Corrective Action Plans

Finding 563693 (2024-002)

Material Weakness 2024

Toole County

MT

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

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

View Audit 357988

Finding 563689 (2024-002)

None 2024

Auburn University

AL

Subrecipient Monitoring Eligibility § 200.332 § 200.501

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Variou...

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2024 Finding 2024-002 Subrecipient Monitoring- Lack of evidence of subrecipient Uniform Guidance report reviews Cluster: Research and Development Sponsoring Agency: Various agencies Award Names: Enabling Low Temperature Plasma (LTP) Ignition Technologies for Multi- Mode Engines Through the Development of a Validated High Fidelity LTP Model for Predictive Simulation Tools, Greater Alabama Black Belt Region (GABBR) LSAMP, and Reimagining controlled environment agriculture in a low carbon world Award Numbers: 211809, 200634, and 205280 Assistance Listing Title: Conservation Research and Development, STEM Education (formerly Education and Human Resources), Agriculture and Food Research Initiative (AFRI) Assistance Listing Number: 81.086, 47.076, and 10.310 Award Year: 2023 - 2024 Pass-through entity: University of Texas Dallas, Association of Public & Land Grant Universities, Tuskegee University, and Clemson University To ensure Auburn University is in compliance with 2CFR 200.332(f), Auburn University has implemented the following corrective action plan: Since the audit period, the University has started a comprehensive review of its subrecipient monitoring framework and has been working to distribute workload more effectively with the goal of building consistency in subrecipient monitoring procedures. This includes efforts to clarify ownership of monitoring tasks, implementing a more centralized and standardized approach to documentation, and balancing the day-to-day operational duties across the subaward team to allow for appropriate focus on Uniform Guidance compliance. Brief internal training sessions or check-ins will be conducted to reinforce expectations and ensure that all staff are aligned with the updated documentation practices. Current procedures will be revised to address risk assessments and annual monitoring. These improvements are designed to ensure consistency, accountability, and compliance with Uniform Guidance expectations moving forward. We will document when all reviews of sub-recipients’ financial statements/Uniform Guidance reports occur and who completed the reviews. These reviews will be entity-specific and conducted annually. The corrective actions noted herein are in process and implementation is expected before the end of the current fiscal year to allow adequate time for review, development, and benchmarking. Contact: Tony Ventimiglia Asst. VP Research Administration Office of the Senior VP for Research & Economic Development Amy Douglas Associate VP Financial Services/Controller Anticipated Completion Date: October 1, 2025

View Audit 357977

Finding 563684 (2024-001)

None 2024

Auburn University

AL

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

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

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

View Audit 357977

Finding 563656 (2024-001)

Significant Deficiency 2024

City of Elizabeth

MN

Subrecipient Monitoring

Segregation of Duties

View Audit 357961

Finding 563656 (2024-001)

Significant Deficiency 2024

City of Elizabeth

MN

Subrecipient Monitoring

Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties...

Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties or add mitigating controls to prevent material misstatement of the financial statements.

View Audit 357961

Finding 563656 (2024-001)

Significant Deficiency 2024

City of Elizabeth

MN

Subrecipient Monitoring

Management’s Response and Actions Planned: The City’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following:

View Audit 357961

Finding 563656 (2024-001)

Significant Deficiency 2024

City of Elizabeth

MN

Subrecipient Monitoring

1. Identifies areas where the lack of segregation of duties exists and where there are higher risks of errors or fraud occurring.

View Audit 357961

Finding 563656 (2024-001)

Significant Deficiency 2024

City of Elizabeth

MN

Subrecipient Monitoring

2. Implements limited segregation to the extent possible to reduce risks without impairing efficiency.

View Audit 357961

Finding 563656 (2024-001)

Significant Deficiency 2024

City of Elizabeth

MN

Subrecipient Monitoring

3. Uses the knowledge that management and the Board of Directors have of operations by having them review certain accounting records and reports.

View Audit 357961

Finding 563656 (2024-001)

Significant Deficiency 2024

City of Elizabeth

MN

Subrecipient Monitoring

Monitors the effectiveness of the above actions and makes changes as considered appropriate.

View Audit 357961

Finding 563613 (2024-002)

Material Weakness 2024

Council of Spanish Speaking Organizations, Inc.

PA

Allowable Costs / Cost Principles Student Financial Aid Subrecipient Monitoring

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

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

View Audit 357894

Finding 563583 (2024-002)

Significant Deficiency 2024

Adelphi University

NY

Procurement, Suspension & Debarment Subrecipient Monitoring

We agree with the finding and have already implemented corrective actions to ensure it does not occur again. Additionally, this procedure has been added to our compliance checklist, which is reviewed on a monthly basis to ensure adherence.

View Audit 357849

Finding 563582 (2024-001)

Significant Deficiency 2024

Adelphi University

NY

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

We acknowledge the finding and have already addressed the issue. Additionally, we have incorporated this procedure into our compliance checklist. As a result, monthly reminders will be sent to a designated group within the Finance team to help prevent recurrence.

View Audit 357849

Finding 563581 (2024-004)

Significant Deficiency 2024

City of La Habra

CA

Subrecipient Monitoring

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

View Audit 357845

Finding 563161 (2024-015)

Material Weakness 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.332

Finding 2024-015 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: No Auditee’s Corrective Action Plan: Comments on Finding Prior to executing subgrant agreements, in accorda...

Finding 2024-015 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: No Auditee’s Corrective Action Plan: Comments on Finding Prior to executing subgrant agreements, in accordance with 2 CFR 200, the Mayor’s Office of Recovery Programs (Recovery Office) confirms that subrecipients have a Unique Entity Identifier (UEI) through SAM.gov. The Recovery Office is responsible for ensuring that UEI information is correctly entered into subgrant agreements that are between the Recovery Office and a subrecipient. Additionally, the Recovery Office shared the UEI requirement with City agencies and developed template ARPA subgrant agreements that City agencies must use with their subrecipients. These templates include a specific field in which to enter the UEI. City agencies are responsible for ensuring that this information is correctly entered into the subgrant agreement. Whether the subgrant agreement is executed by the Recovery Office or another City agency, the Recovery Office collects and retains the SAM.gov record for each subrecipient on the City’s secure network and records the UEI number in a spreadsheet. UEIs are also included in all statutorily required quarterly and annual reporting to the U.S. Department of Treasury. This information has consistently and accurately been reported to the Treasury. However, though required reports to Treasury are accurate, the Recovery Office acknowledges that the UEI was missing or incorrect for some subgrant agreements. This is due to the following: • Clerical errors in the preparation of draft agreements; and • An early version of a funding exhibit in ARPA template subgrant agreements that did not include a specific field in which to enter the UEI (this funding exhibit has since been corrected). CAP for Agreements Executed by the Mayor’s Office of Recovery Programs Subgrant Agreement Review • The Recovery Office will complete a review of all executed subgrant agreements to confirm that the correct Unique Entity Identifier (UEI) appears in the agreement. o This review will exclude Interagency Agreements with City agencies since they are not considered subrecipients, but as the prime recipient, the City of Baltimore. o This review will also exclude any agreements related to projects classified under Expenditure Category 6.1 in ARPA SLFRF guidance. According to Frequently Asked Questions (FAQs) issued by the Treasury, this EC does not give rise to subrecipient relationships, therefore UEI information is not required1. Resolution of Identified UEI Errors in Subgrant Agreements • For any subgrant agreements with an incorrect or missing UEI, the Recovery Office will submit a single memorandum that presents correct UEIs to the Board of Estimates (BOE) to ensure that the official record has correct UEI information. New Subgrant Agreements • The Recovery Office will implement a revised business process for the review of subgrant agreements. All ARPA funding was obligated as of December 31, 2024. According to Treasury guidance, there are very limited circumstances in which a jurisdiction may enter new subgrant agreements after the statutory obligation deadline. If the Recovery Office does execute a new subgrant agreement, the Recovery Office Project Manager must include the following two items in their request for the Chief Recovery Officer’s signature on the document: o a copy of the subrecipient’s SAM.gov record; and o written confirmation that the UEI number presented in the agreement matches the subrecipient’s SAM.gov record. CAP for Agreements Signed by Other City of Baltimore Agencies Subgrant Agreement Review • The Recovery Office will distribute a list to City agencies with all subgrants funded by ARPA. The list will include the subgrant agreement amount, subgrantee name, Workday identifiers (e.g., Purchase Order or Supplier Contract numbers), and the UEI number on file. o This review will also exclude any agreements related to projects classified under Expenditure Category 6.1 in ARPA SLFRF guidance. According to Treasury FAQs, this EC does not give rise to subrecipient relationships2. o City agencies must complete a review of all ARPA-funded subgrant agreements included on the list and confirm that the UEIs are accurate. Resolution of Identified UEI Errors in Subgrant Agreements • For any subgrant agreements with an incorrect or missing UEI, the Recovery Office will require each City agency to submit a single memorandum that presents correct UEIs to the Board of Estimates (BOE) to ensure that the official record has correct UEI information. • Using the list distributed by the Recovery Office, City agencies will confirm that the correction memo has been submitted and approved by the BOE. New Subgrant Agreements • The Recovery Office will implement a revised business process for the review of subgrant agreements in Workday. Though the Recovery Office does not execute ARPA-funded agreements initiated by other City agencies, executed agreements are routed in Workday for Recovery Office approval. The Recovery Office Project Manager will review the UEI presented in the agreement and confirm its accuracy. If it is missing or inaccurate, the Project Manager will notify the agency and instruct them to submit a memorandum to the BOE with the correct UEI information. 1 According to FAQ 13.14 Treasury is not collecting subaward data for projects categorized under Expenditure Category Group 6 “Revenue Replacement.” Treasury has determined that there are no subawards under this eligible use category. U.S. Department of the Treasury. (2021). Final Rule Frequently Asked Questions (FAQ). Retrieved from https://home.treasury.gov/system/files/136/SLFRF-Final-Rule-FAQ.pdf. 2 According to FAQ 13.14 Treasury is not collecting subaward data for projects categorized under Expenditure Category Group 6 “Revenue Replacement.” Treasury has determined that there are no subawards under this eligible use category. U.S. Department of the Treasury. (2021). Final Rule Frequently Asked Questions (FAQ). Retrieved from https://home.treasury.gov/system/files/136/SLFRF-Final-Rule-FAQ.pdf. Contact Person: Elizabeth Tatum, Deputy Director, Mayor’s Office of Recovery Programs Completion Date: June 30, 2025

View Audit 357839

Finding 563034 (2024-028)

Material Weakness 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.331 § 200.332 § 200.501

Finding 2024-028 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2023-024 Auditee’s Corrective Action Plan: BCHD has develo...

Finding 2024-028 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2023-024 Auditee’s Corrective Action Plan: BCHD has developed a subrecipient monitoring policy currently routing internally for approval that addresses the assessment, monitoring and documentation portions of subrecipient monitoring as well as other key elements to ensure adherence to 2CFR 200. The following tools have been created and implemented or in progress to use during monitoring: A. Subrecipient vs. Contractor Determination Checklist that must be completed by staff when submitting contract request to the contract unit to ensure subrecipients are properly identified and to develop a comprehensive monitoring schedule for the agency. B. Comprehensive risk assessment tool to determine monitoring plan for subrecipient. C. Both programmatic and fiscal baseline monitoring tools. Programmatic tools are at the beginning stages of implementation and continue to be customized for specific grant award requirements when necessary. D. Updated expense tracker for the accountants to utilize for review of subrecipient invoices. E. Updated monitoring and risk assessment tools to include requesting and documenting both single audit reports and SAMS.gov status. F. Subrecipient contract agreement templates are being updated to ensure subaward is clearly identified and includes the Federal Award Identification Number, subrecipient’s UEI, along with clear monitoring expectations. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: June 30, 2025

View Audit 357839

Finding 563032 (2024-026)

Material Weakness 2024

City of Baltimore, Maryland

MD

Cash Management Subrecipient Monitoring § 200.302 § 200.303

Finding 2024-026 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes; 2023-022 Auditee’s Corrective Action Plan: BCHD fiscal department ...

Finding 2024-026 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes; 2023-022 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562945 (2024-025)

Material Weakness 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.331 § 200.332 § 200.501

Finding 2024-025 U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2023-021 Auditee’s Corrective Action Plan: BCHD has developed a subrecipient moni...

Finding 2024-025 U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2023-021 Auditee’s Corrective Action Plan: BCHD has developed a subrecipient monitoring policy currently routing internally for approval that addresses the assessment, monitoring and documentation portions of subrecipient monitoring as well as other key elements to ensure adherence to 2CFR 200. The following tools have been created and implemented or in progress to use during monitoring: A. Subrecipient vs. Contractor Determination Checklist that must be completed by staff when submitting contract request to the contract unit to ensure subrecipients are properly identified and to develop a comprehensive monitoring schedule for the agency. B. Comprehensive risk assessment tool to determine monitoring plan for subrecipient. C. Both programmatic and fiscal baseline monitoring tools. Programmatic tools are at the beginning stages of implementation and continue to be customized for specific grant award requirements when necessary. D. Updated expense tracker for the accountants to utilize for review of subrecipient invoices. Updated monitoring and risk assessment tools to include requesting and documenting both single audit reports and SAMS.gov status. E. Update subrecipient contract agreement templates ensure subawards are clearly identified and include the Federal Award Identification Number, subrecipient’s UEI, along with clear monitoring expectations. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: June 30, 2025

View Audit 357839

Finding 562944 (2024-024)

Material Weakness 2024

City of Baltimore, Maryland

MD

Cash Management Subrecipient Monitoring § 200.302 § 200.303

Finding 2024-024 U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes; 2023-020 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its...

Finding 2024-024 U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes; 2023-020 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562904 (2024-023)

Material Weakness 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring Eligibility Material Weakness § 200.302 § 200.303

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

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

View Audit 357839

Finding 562865 (2024-022)

Material Weakness 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.331 § 200.332 § 200.501

Finding 2023-022 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2023-017 BCHD has developed a subrecipient monitoring policy currently ro...

Finding 2023-022 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes; 2023-017 BCHD has developed a subrecipient monitoring policy currently routed internally for approval that addresses the assessment, monitoring and documentation portions of subrecipient monitoring as well as other key elements to ensure adherence to 2 CFR 200. The following tools have been created and implemented or in progress to use during monitoring: A. Subrecipient vs. Contractor Determination Checklist that must be completed by staff when submitting contract request to the contract unit to ensure subrecipients are properly identified and to develop a comprehensive monitoring schedule for the agency. B. Comprehensive risk assessment tool to determine monitoring plan for subrecipient. C. Both programmatic and fiscal baseline monitoring tools. Programmatic tools are at the beginning stages of implementation and continue to be customized for specific grant award requirements when necessary. D. Updated expense tracker for the accountants to utilize for review of subrecipient invoices. E. Updated monitoring and risk assessment tools to include requesting and documenting both single audit reports and SAMS.gov status. E. Update subrecipient contract agreement templates ensure subawards are clearly identified and include the Federal Award Identification Number, subrecipient’s UEI, along with clear monitoring expectations. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: June 30, 2025

View Audit 357839

Finding 562864 (2024-021)

Material Weakness 2024

City of Baltimore, Maryland

MD

Reporting Subrecipient Monitoring Material Weakness § 200.302 § 200.303

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

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

View Audit 357839

Finding 562862 (2024-019)

Significant Deficiency 2024

City of Baltimore, Maryland

MD

Cash Management Subrecipient Monitoring § 200.302 § 200.303

Finding 2024-019 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 Cash Management Repeat Finding: No Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise i...

Finding 2024-019 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 Cash Management Repeat Finding: No Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

Finding 562859 (2024-018)

Significant Deficiency 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.332

Finding 2024-018 U.S. Department of Health and Human Services AL No. 93.600 Head Start Significant Deficiency in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: While the FAIN was included in the package approved by BOE and sent t...

Finding 2024-018 U.S. Department of Health and Human Services AL No. 93.600 Head Start Significant Deficiency in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: While the FAIN was included in the package approved by BOE and sent to the subrecipient and the budget and the Federal award also included in the package showed that only direct costs would be reimbursed, the City’s Law Department will revise Exhibit G Funding Source in Subrecipient contracts to include the FAIN, the subrecipient’s UEI and a statement regarding indirect costs. Consequently, the information noted as missing will be specifically referenced/included in contracts signed by the subrecipients moving forward. Contact Person: Shannon Burroughs-Campbell, Executive Director of Baltimore City Head Start Lisa Dooley, Head Start Accountant Completion Date: June 30, 2025

View Audit 357839

Finding 562858 (2024-017)

Significant Deficiency 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

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

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

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