Corrective Action Plans

Finding 1171679 (2025-014)

Material Weakness 2025

MD

Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.332

Finding 2025-014 U.S. Department of Treasury AL No. 21.027 American Rescue Plan Act (ARPA) Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2024-015 Auditee’s Corrective Action Plan: The Recovery Office will complete a review of all executed ...

Finding 2025-014 U.S. Department of Treasury AL No. 21.027 American Rescue Plan Act (ARPA) Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2024-015 Auditee’s Corrective Action Plan: The Recovery Office will complete a review of all executed subgrant agreements to confirm that the correct Unique Entity Identifier (UEI) and Federal Award Identification Number (FAIN) appear in the agreement. • This review will exclude Interagency Agreements with City agencies since they are not considered subrecipients, but as the prime recipient, the City of Baltimore. • This review will also exclude any agreements related to projects classified under Expenditure Category (EC) 6.1 in ARPA SLFRF guidance. According to Frequently Asked Questions (FAQs) issued by the U.S. Department of Treasury, this EC does not give rise to a subrecipient relationship, therefore UEI information is not required. • For any subgrant agreements with an incorrect or missing UEI or FAIN, the Recovery Office will submit a single memorandum that presents correct UEIs and FAIN to the Board of Estimates (BOE) to ensure that the official record has correct UEI and FAIN information. We believe there is a direct conflict between Treasury guidance and 2 CFR 200 regarding the requirement for active SAM.gov registration. Treasury does not require subrecipients to maintain an active SAM.gov registration and instead permits the use of alternative screening questions in lieu of an active registration. Treasury does not collect individualized subrecipient data for subawards at or below $50,000. Each of these three awards are at or below that threshold, therefore the SAM.gov information, including the subrecipient UEI, registration, or the alternative screening questions, were not collected. The total amount of funding for the three identified subrecipients combined is $100,000. The Recovery Office will require that all subrecipients fully register in SAM.gov. The Recovery Office will require that agencies provide a 30-day window to allow all subrecipients to fully register or funds will be withheld until the subrecipient can fully register to demonstrate the organization is not suspended or debarred. In those cases where the Recovery Office is unable to withhold disbursements for noncompliant subrecipients, the Recovery Office will issue a Corrective Action Plan or issue a finding in the subrecipient's closeout letter. For any grants that expired, if payments occurred outside the period of performance, and did not have written justification for and approval of an extension to the allowable closeout period, the Recovery Office will require that the agency to take the agreement back to the Board of Estimates for a retroactive extension. In certain cases, such as when extended monitoring or implementation of corrective action items go beyond the period of performance, a payment may be made outside of the allowable closeout period. According to 2 CFR 200.344c, "The recipient must liquidate all financial obligations incurred under the Federal award no later than 120 calendar days after the conclusion of the period of performance. A subrecipient must liquidate all financial obligations incurred under a subaward no later than 90 calendar days after the conclusion of the period of performance of the subaward (or an earlier date as agreed upon by the pass-through entity and subrecipient). When justified, the Federal agency or pass-through entity may approve extensions for the recipient or subrecipient." In these cases, the Recovery Office will assure there is written justification for the extension on liquidating all financial obligations. Contact Person: Elizabeth Tatum, Director Completion Date: June 30, 2026

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Finding 1171579 (2025-020)

Material Weakness 2025

City of Baltimore, Maryland

MD

Subrecipient Monitoring § 200.303

Finding 2025-020 U.S. Department of Health and Human Services AL No. 93.977 Sexually Transmitted Diseases (STD) Prevention and Control Grants Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: In FY 2025 BCHD dev...

Finding 2025-020 U.S. Department of Health and Human Services AL No. 93.977 Sexually Transmitted Diseases (STD) Prevention and Control Grants Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: In FY 2025 BCHD developed an internal subrecipient monitoring policy awaiting final approval from the department’s executive leadership. Due to the appointment of a new Health Commissioner and changes in leadership, the approval process within the department restarted. The following steps were completed in 2025. • Created Subrecipient vs. Contractor determination checklist required to be completed by staff when submitting contract request to Contracts and Compliance team. • Compliance team created and managed the comprehensive subrecipient monitoring tracker via Smartsheet, which houses SAM.gov verifications, subrecipients’ audit reports and final monitoring reports. • Developed fiscal and programmatic baseline monitoring tools based on 200 CFR standards. • Updated subrecipient contract agreement budget templates to include the Federal Award Identification Number (FAIN) and subrecipient’s UEI. • Hired a Compliance Analyst. Specific activities BCHD plans on executing to remediate this finding in FY 2026 are as follows: • Retrain contract administrators to thoroughly review subrecipient budget templates to ensure both the FAIN and subrecipient’s UEI are included. • Conduct separate workshops with division leaders and programs directors to review all grant awards and compliance requirements for each award. • Prioritize meetings with programs that have not conducted monitoring in the prior fiscal year to strategize and to ensure monitoring occurs in FY 2026. BCHD will utilize the GMO’s subrecipient monitoring templates provided on their centralized SharePoint platform which include risk assessments, reporting forms, expenditure forms, and metrics forms to ensure all required subrecipient monitoring reporting is completed. Additionally, BCHD will require all grant staff to attend GMO monthly trainings and quarterly grant monitoring meetings to ensure subrecipient monitoring is being conducted and completed. BCHD will also require all grant staff to familiarize themselves with Administrative Manual policy 413-51 Subrecipient Monitoring and Management, which specifies all city-wide requirements for subrecipient monitoring. BCHD will maintain copies of all subrecipient monitoring documents in Workday, the City’s financial system of record. Contact Person: Nkenge Williams, Director of Audits Completion Date: May 31, 2026

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Finding 1171561 (2025-018)

Material Weakness 2025

City of Baltimore, Maryland

MD

Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.332

Finding 2025-018 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Significant Deficiency in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2024-028 Auditee’s Corrective Action Plan: In FY 2025...

Finding 2025-018 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Significant Deficiency in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2024-028 Auditee’s Corrective Action Plan: In FY 2025 BCHD developed an internal subrecipient monitoring policy awaiting final approval from the department’s executive leadership. Due to the appointment of a new Health Commissioner and changes in leadership, the approval process within the department restarted. The following steps were completed in 2025. • Created Subrecipient vs. Contractor determination checklist required to be completed by staff when submitting contract request to Contracts and Compliance team. • Compliance team created and managed the comprehensive subrecipient monitoring tracker via Smartsheets, which houses SAM.gov verifications, subrecipients’ audit reports and final monitoring reports. • Developed fiscal and programmatic baseline monitoring tools based on 200 CFR standards. • Updated subrecipient contract agreement budget templates to include the Federal Award Identification Number (FAIN) and subrecipient’s UEI. • BCHD’s Director of Contracts and Compliance began conducting meetings with program directors to discuss monitoring processes and clarify federal requirements. • Hired a Compliance Analyst. Specific activities BCHD plans on executing to remediate this finding in FY 2026 are as follows: • Retrain contract administrators to thoroughly review subrecipient budget templates to ensure both the FAIN and subrecipient’s UEI are included. If either one is missing from the template, the contract package will be returned to the staff who initiated the contract process and instruct to include those items or the contract process will not move forward. • During bi-weekly fiscal office hours remind staff of the requirement to include both the FAIN and UEI in all agreements. • Conduct separate workshops with division leaders and programs directors to review all grant awards and compliance requirements for each award. BCHD will utilize the GMO’s subrecipient monitoring templates provided on their centralized SharePoint platform which include risk assessments, reporting forms, expenditure forms, and metrics forms to ensure all required subrecipient monitoring reporting is completed. Additionally, BCHD will require all grant staff to attend GMO monthly trainings and quarterly grant monitoring meetings to ensure subrecipient monitoring is being conducted and completed. BCHD will also require all grant staff to familiarize themselves with Administrative Manual policy 413-51 Subrecipient Monitoring and Management, which specifies all city-wide requirements for subrecipient monitoring. BCHD will maintain copies of all subrecipient monitoring documents in Workday, the City’s financial system of record. Contact Person: Nkenge Williams, Director of Audits Completion Date: May 31, 2026

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Finding 1171537 (2025-016)

Material Weakness 2025

City of Baltimore, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.332

Finding 2025-016 U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Significant Deficiency in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2024-025 Auditee’s Corrective Action Plan: In FY 2025 BCHD developed an inte...

Finding 2025-016 U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Significant Deficiency in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2024-025 Auditee’s Corrective Action Plan: In FY 2025 BCHD developed an internal subrecipient monitoring policy awaiting final approval from the department’s executive leadership. Due to the appointment of a new Health Commissioner and changes in leadership, the approval process within the department restarted. The following steps were completed in 2025. • Created Subrecipient vs. Contractor determination checklist required to be completed by staff when submitting contract request to Contracts unit. • Compliance team created and managed the comprehensive subrecipient monitoring tracker via Smartsheet, which houses SAM.gov verifications, subrecipients’ audit reports and final monitoring reports. • Developed fiscal and programmatic baseline monitoring tools based on 200 CFR standards. • Updated subrecipient contract agreement budget templates to include the Federal Award Identification Number (FAIN) and subrecipient’s UEI. • BCHD’s Director of Contracts and Compliance began conducting meetings with program directors to discuss monitoring processes and clarify federal requirements. • Hired a Compliance Analyst. Specific activities BCHD plans on executing to remediate this finding in FY 2026 are as follows: • Retrain contract administrators to thoroughly review subrecipient budget templates to ensure both the FAIN and subrecipient’s UEI are included. If either one is missing from the template, the contract package will be returned to the staff who initiated the contract process and instruct to include those items or the contract process will not move forward. • During bi-weekly fiscal office hours remind staff of the requirement to include both the FAIN and UEI in all agreements. • Conduct separate workshops with division leaders and programs directors to review all grant awards and compliance requirements for each award. BCHD will utilize the GMO’s subrecipient monitoring templates provided on their centralized SharePoint platform which include risk assessments, reporting forms, expenditure forms, and metrics forms to ensure all required subrecipient monitoring reporting is completed. Additionally, BCHD will require all grant staff to attend GMO monthly trainings and quarterly grant monitoring meetings to ensure subrecipient monitoring is being conducted and completed. BCHD will also require all grant staff to familiarize themselves with Administrative Manual policy 413-51 Subrecipient Monitoring and Management, which specifies all city-wide requirements for subrecipient monitoring. BCHD will maintain copies of all subrecipient monitoring documents in Workday, the City’s financial system of record. Contact Person: Nkenge Williams, Director of Audits Completion Date: May 31, 2026

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Finding 1171514 (2025-015)

Material Weakness 2025

City of Baltimore, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.332

Finding 2025-015 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 Subrecipient Monitoring Repeat Finding: Yes; 2024-022 Auditee’s Corrective Action Plan: In FY 2025 BCHD developed...

Finding 2025-015 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 Subrecipient Monitoring Repeat Finding: Yes; 2024-022 Auditee’s Corrective Action Plan: In FY 2025 BCHD developed an internal subrecipient monitoring policy awaiting final approval from the department’s executive leadership. Due to the appointment of a new Health Commissioner and changes in leadership, the approval process within the department restarted. The following steps were completed in 2025. • Subrecipient vs. Contractor determination checklist that are required to be completed by staff when submitting contract request to Contracts and Compliance team. • Compliance team created and managed the comprehensive subrecipient monitoring tracker via Smartsheets, which houses SAM.gov verifications, subrecipients’ audit reports and final monitoring reports. • Created fiscal and programmatic baseline monitoring tools based on 200 CFR standards. • Updated subrecipient contract agreement budget templates to include the Federal Award Identification Number (FAIN) and subrecipient’s UEI. • BCHD’s Director of Contracts and Compliance began conducting meetings with program directors to discuss monitoring processes and clarify federal requirements. • Hired a Compliance Analyst. Specific activities BCHD plans on executing to remediate this finding in FY 2026 are as follows: • Retrain contract administrators to thoroughly review subrecipient budget templates to ensure both the FAIN and subrecipient’s UEI are included. • Conduct separate workshops with division leaders and programs directors to review all grant awards and compliance requirements for each award. BCHD will utilize the GMO’s subrecipient monitoring templates provided on their centralized SharePoint platform which include risk assessments, reporting forms, expenditure forms, and metrics forms to ensure all required subrecipient monitoring reporting is completed. Additionally, BCHD will require all grant staff to attend GMO monthly trainings and quarterly grant monitoring meetings to ensure subrecipient monitoring is being conducted and completed. BCHD will also require all grant staff to familiarize themselves with Administrative Manual policy 413-51 Subrecipient Monitoring and Management, which specifies all City-wide requirements for subrecipient monitoring. BCHD will maintain copies of all subrecipient monitoring documents in Workday, the City’s financial system of record. Contact Person: Nkenge Williams, Director of Audits Completion Date: June 30, 2026

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Finding 1171506 (2025-013)

Material Weakness 2025

City of Baltimore, Maryland

MD

Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.332

Finding 2025-013 U.S. Department of Labor AL No. 17.258, 17.259, 17.278 Workforce Innovation and Opportunity Act (WIOA) Cluster Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: Notice of Award (NOA): To strengt...

Finding 2025-013 U.S. Department of Labor AL No. 17.258, 17.259, 17.278 Workforce Innovation and Opportunity Act (WIOA) Cluster Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: Notice of Award (NOA): To strengthen internal controls, MOED will establish separate grant worktags for all parts of the grant award to ensure the grant reference number is unique within the Workday award setup. UEI Subaward Validation: As a corrective action, Contracts Specialist training has been updated to require verification and documentation of the sub-recipient’s Unique Entity Identifier (UEI) through SAM.Gov as part of the subaward setup process. MOED will require grant staff to familiarize themselves with Administrative Manual policy 413- 21 Federal Grant Registration and Unique Entity Identifier, which requires UEI verification and identification in the City’s financial system of record for all subrecipients. Subrecipient Monitoring: MOED does maintain a standardized sub-recipient monitoring checklist designed to ensure subawards are administered in compliance with applicable federal statutes, regulations, and the terms and conditions of the subaward as well as relevant supporting documentation. FY2025 subrecipient monitoring was not scheduled in accordance with the monitoring timeframes outlined in the terms and conditions of the grant award. Management acknowledges this oversight and will ensure that all subrecipient monitoring is scheduled and conducted timely in accordance with the monitoring timeframes outlined in the award. Review of Subrecipient Single Audit Report: MOED performs a review of subrecipient Single Audit reports during the technical proposal evaluation and confirms the subrecipient’s inclusion on the State of Maryland’s Eligible Training Provider List (ETPL). Due to document volume size, this documentation has not historically been included in BOE-approved subrecipient agreements or retained within Workday award files. As a corrective action, MOED will formally incorporate ETPL verification into subrecipient agreements. Single Audit reports will be retained separately from the BOE approval package and uploaded to the applicable Grant Award record in Workday to ensure consistent documentation and accessibility. MOED will utilize the GMO’s subrecipient monitoring templates provided on the centralized SharePoint Grants Management platform which include risk assessments, reporting forms, expenditure forms, and metrics forms to ensure all required subrecipient monitoring reports are completed. Additionally, MOED will require all grant staff to attend GMO monthly trainings and quarterly grant monitoring meetings to ensure subrecipient monitoring is being conducted and completed. MOED will also require all grant staff to familiarize themselves with Administrative Manual policy 413-51 Subrecipient Monitoring and Management, which specifies all City-wide requirements for subrecipient monitoring. MOED will maintain copies of all subrecipient monitoring documents in Workday, the City’s financial system of record. Contact Person: David Hagans, Chief Financial Officer Jasmine Armstrong, Fiscal Operations Director Riley Grant, Chief Contracts Officer Completion Date: September 30, 2026

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Finding 1171504 (2025-011)

Material Weakness 2025

City of Baltimore, Maryland

MD

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.430

Finding 2025-011 U.S. Department of Labor AL No. 17.258, 17.259, 17.278 Workforce Innovation and Opportunity Act (WIOA) Cluster Significant Deficiency in Internal Controls and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Payroll) Repeat Finding: No Auditee’...

Finding 2025-011 U.S. Department of Labor AL No. 17.258, 17.259, 17.278 Workforce Innovation and Opportunity Act (WIOA) Cluster Significant Deficiency in Internal Controls and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Payroll) Repeat Finding: No Auditee’s Corrective Action Plan: MOED follows the standard process and employees’ clock in/out at timeclock or enter their time; prior to pay period close, that time is reviewed and approved as required. MOED currently runs a report named "Audit TT - Workers with Time Submitted but Not Approved" two hours prior to the final payroll submission deadline to identify timesheets that have been submitted by employees but not yet approved as of the morning following the close of the payroll period. MOED HR will run the “Audit TT - Workers with Time Submitted but Not Approved” report 30 minutes prior to the payroll submission deadline and will ensure that all timesheets are reviewed and approved by supervisors prior to final payroll processing. Contact Person: David Hagans, Chief Financial Officer Jasmine Armstrong, Fiscal Operations Director Riley Grant, Chief Contracts Officer Completion Date: March 31, 2026

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Finding 1171473 (2025-010)

Material Weakness 2025

City of Baltimore, Maryland

MD

Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.330 § 200.331 § 200.332 § 200.501

Finding 2025-010 U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunity for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2024-014 Auditee’s Corrective Action Plan: MOHS will enhance and ...

Finding 2025-010 U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunity for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2024-014 Auditee’s Corrective Action Plan: MOHS will enhance and formalize subrecipient monitoring procedures to ensure full compliance with Uniform Guidance requirements. Subrecipient agreement templates will be revised to require inclusion of the subrecipient’s Unique Entity Identifier (UEI) and Federal Award Identification Number (FAIN) for all subawards, in accordance with 2 CFR §§25.300 and 200.332. MOHS has previously developed subrecipient risk assessment and monitoring tools for the Continuum of Care (CoC) program. These tools and procedures will be reviewed, updated as needed, and expanded to apply to all MOHS grants, including HOPWA. This includes documented risk assessments, monitoring plans, and verification that required Single Audit reports are obtained, reviewed, and retained when applicable. MOHS will maintain centralized subrecipient monitoring files containing executed agreements, audit reviews, monitoring documentation, and follow-up actions. Program and fiscal staff will receive training on updated subrecipient monitoring policies and documentation standards to ensure consistent implementation across all funding sources. MOHS will utilize the GMO’s subrecipient monitoring templates provided on their centralized SharePoint platform which include risk assessments, reporting forms, expenditure forms, and metrics forms to ensure all required subrecipient monitoring reporting is completed. Additionally, MOHS will require all grant staff to attend GMO monthly trainings and quarterly grant monitoring meetings to ensure subrecipient monitoring is being conducted and completed. MOHS will also require all grant staff to familiarize themselves with Administrative Manual policy 413-51 Subrecipient Monitoring and Management, which specifies all city-wide requirements for subrecipient monitoring. MOHS will maintain copies of all subrecipient monitoring documents in Workday, the City’s financial system. Contact Person: Sade Creighton-Wade, Chief of Fiscal Services Completion Date: September 30, 2026

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Finding 1171472 (2025-009)

Material Weakness 2025

City of Baltimore, Maryland

MD

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

Finding 2025-009 U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunity for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2024-013 Auditee’s Corrective Action Plan: MOHS will strengthen internal contro...

Finding 2025-009 U.S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunity for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2024-013 Auditee’s Corrective Action Plan: MOHS will strengthen internal controls over federal reporting to ensure accuracy, completeness, and compliance with HUD and Uniform Guidance requirements. Specifically, MOHS will implement a documented reconciliation process requiring all HOPWA expenditures reported in the Federal Financial Report (FFR) to be reconciled to the general ledger prior to regular submission, with supervisory review and approval documented. MOHS will establish a formal reporting calendar and standardized checklist to ensure timely preparation, review, and submission of all required HUD reports, including the FFR, Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting (FSRS), and the Consolidated Annual Performance and Evaluation Report (CAPER). • Written procedures will be developed to clearly define staff roles and responsibilities for federal reporting and FFATA compliance, including identification of reportable first-tier subawards and documentation of FSRS submissions. MOHS will also provide targeted training to program and fiscal staff responsible for federal reporting and will conduct periodic internal monitoring to verify compliance with 2 CFR §200.303 and 2 CFR Part 170. MOHS will require grant staff to attend GMO monthly training sessions and review GMO provided training materials pertaining to grant management, grant reporting, and subrecipient monitoring and will require grant staff to review and comply with Administrative Manual policies 413-00 through 413-70 pertaining to all aspects of City-wide grant management. • Per the GMO’s guidance, MOHS will add award reporting tasks to all grant awards in Workday, the City’s financial system of record, to ensure timely completion of all grant reporting as well as upload regular reports into Workday. Contact Person: Sade Creighton-Wade, Chief of Fiscal Services Completion Date: June 30, 2026

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Finding 1171360 (2025-003)

Material Weakness 2025

South Putnam Community School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2025-003 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Numbers: 84.425D, 84.425U Federal Award Number(s) and Year(s) (or Other Identifying Numbers): S425...

FINDING 2025-003 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Numbers: 84.425D, 84.425U Federal Award Number(s) and Year(s) (or Other Identifying Numbers): S425D200013, S425U200013 Audit Finding: Significant Deficiency This is a repeat finding from the immediately prior audit report. The prior finding number was 2023-003. Condition and Context The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit annual data reports to the Indiana Department of Education via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the prior audit period, the School Corporation submitted two ESSER I reports, two ESSER II reports, and two EESER III reports, for a total of six reports. The Superintendent of Schools submitted all the reports without an oversight or review process in place to prevent, detect and correct errors. As a follow up in the current audit period, it was found that this issue was not resolved. The lack of internal controls was a systematic issue throughout the audit period. . Contact Person Responsible for Corrective Action: Erin Roach Contact Phone Number and Email Address: 765-653-3119 eroach@sputnam.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The grants director will print out the reports for review and approval prior to submission. Anticipated Completion Date: February, 2026

View Audit 384655

Finding 1171338 (2025-002)

Material Weakness 2025

Spartanburg Community College

SC

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

COMPLIANCE FINDING 2025-002 SFA Cluster: Disbursement to or on Behalf of Students Contact Person: Missy Hughes, Director of Finance Corrective Action Plan: The Business Office is currently seeking an AP/Payroll Manager who will supervise the outstanding check process. The process will be performed a...

COMPLIANCE FINDING 2025-002 SFA Cluster: Disbursement to or on Behalf of Students Contact Person: Missy Hughes, Director of Finance Corrective Action Plan: The Business Office is currently seeking an AP/Payroll Manager who will supervise the outstanding check process. The process will be performed and maintained by the Financial Coordinator, Kyle Burnett. 1. Track all Title IV disbursements issued by check, including the issuance date and applicable return deadlines. During monthly bank and check reconciliations, any outstanding check related to Title IV funds will be reviewed by Kyle Burnett, Financial Coordinator. 2. Perform periodic (at least monthly) reviews of outstanding Title IV checks to identify uncashed items approaching the 240-day return requirement. The process of reviewing outstanding Title IV checks will be performed and maintained by the Financial Coordinator, Kyle Burnett. Kyle will review the outstanding checks related to student refunds monthly. 3. Ensure uncashed Title IV checks are returned to the U.S. Department of Education within 240 days of issuance when checks are not cashed or otherwise negotiated. Kyle Burnett, Financial Coordinator, will work with Linda Briggs, Student Account Coordinator and Financial Aid to be sure Title IV checks are returned to the U.S. Department of Education within 240 days of issuance, if still outstanding. 4. Assign clear responsibility for monitoring outstanding checks and returning funds and provide training to staff involved in Title IV disbursement and reconciliation processes. Kyle Burnett, Financial Coordinator, will be trained in Title IV disbursement and reconciliation processes and will work with the Accounts Receivable staff as well as Financial Aid to determine appropriate actions regarding the stale dated check items. 5. Retain documentation evidencing timely monitoring, review, and return of Title IV funds to support compliance and audit review. A SharePoint has been established that is currently maintained by Linda Briggs, Student Account Coordinator and Jeremy Elam, Controller. Kyle Burnett, Financial Coordinator, will be added to this SharePoint. This will be monitored and updated regarding check statuses related to Title IV funds.

View Audit 384632

Finding 1171337 (2025-001)

Material Weakness 2025

Spartanburg Community College

SC

Student Financial Aid Special Tests & Provisions Subrecipient Monitoring

MW 2025-001 SFA Cluster: R2T4 Corrective Action Plan Contact Person: Jeff Boyle, Director of Financial Corrective Action Plan: 1. Have at least two staff members enroll and complete the R2T4 training module conducted by NASFAA. Tonja Suttles and Melissa Satterwhite completed the course and passed th...

MW 2025-001 SFA Cluster: R2T4 Corrective Action Plan Contact Person: Jeff Boyle, Director of Financial Corrective Action Plan: 1. Have at least two staff members enroll and complete the R2T4 training module conducted by NASFAA. Tonja Suttles and Melissa Satterwhite completed the course and passed the credential exam. Suzanne Bonner sat in on a few of the sessions. 2. Make changes to the R2T4 spreadsheet. a. Maintain a separate tab for each calculation group to make tracking and internal reviews easier. Process has been completed and started being used during the 2025 fall semester. b. Add additional columns to the spreadsheet that will provide the necessary data to perform the R2T4 calculation within Colleague and act as a check and balance as the calculation is being performed. There are several columns with calculated data or data coming from a source outside of Colleague. These data values can then be compared to the values Colleague calculates and the two should match. Columns have been added and began being used with the 2025 fall semester. 3. It will be established that one staff member will do the R2T4 calculation and a second staff member will do a spot check of a spot check to ensure the calculation was done properly using the correct data. The number of students checked will depend on the number of students within the calculation groups. The number of students in a group can range from 2 to several hundred. This process was put into practice starting with the 09/17/25 calculation group. Jeff Boyle, Director of Financial Aid, performed all the R2T4 calculations for the 2025 fall term and Tonja Suttles, Assistant Director of Financial Aid, performed 100% review of all the calculations. This will change once we are assured this process is working the way we expect it. 4. The external spreadsheets and charts used for the R2T4 calculation contain a tremendous amount of data elements and are created two years in advance of being used. A process will be established where various staff members within the office will review the data prior to our using it for the R2T4 calculation. This has been implemented as of the 2025 fall semester. All the 2025-2026 terms have been reviewed. A secondary review will be done on each term just prior to the data being used for that term’s R2T4 calculations. The data will be reviewed again at any point we determine the data may not be correct.

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Finding 1171324 (2025-001)

Material Weakness 2025

Town of Woodbury, Connecticut

CT

Procurement, Suspension & Debarment Subrecipient Monitoring

FINDING 2024-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awar...

FINDING 2024-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are required to ensure that they do not award contracts or make subawards to any parties that are suspended or debarred from receiving federal funds. This verification may be accomplished by checking the System for Award Management (SAM). The Town implemented a policy to check that vendors are not suspended or debarred by checking the System for Award Management (SAM). However, the policy was implemented in January 2025, during the fiscal year under audit. Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town established policies and procedures to ensure vendors are not suspended or debarred by checking the System for Award Management (SAM) and maintains documentation showing that verification. The new procedures begin during FY 2025 and will be in full effect for fiscal years 2026 and beyond. Name of Contact Person: Nyree Pieck, Interim Fiscal Officer (203) 263-2449. Projected Completion Date: Completed, January 2025.

View Audit 384596

Finding 1171320 (2025-005)

Material Weakness 2025

Eastern Greene Schools

IN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.208 § 200.303

FINDING 2025-005 Finding Subject: Title I Grants to Local Educational Agencies – Special Tests and Provisions – Assessment System Security Contact Person Responsible for Corrective Action: Superintendent and Title I Program Director Mr. Todd Tanksley Contact Phone Number and Email Address: 812-849-4...

FINDING 2025-005 Finding Subject: Title I Grants to Local Educational Agencies – Special Tests and Provisions – Assessment System Security Contact Person Responsible for Corrective Action: Superintendent and Title I Program Director Mr. Todd Tanksley Contact Phone Number and Email Address: 812-849-4481 – tanksleyto@mitchell.k12.in.us Views of Responsible O􀆯icial: We concur with the finding. Description of Corrective Action Plan The School Corporation has implemented enhanced internal control procedures to ensure compliance with Assessment System Security requirements and applicable state and federal regulations. E􀆯ective immediately, the School Corporation will: 1. Require all employees who administer, handle, or have access to secure test materials to complete annual assessment security training in accordance with the Indiana Assessment Policy Manual. 2. Require all such employees to sign the Indiana Testing Security and Integrity Agreement annually by an established deadline. INDIANA STATE BOARD OF ACCOUNTS 34 3. Establish a standardized process to collect, review, and retain signed testing security agreements at the building level. 4. Maintain a centralized tracking log of all employees required to complete training and sign agreements. 5. Conduct an annual verification review to ensure that all required documentation is complete prior to the testing window. 6. Retain all assessment security training documentation and signed agreements in accordance with federal record retention requirements under 2 CFR 200.334. Planned Evidence of Correction The School Corporation will maintain the following documentation as evidence of corrective action: ● Annual assessment security training agendas and attendance record ● Signed Indiana Testing Security and Integrity Agreements for all applicable sta􀆯 ● Centralized tracking logs indicating completion of training and agreement signatures ● Building-level verification checklists signed and dated by administrators ● Written internal procedures related to assessment system security compliance Anticipated Completion Date Implemented and ongoing beginning with the FY2026 assessment cycle.

View Audit 384594

Finding 1171318 (2025-004)

Material Weakness 2025

Eastern Greene Schools

IN

Subrecipient Monitoring Eligibility Material Weakness § 200.303 § 200.334 § 200.77 § 200.78

Finding 2025-004 Title I Grants to Local Educational Agencies – Eligibility Contact Person Responsible for Corrective Action: Superintendent and Title I Program Director Mr. Todd Tanksley Contact Phone Number and Email Address: 812-849-4481 – tanksleyto@mitchell.k12.in.us Views of Responsible Offici...

Finding 2025-004 Title I Grants to Local Educational Agencies – Eligibility Contact Person Responsible for Corrective Action: Superintendent and Title I Program Director Mr. Todd Tanksley Contact Phone Number and Email Address: 812-849-4481 – tanksleyto@mitchell.k12.in.us Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan The School Corporation has established and implemented written internal control procedures to ensure that enrollment and poverty data reported in the October Real Time Reports are reviewed for accuracy and compared to the Title I application prior to submission. Beginning with the current grant cycle, the School Corporation will: 1. Obtain and retain copies of the October Real Time Report data used for each Title I application year. 2. Perform and document a detailed review of enrollment and poverty counts by school utilizing a worksheet that itemizes total enrollment at each school within the district, compares the low-income count according to the Real Time report, the utilized lunch software, and the counts indicated on the Title I application, and indicates a match (or variance in the event of data discrepancy) of the data among those three data sources. INDIANA STATE BOARD OF ACCOUNTS 32 3. Compare the poverty and enrollment data from the October Real Time Reports to the Eligible School Summary within the Title I application. 4. Verify poverty data using source documentation from the school lunch software system. 5. Investigate and resolve any discrepancies identified prior to submission. 6. Maintain documentation supporting the review, comparison, and verification process in accordance with federal record retention requirements under 2 CFR 200.334. Planned Evidence of Correction The School Corporation will maintain the following documentation as evidence of corrective action: ● October Real Time Reports ● Poverty and enrollment comparison worksheets ● School lunch software reports ● Signed and dated review checklists ● Copies of submitted Title I application Anticipated Completion Date Implemented and ongoing beginning with the 2026 Title I application.

View Audit 384594

Finding 1171308 (2025-003)

Material Weakness 2025

City of Asheville

NC

Subrecipient Monitoring

2024-2025 CDBG AUDIT 1. Establish Procedure to Ensure FFATA Reports Are Uploaded ● Action: Formalize the reporting of FFATA into SAMS.gov as part of our contracting process ● Completion Date: 6/30/2026 ● Responsible: Community Development Division Manager, Community Development Analysts, Community D...

2024-2025 CDBG AUDIT 1. Establish Procedure to Ensure FFATA Reports Are Uploaded ● Action: Formalize the reporting of FFATA into SAMS.gov as part of our contracting process ● Completion Date: 6/30/2026 ● Responsible: Community Development Division Manager, Community Development Analysts, Community Development Coordinator ● Content: Checklist for compiling content for executed grant agreements with subrecipients will include the addition of completing FFATA requirements in SAM.gov, downloading a copy of the report, and adding to the project file folder with the fully executed agreement ● Documentation: FFATA report submitted via SAM.gov and downloaded to the project file within 30 days of agreement execution

View Audit 384579

Finding 1171305 (2025-002)

Material Weakness 2025

City of Asheville

NC

Subrecipient Monitoring Allowable Costs / Cost Principles

2026 HOME AUDIT 1. Establish Annual Monitoring Plan ● Action: Create a formalized Annual Monitoring Plan based on subrecipient risk assessments and total annual federal funding. ○ Tiered Oversight: ■ High Risk: Required on-site visits (or deep-dive virtual audits) ■ Medium/Low Risk: Desk reviews and...

2026 HOME AUDIT 1. Establish Annual Monitoring Plan ● Action: Create a formalized Annual Monitoring Plan based on subrecipient risk assessments and total annual federal funding. ○ Tiered Oversight: ■ High Risk: Required on-site visits (or deep-dive virtual audits) ■ Medium/Low Risk: Desk reviews and annual check-ins, sampling beneficiaries for eligibility. ■ Funding amount: Activities with $750,000 or more in federal funding (inclusive of all federal assistance) must undertake a single audit in addition to monitoring ● Completion Date: 2/27/2026 ● Responsible: Community Development Division Manager, Community Development Analysts ● Content: The plan will explicitly list which subrecipients are slated for which type of review each year. ● Documentation: Approved Annual Monitoring plan 2. Training and Capacity Building ● Action: All Community Development staff will undergo monitoring training ● Completion Date: 2/27/2026 ● Responsible: Community Development Manager, Community Development Analysts, Community Development Coordinator ● Content: Training will cover compliance requirements, identifying "red flags", confirming beneficiary eligibility, and internal monitoring Standard Operating Procedures and checklists. ● Documentation: Training logs and updated job aids. 3. Implementation & Execution ● Action: Initiate monitoring activities, prioritizing Higher Risk subrecipients identified in the initial assessment, and requesting single audits from subrecipients who received more than $750,000 in federal funding ● Completion Date: 6/30/2026 and on-going ● Responsible: Community Development Analysts, Community Development Coordinator ● Content: Analysts will produce written monitoring reports for each review following established policies and checklists for each program, which the Community Development Manager will sign off on. ● Documentation: Approved monitoring reports will be recorded and accessible for reference

View Audit 384579

Finding 1171139 (2025-001)

Material Weakness 2025

Community Coalition Alliance, INC

FL

Subrecipient Monitoring § 200.332

Management is working to obtain the overdue reports.

View Audit 384551

Finding 1171137 (2025-001)

Material Weakness 2025

Volunteers of America Colorado

CO

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

Management did not have documented controls in place to ensure contractors are not suspended or debarred from participating in federally funded activity Planned Corrective Action: To strengthen compliance documentation and ensure consistent audit support, VOAC has implemented the following correctiv...

Management did not have documented controls in place to ensure contractors are not suspended or debarred from participating in federally funded activity Planned Corrective Action: To strengthen compliance documentation and ensure consistent audit support, VOAC has implemented the following corrective actions: 1.Policy Enhancement: The procurement procedure has been updated to explicitly require saving and retaining a time-stamped screenshot or PDF confirmation of each SAM.gov verification showing the verification date and results. Where applicable, contractors subject to 2 CFR 200.214 must also provide a self-certification statement within the executed agreement. 2.Centralized Recordkeeping: Verification evidence will be maintained in both the individual contract file and the centralized grant management system. 3.Annual Training and Refresher: Procurement and grants management staff will participate in annual training to reinforce 2 CFR 200.214 requirements and best practices for documentation and record retention. Contact person responsible for corrective action: Ian Kile, Director of Internal Control, and Chiyoko Yokota, Chief Financial Officer Anticipated Completion Date: 2/28/26

View Audit 384538

Finding 1171132 (2025-001)

Material Weakness 2025

Pacific House, Inc.

CT

Subrecipient Monitoring Reporting Significant Deficiency

Pacific House and Subsidiaries has transitioned to a new CPA firm and is working closely with them to ensure the Data Collection Form is timely submitted for the fiscal year ended June 30, 2025 and in future.

View Audit 384518

Finding 1171099 (2025-002)

Material Weakness 2025

Northeast Ohio Medical University

OH

Student Financial Aid Subrecipient Monitoring Reporting

Finding Number: 2025-002 Anticipated Completion Date: 10/07/2025 Responsible Contact Person: Katherine Miranda, University Registrar Kelly Burt, Assistant Registrar Records Management and Reporting Michele Bergman, Assistant Registrar, Records Management and Reporting Planned Corrective Action: The ...

Finding Number: 2025-002 Anticipated Completion Date: 10/07/2025 Responsible Contact Person: Katherine Miranda, University Registrar Kelly Burt, Assistant Registrar Records Management and Reporting Michele Bergman, Assistant Registrar, Records Management and Reporting Planned Corrective Action: The Offices of the Registrar and Admission Operations reviewed the case, reviewed the proper student record protocol, and added a reporting checkpoint to review for dually enrolled students before submitting enrollment reports to the National Student Clearinghouse (NSC). Once NSLDS is updated with NSC data, the Office of the Registrar will work with Office of Financial Aid to confirm NSLDS is accurate for the dually enrolled students.

View Audit 384492

Finding 1171092 (2025-001)

Material Weakness 2025

Northeast Ohio Medical University

OH

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

Finding Number: 2025-001 Completion Date: 03/31/2025 Responsible Contact Person: Kami Greene, Director of Accounting and Controller Kristen Cope, Assistant Controller Corrective Action: The University enhanced its written procedures for requesting cash draws and further trained new staff on policies...

Finding Number: 2025-001 Completion Date: 03/31/2025 Responsible Contact Person: Kami Greene, Director of Accounting and Controller Kristen Cope, Assistant Controller Corrective Action: The University enhanced its written procedures for requesting cash draws and further trained new staff on policies and procedures to ensure compliance. In addition, a review process has been established before each cash draw takes place to ensure that all cash draws are for expenses that were incurred to prevent funds from being overdrawn.

View Audit 384492

Finding 1171041 (2025-001)

Material Weakness 2025

Louisville Metro Housing Authority

KY

HUD Housing Programs Subrecipient Monitoring Cash Management

Finding Reference: 2025-001 Description of Finding: HUD regulations require certifications to be completed and entered timely to ensure accurate calculation of Housing Assistance Payments (HAP), Total Tenant Payment (TTP) and utility reimbursements. Per 24 CFR section 982.516, the Authority must ree...

Finding Reference: 2025-001 Description of Finding: HUD regulations require certifications to be completed and entered timely to ensure accurate calculation of Housing Assistance Payments (HAP), Total Tenant Payment (TTP) and utility reimbursements. Per 24 CFR section 982.516, the Authority must reexamine family income and composition at least once every two years and adjust the tenant rent and housing assistance payment as necessary using the documentation from third party verification. Of the 60 Moving to Work files tested, the following items were noted: • 40 instances of certifications not completed timely • 6 instances where the file did not contain income support • 3 instances where housing quality standards inspections were not completed within the last 2 years • 1 instance in which a rent comparison was not completed for a new move in Statement of Concurrence or Nonconcurrence: Louisville Metro Housing Authority agrees with Cherry Bekaert in reference to audit finding 2025-001. Corrective Action: LMHA continues to work through issues around the proper and timely processing of program certifications to support accurate Housing Assistance Payments, Total Tenant Payments and utility reimbursements. Currently, recertifications are processed on a biennial basis schedule, through a three-tiered system outlined in our updated MTW plan. This will address timeliness of recertification while also ensuring compliance and review of supporting documentation. Please note the following rules tied to LMHA’s three-tiered recertification system: 1) When the family is zero income, they will go to an annual recertification. 2) When family is working, (enrolling in KTAP (Kentucky Transitional Assistance Program), receiving Child Support, and other similar sources of income) they will go to a biennial recertification. 3) When a family has fixed income, (receiving Social Security, Supplemental Security Income, and/or Pension payments), they will go to a triennial recertification. The HCV Team is also working with Yardi (ERP system) to maximize the reporting and monitoring of the recertification schedule. The manager initiates the tracking for needed processing and possible termination of participants. With the three-tiered system, staff will be able to review all tenant information closely during recertifications to ensure proper housing assistance payments. Additionally, to improve sufficient controls and internal monitoring, the HCV Team is partnering with the Compliance Team to review tenant files for errors and improper supporting documentation.

View Audit 384423

Finding 1170952 (2025-001)

Material Weakness 2025

Healthfirst Family Care Center, Inc.

MA

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2025.001 - Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors and individuals in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff ...

Finding 2025.001 - Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors and individuals in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requirement. Repeat Finding No Action Taken To establish, implement, and maintain a standardized screening process that ensures no federal funds are paid to excluded or debarred individuals or vendors, with documented evidence and ongoing monitoring, HealthFirst has developed written policies and procedures, outlining assigned responsibilities, screening frequencies, and documentation & retention. Staff training to correct inaccurate searches have been provided. If there are any question regarding this plan, please e-mail Lisa Jones at ljones@healthfirstfr.org. Sincerely, Lisa Jones Chief Executive Offi

View Audit 384316

Finding 1170941 (2025-003)

Material Weakness 2025

Jewish Family Services, Inc.

WI

Procurement, Suspension & Debarment Subrecipient Monitoring Cash Management § 200.305 § 200.318 § 200.326 § 200.430 § 200.431

Criteria or Specific Requirement: Subparts D and E of 2 CFR Part 200 require a nonfederal entity to establish written policies, procedures, and standards of conduct, including procedures to implement the cash management requirements of 2 CFR section 200.305, procedures that comply with the procureme...

Criteria or Specific Requirement: Subparts D and E of 2 CFR Part 200 require a nonfederal entity to establish written policies, procedures, and standards of conduct, including procedures to implement the cash management requirements of 2 CFR section 200.305, procedures that comply with the procurement standards of 2 CFR sections 200.318 through 200.326, and procedures for determining the allowability of costs in accordance with Subpart E of 2 CFR Part 200. Specifically, 2 CFR sections 200.430, 200.431, and 200.475 require written policies concerning compensation for personal services, fringe benefits, and travel costs, respectively. Views from Responsible Officials: Management agrees with the finding. Management has established written policies and procedures after yearend that were the policies and procedures followed during the year under audit and meets the requirements of Subparts D and E of 2 CFR Part 200. Contact Person: John Jacques Date of Completion: November 14, 2025

View Audit 384246

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