguevalley.org Explanation and Specific Reasons for Disagreement With the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned 1. Establish FSRS Reporting Policy and Proced...

Contact Person Mark Bell Director of Finance vcc.m.bell@ontrackroguevalley.org Explanation and Specific Reasons for Disagreement With the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned 1. Establish FSRS Reporting Policy and Procedures o The Organization will develop and implement a formal Subaward Reporting Policy to ensure that all first-tier subawards of $30,000 or more are reported in FSRS in compliance with 2 CFR Part 170. 2. Assign Responsibility and Oversight o A specific staff member within the Grants department will be designated as the FSRS Reporting Coordinator and will be responsible for verifying the completeness and accuracy of subaward reporting and for timely submission to FSRS. o A pre-submission review will be conducted by the FSRS Reporting Coordinator to verify that subawards over $30,000 are captured and reported. 3. Implement Internal Controls and Review Checkpoints o All subawards will be reviewed as part of the pre-award and post-award grant workflow to determine FSRS applicability. o A pre-submission review will be conducted by the Grants Compliance Officer to verify that subawards over $30,000 are captured and reported. 4. Monitoring and Audit Trail Documentation o FSRS submissions will be documented and retained in the grant file along with confirmation of submission and reporting screenshots. Anticipated Completion Date September 30, 2025

View Audit 351003

Finding 544359 (2024-002)

Significant Deficiency 2024

New Mexico Coalition Against Domestic Violence

NM

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

To ensure accountability and timely completion, management conducts periodic meetings to review upcoming deadlines and confirm that the departments responsible have completed and submitted the required reports. These meetings serve to reinforce compliance, address any potential delays proactively, a...

To ensure accountability and timely completion, management conducts periodic meetings to review upcoming deadlines and confirm that the departments responsible have completed and submitted the required reports. These meetings serve to reinforce compliance, address any potential delays proactively, and ensure adherence to all reporting obligations.

View Audit 350999

Finding 544350 (2024-002)

None 2024

Voorhees University

SC

Cash Management Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.305

We concur with the recommendation. The one (1) instance of drawdown that exceeded the three day rule for drawdowns was an oversight on the part fo the institution. In addition, we will revise the spreadsheet used to track cumulative program expenditures against drawdowns.

View Audit 350984

Finding 544348 (2024-001)

Significant Deficiency 2024

City of Bell, California

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2024-001 Procurement and Suspension and Debarment – Internal Control over Suspension and Debarment City will incorporate the Uniform Guidance requirements into its existing grant policies and procedures to ensure the City is in compliance with the Uniform Guidance. City Accounting staff (Acc...

Finding 2024-001 Procurement and Suspension and Debarment – Internal Control over Suspension and Debarment City will incorporate the Uniform Guidance requirements into its existing grant policies and procedures to ensure the City is in compliance with the Uniform Guidance. City Accounting staff (Accountant) will access SAM.Gov to check for possible party ineligibility following receipts of an offer or proposal and again, immediately before making the award and keep record of that check with the time stamped for every CIP project that is advertised for bids. In addition, staff will verify that neither the contractor nor any of its key personnel appear on the Federal or State debarment lists. All this documentation then will be compiled in the project file in both hard-copy and electronically. Responsible Person: Director of Finance Expected Implementation Date: July 1, 2025

View Audit 350982

Finding 544337 (2024-001)

Material Weakness 2024

Dominican University

IL

Student Financial Aid Special Tests & Provisions Subrecipient Monitoring

Reporting – The University will review and update current procedures to ensure timely processing and monitoring of NSLDS reports. Internal reports will be run simultaneously to make sure all students are captured and their status is correctly reported. Anticipated Completion Date - September 30, ...

Reporting – The University will review and update current procedures to ensure timely processing and monitoring of NSLDS reports. Internal reports will be run simultaneously to make sure all students are captured and their status is correctly reported. Anticipated Completion Date - September 30, 2024; Responsible Contact Person for Planned Corrective Action - Tina Baskin, Executive Director of Financial Aid & Enrollment Services

View Audit 350931

Finding 544178 (2024-007)

Significant Deficiency 2024

Delaware State University

DE

Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance § 200.308 § 200.309 § 200.403

2024-007 Research and Development Cluster – Federal Assistance Listing Nos. 84.017 and 47.081 – Period of Performance Recommendation: We recommend that the University review and revise their current procedures in place and provide training to employees within the grant and finance functions related ...

2024-007 Research and Development Cluster – Federal Assistance Listing Nos. 84.017 and 47.081 – Period of Performance Recommendation: We recommend that the University review and revise their current procedures in place and provide training to employees within the grant and finance functions related to the grant reconciliation and recording process to ensure expenses are reflected prior to the grant ending and recorded in the correct period on the SEFA. Explanation of disagreement with audit finding: There is no disagreement to the audit finding. Action taken in response to finding: Restricted Funds Accounting (RFA) team has restructured with new leadership and added all new staff. RFA will train new staff, develop and update policies and procedures, and automate processes within ERP systems, as appropriate. RFA is creating current and updated SOPS for each task and making sure the current staff is learning processes the correct way; this includes reconciliation and recording in the correct period. Name(s) of the contact person(s) responsible for corrective action: Director of Accounting, Tonya Cardwell. Planned completion date for corrective action plan: December 2026

View Audit 350927

Finding 544177 (2024-006)

Material Weakness 2024

Delaware State University

DE

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

2024-006 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation o...

2024-006 Student Financial Assistance Cluster – Federal Assistance Listing Nos. 84.007, 84.063, 84.033 and 84.268 – Gramm-Leach-Bliley Act (GLBA) Recommendation: We recommend the University review is policies and procedures and update the information security plan to be GLBA compliant. Explanation of disagreement with audit finding: There is no disagreement to the audit finding. Action taken in response to finding: The Division of Information Technology will implement a comprehensive user account deactivation procedure. The user account deactivation procedure will significantly reduce security risks, ensure compliance with regulatory requirements, and protect sensitive information from unauthorized access. Name(s) of the contact person(s) responsible for corrective action: Executive Director of Network Services, Russell Weaver & Vice President / CIO, Darrell McMillon Planned completion date for corrective action plan: June 2025

View Audit 350927

Finding 544141 (2024-006)

Significant Deficiency 2024

Washington Adventist University

MD

Subrecipient Monitoring Student Financial Aid

Action taken in response to finding: To address the identified deficiencies in WAU’s written information security program and ensure compliance with 16 CFR § 314.4, the following actions have been taken: 1. Approval of the Information Security Program: o Action: We have updated the written informat...

Action taken in response to finding: To address the identified deficiencies in WAU’s written information security program and ensure compliance with 16 CFR § 314.4, the following actions have been taken: 1. Approval of the Information Security Program: o Action: We have updated the written information security program as formally approved by the appropriate individual within the institution, Rosalee Pedapudi, ITS Director. This step designates a qualified individual responsible for overseeing and implementing the information security program as a requirement under 16 CFR § 314.4(a). 2. Design and Implementation of Safeguards: o Action: According to 16 CFR § 314.4(c), institutions must implement safeguards to control identified risks, including encryption of customer information in transit and at rest. We have documented specific safeguards to control the risks identified through the institution's risk assessment, including a policy mandating the encryption of customer information both on the institution's systems and during transmission. As such, the university encrypts Non-Public Financial information both at rest and in transit using industry-standard encryption protocols (e.g. VPN). Where encryption is not feasible, compensating controls are implemented to protect sensitive data. The university also requires Multifactor Authentication (MFA) for systems that process, store, or transmit protected financial information. Access is governed by the principle of least privilege, with privileged access granted by authorized university officers, ensuring that only approved personnel can access sensitive data. 3. Regular Testing and Monitoring of Safeguards: o Action: According to 16 CFR § 314.4(d), WAU is required to regularly test and monitor the effectiveness of their safeguards to ensure the security of customer information. We have established procedures for annual penetration testing through Applied Technology Services and monitoring of the effectiveness of the implemented safeguards. Name(s) of the contact person(s) responsible for corrective action: Rosalee Pedapudi Planned completion date for corrective action plan: July 15, 2025.

View Audit 350924

Finding 544075 (2024-001)

Material Weakness 2024

Williams Unified School District No. 2

AZ

Subrecipient Monitoring Material Weakness Reporting

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: April 7,2025 Planned Corrective Action: WUSD2 has designed and implemented an effective internal ...

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425 Contact Person: Brianne Ford, Business Manager Anticipated Completion Date: April 7,2025 Planned Corrective Action: WUSD2 has designed and implemented an effective internal control procedure to ensure that the federal reporting is tracked and completed in a timely manner. The Business Manager and Federal Programs Director will meet monthly to review grant funding and reporting. This will include any deadlines for submissions of grants and reporting.

View Audit 350877

Finding 544047 (2024-003)

Significant Deficiency 2024

The Pennsylvania State University

PA

Subrecipient Monitoring Internal Control / Segregation of Duties Cash Management § 200.305

Finding Number: 2024-003, Subrecipient Payments Condition: The University did not have adequate controls in place to ensure invoices to subrecipients were paid timely within the 30-calendar-day requirement. Planned Corrective Action: Penn State has created a new Subaward Administration and Complian...

Finding Number: 2024-003, Subrecipient Payments Condition: The University did not have adequate controls in place to ensure invoices to subrecipients were paid timely within the 30-calendar-day requirement. Planned Corrective Action: Penn State has created a new Subaward Administration and Compliance Office (SACO), which is part of the new Post Award Contractual Compliance Office. The SACO is led by its own director and will provide central oversight over key subaward compliance processes, such as subrecipient payments, and provide training to campus on subrecipient processes. This function has previously not existed in a central office at Penn State. The creation of this office demonstrates Penn State’s commitment to compliance for subaward activities. Contact person responsible for corrective action: John Hanold, Associate Vice President for Research; Director, Office of Research Administrative Services Anticipated Completion Date: June 30, 2025

View Audit 350858

Finding 542032 (2024-002)

Significant Deficiency 2024

The Pennsylvania State University

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Finding Number: 2024-002, Effort Certification Condition: One of the internal controls that the University has designed related to ensuring that personnel expenses charged to federal grants were accurate is an effort certification that is completed at least annually. This control was not operating ...

Finding Number: 2024-002, Effort Certification Condition: One of the internal controls that the University has designed related to ensuring that personnel expenses charged to federal grants were accurate is an effort certification that is completed at least annually. This control was not operating effectively during the year ended June 30, 2024, as certain effort certifications were not completed timely. Planned Corrective Action: Penn State raised awareness of the late effort certification issue at various committee and council meetings during Fall 2024 and enforced compliance with our existing policy. These meetings involve research leadership at all colleges, such as Associate Deans for Research, College Research Administration Officers, and College Financial Officers. Penn State followed its policy on overdue effort certifications, and we have implemented additional internal controls in the process. The University’s Office of the Senior Vice President for Research has restructured oversight of effort certification, along with many other post award financial matters, to a newly created office, Post Award Contractual Compliance (PACC). This office includes the existing Research Accounting Office (which was part of the Office of Budget and Finance prior to July 1, 2024), and Penn State has hired an Assistant Vice President to oversee this team. A new suboffice, led by a new director, within PACC is the Financial Analysis and Compliance Office (FACO), which is responsible for central oversight and training over the effort certification process. This office has recently created a new dashboard to monitor the completion of effort certifications and works closely with business units within Penn State to ensure timely completion via sending out reminders, holding meetings, and providing training on the process. Contact person responsible for corrective action: John Hanold, Associate Vice President for Research; Director, Office of Research Administrative Services Anticipated Completion Date: June 30, 2025

View Audit 350858

Finding 542019 (2024-002)

Significant Deficiency 2024

Urban League of Portland

OR

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Contact Person NAME: Julia Delgado PHONE: (503) 280-2600 E-Mail: jdelgado@ulpdx.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned Urban League of Portland shall review an...

Contact Person NAME: Julia Delgado PHONE: (503) 280-2600 E-Mail: jdelgado@ulpdx.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned Urban League of Portland shall review and revise the current policy to enhance recommendations that assure rent reasonableness procedures are instituted. Further training shall be provided to Program Managers to support a due diligent interim review of Master Leases. Anticipated Complete Date: 05/01/2024

View Audit 350845 Questioned Costs: $1

Finding 542005 (2024-003)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Questioned Costs Subrecipient Monitoring Procurement, Suspension & Debarment

2024-003 H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that th...

2024-003 H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that the Corporation works with the funding agency to remedy the period of performance noncompliance. In addition, we recommend that the Corporation reassess the design of its period of performance controls to identify where enhancement or additional controls are needed over liquidation of financial obligations subsequent to the end of a grant award. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendations. 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 to educate all grant managers on (1) the reporting capabilities within the system that can be utilized in the execution of monitoring payment status on individual invoices that have been submitted to granting agencies for reimbursement, and (2) the requirement to use their grant specific general ledger coding when orders are placed with vendors that are set up under the Corporation’s group purchasing process. For the specific vendor noted in Finding 2024-003, a grant number input field has been added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants and the monitoring of payment of those expenditures. The use of the accurate grant general ledger coding by grant managers when orders are placed, will reduce the time between placement of order and payment of the invoice. Additionally, management will develop a federal grant policy that covers all requirements for compliance and internal controls for federal grants. The grant manager responsible for oversight of BHSB grants will work with BHSB to remedy the period of performance noncompliance noted in Finding 2024-003. 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 350833 Questioned Costs: $1

Finding 542004 (2024-002)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles Cash Management Reporting

2024-002 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 Recommen...

2024-002 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 recommendations. 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 will develop a federal grant policy that includes the requirements for compliance and internal controls for federal grants. The policy 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, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 350833

Finding 541995 (2024-003)

Material Weakness 2024

University City District

PA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.213 § 200.319

Finding No. 2024-003: Procurement – Material Weakness in Internal Control Over Compliance Contact for Corrective Action: Matt Bergheiser, President The procurement policy for the organization will be updated to include a search of the suspension and debarment list as a first step towards complianc...

Finding No. 2024-003: Procurement – Material Weakness in Internal Control Over Compliance Contact for Corrective Action: Matt Bergheiser, President The procurement policy for the organization will be updated to include a search of the suspension and debarment list as a first step towards compliance. UCD will implement and adhere to a strict protocol for verifying suspension and debarment status and conduct an open and competitive bidding process prior to awarding any contracts or subawards under federal programs as is outlined in our procurement policy document. All of the results of the process will be documented and submitted to the Finance department prior to the selection of a new vendor, in order to remain in compliance. Expected Completion Date: 3/31/2025

View Audit 350805

Corrective Action Plans

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