Corrective Action Plans

Finding 1159443 (2024-002)

Material Weakness 2024

NV

Procurement, Suspension & Debarment § 200.218 § 200.317 § 200.327

2024 -002 Documentation of Procurement History Corrective Action Plan: The Standard Operating Procedures currently outlines procurement based on Uniform Guidance. Additional procedures will be implemented to ensure compliance with the policy. An internal Procurement Checklist and Pre-Award Review Fo...

2024 -002 Documentation of Procurement History Corrective Action Plan: The Standard Operating Procedures currently outlines procurement based on Uniform Guidance. Additional procedures will be implemented to ensure compliance with the policy. An internal Procurement Checklist and Pre-Award Review Form prepared by the Chief Operating Officer will be implemented to ensure compliance is documented before federal funds are expended. That document will be reviewed and approved by the President / CEO. All procurements over the simplified acquisition threshold will be reviewed by the Chief Operating Officer for compliance before a purchase order is issued or a quote is approved. All vendors solicited for proposal on procurements over the simplified acquisition threshold will be discussed during board meetings and documented in board meeting minutes. Personnel Responsible for Corrective Action: Alison Elder, CFO Anticipated Completion Date: May 2025

View Audit 370180

Finding 1159439 (2024-001)

Material Weakness 2024

Montefiore Health System, Inc.

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice...

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.

View Audit 370177

Finding 1159437 (2024-002)

Material Weakness 2024

Housing Authority of the City of La Joya

TX

PHA Response and Action Plan- Management continues to resolve old tenant filed deficiencies lacking required documentation. While 55% failure rate is unacceptable, please note the 2023 audit file review was a 100% failure rate for this component. Management will resolve deficiency before end of the ...

PHA Response and Action Plan- Management continues to resolve old tenant filed deficiencies lacking required documentation. While 55% failure rate is unacceptable, please note the 2023 audit file review was a 100% failure rate for this component. Management will resolve deficiency before end of the 2025 FYE.

View Audit 370171

Finding 1159436 (2024-001)

Material Weakness 2024

Housing Authority of the City of La Joya

TX

PHA Response and Action Plan- Financial department management has been in contact with the Internal Revenue Service for the transfer of credentials from the previous management agent to Mission HA. This process has been tedious and at times unresponsive. We are currently working with the IRS for cha...

PHA Response and Action Plan- Financial department management has been in contact with the Internal Revenue Service for the transfer of credentials from the previous management agent to Mission HA. This process has been tedious and at times unresponsive. We are currently working with the IRS for change of credentials and submission of all pending 941 payments. Deficiency will be resolved before close of 2025 FYE

View Audit 370171

Finding 1159428 (2024-002)

Material Weakness 2024

Mhub

IL

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.319 § 200.320

Condition: The Organization did not have controls to retain documentation that the procurement process was followed to ensure more than one vendor was reviewed for pricing before selecting the vendor chosen (as required under 2 CFR 320(a)(2)(i)). Planned Corrective Action: Management will implement ...

Condition: The Organization did not have controls to retain documentation that the procurement process was followed to ensure more than one vendor was reviewed for pricing before selecting the vendor chosen (as required under 2 CFR 320(a)(2)(i)). Planned Corrective Action: Management will implement controls to ensure proper support of the procurement process is retained. Contact person responsible for corrective action: Manas Mehandru, COO Anticipated Completion Date: December 31, 2025

View Audit 370163 Questioned Costs: $1

Finding 1159427 (2024-001)

Material Weakness 2024

Coastal Community Action Program

WA

Reporting Subrecipient Monitoring § 200.302

September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an...

September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an unusual reallocation of funding by the Washington State Department of Commerce. The award was originally awarded and recorded as state funds. In September 2024, the Washington State Department of Commerce reallocated a portion of its funding and amended the grant terms to designate the award as being funded under the Coronavirus State and Local Fiscal Recovery Funds (21.027). Because the reallocation and revised terms were communicated late in the fiscal year, management did not identify the change in time to ensure that the award was correctly reported as federal on the SEFA. The adjustment was therefore an oversight and not an intentional misclassification. 2024-001 Preparation of the Schedule of Expenditures of Federal Awards CCAP Executive Leadership understands the function and necessity of preparing a complete and accurate SEFA. 1. Policy and Procedures Development: By November 15, 2025, management will develop and adopt written policies and procedures requiring formal review of all grant amendments, reallocations, and correspondence from pass-through entities to determine whether funding sources have changed and whether SEFA reporting is affected. 2. Internal Control Implementation: Management will implement a dual-review process in which both the Finance Director and Grants Manager verify the funding source and assistance listing number for all awards and amendments before SEFA preparation. 3. Training: Staff responsible for grants management and financial reporting will complete training on Uniform Guidance financial management and SEFA preparation requirements by November 15, 2025, with refresher training annually thereafter. 4. Ongoing Monitoring: Management will conduct a pre-audit SEFA review each year, reconciling all awards and amendments to source documentation, including grant agreements, amendments, and communications from pass-through entities. Responsible Party: Lucy Machowek, CFO Planned Completion Date: November 15, 2025

View Audit 370154

Finding 1159426 (2024-003)

Material Weakness 2024

Capital Region Minority Supplier Development Council

MD

Questioned Costs Matching / Level of Effort / Earmarking § 200.306

Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the ...

Thank you for your review and the findings shared in the recent audit. We appreciate the thorough assessment and the opportunity to strengthen our processes. We acknowledge the findings; however we respectfully disagree with [Finding Reference 2024-003, Insufficient Non-Federal Share]. Based on the support and documentation we provided we captured $191,000 (25% non-federal match) of in-kind to meet our obligation of $189,250 for grant award Year 1, 2023. And although we met our in-kind obligation, we experienced several delays which were recognized by our grantee, MBDA. The delay in funding the grant award took place from July 2023 to September 2023 and subsequently after funding was released an additional black-out period from September 2023 to October 2023 was experienced due to a system transition from BAS to GEMS/era Commons. Acknowledgement of these delays was addressed by an official during an MBDA All Equities call on October 18, 2023. During that call awardees were advised to continue focusing on our program activities and clients as the situation was being addressed. To account for the delays, we later submitted a budget revision request through the new system, eRA Commons on 12.09.2024 asking for a budget carryover of $337,825.00 which also outlines how the funds will be expended. Additionally, it is noted in your finding that the allowable in-kind contribution is being reduced given that budget categories were not met by line item. However, our interpretation of MBDA Capital Readiness NOFO (pg.14), we are directed to Section CFR200.306 [https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-D/section-200.306] which does not cap in-kind by line-item. Lastly, the MBDA organization has changed dramatically since the inception of the Capital Readiness grant in 2023, yet we have been in communication with an MBDA government official who acknowledges the delays during the time outlined above and ask that flexibility for this non-federal share requirement be re-considered. Supporting documentation has been sent to support the statements. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: We plan to continue to seek validation of our position from our grantor and grant management entity – 4th Quarter 2025.

View Audit 370152 Questioned Costs: $1

Finding 1159425 (2024-002)

Material Weakness 2024

Capital Region Minority Supplier Development Council

MD

Reporting Significant Deficiency § 200.510

Management acknowledges the finding and concurs with the auditor’s recommendation. The challenges identified were primarily the result of a major transition in accounting personnel during 2024. In August 2024, CRMSDC’s long-serving in-house accountant of nine years resigned unexpectedly, leaving lim...

Management acknowledges the finding and concurs with the auditor’s recommendation. The challenges identified were primarily the result of a major transition in accounting personnel during 2024. In August 2024, CRMSDC’s long-serving in-house accountant of nine years resigned unexpectedly, leaving limited time for an adequate transfer of knowledge and responsibilities. To preserve continuity in financial operations, CRMSDC immediately engaged outsourced accounting support. Looking ahead, CRMSDC will undertake a full review of its financial management structure and secure a highly qualified accountant or financial professional with specialized expertise in nonprofit accounting and federal grant compliance. Combined with strengthened procedures and enhanced supervisory oversight, these actions will build organizational capacity, reinforce internal controls, and ensure accurate and timely financial reporting. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: Assessment and Correction – 4th Quarter 2025

View Audit 370152

Finding 1159424 (2024-003)

Material Weakness 2024

Social & Environmental Entrepreneurs, Inc.

CA

Questioned Costs Allowable Costs / Cost Principles

Single Audit Finding: 2024-003 Allowable Costs and Allowable Activities (Material Weakness in Internal Controls over Compliance) Condition: The auditors identified an instance of material noncompliance; for transactions sampled under ALN 21.027, timesheets did not adequately support the charges to g...

Single Audit Finding: 2024-003 Allowable Costs and Allowable Activities (Material Weakness in Internal Controls over Compliance) Condition: The auditors identified an instance of material noncompliance; for transactions sampled under ALN 21.027, timesheets did not adequately support the charges to grants. Additionally, in the transactions tested for ALN 66.615, there was no sufficient documentation to support the total fringe benefit amounts charged to the grants. Repeat Finding: Yes, similar deficiencies noted in 2023‐003. Views of Responsible Officials: There was a finding that was noted related to the tracking of personnel costs to the federally funded contract. SEE Accounting and Administration, which includes HR, has established and implemented uniform timekeeping procedures requiring all employees, both exempt and non-exempt, whose salaries are charged to federal contracts to submit accurate and complete timecards that reflect the actual hours worked. These formal procedures are monitored, reviewed, and reconciled on a monthly basis. Official Responsible for Ensuring CAP: Jennifer Hoffman, CEO; Anna Zaricki, CFO; Trevis Bird, COO; Monique Gutierrez, Sr-HRD; Arthur Doi, Controller; and Justin Yamashiro, Audit Manager are responsible for ensuring corrective action is implemented. Planned Completion Date for CAP: December 31, 2026

View Audit 370147 Questioned Costs: $1

Finding 1159421 (2024-001)

Material Weakness 2024

Brooklyn Plaza Medical Center, Inc.

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the Decemb...

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410, H8N53897, and H8L50850 for 2024 Finding 2024-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in September 2024 We agree with the auditors finding. We acknowledge that, within the current audit sample of 57 patient files, 2 were found to contain instances of noncompliance with the Sliding Fee Scale (SFS) requirements. We recognize the importance of full compliance and remain firmly to continuous improvement in this area. It is important to note that this represents a significant improvement from the prior year’s audit. The identification of only 2 errors out of 57 patients’ files selected highlights the effectiveness of the corrective actions plan we implemented in response to the previous finding. Corrective Actions and Improvements Implemented: 1. Staff Training- Following the prior audit, front desk staff received additional training emphasized accurate application of SFS policies, required documentation, and proper income verification protocols. 2. Internal Auditing- Beginning in September 2024, The CEO designated the Compliance Officer to conduct daily audits of SFS related documentation. These real time audits help identify and correct issues promptly, with findings continuously incorporated into staff training programs. While we are encourage with the progress made, we remain focused on achieving full compliance and will continue to refine our processes and training to meet that goal. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Daniel Desire, CFO

View Audit 370146

Finding 1159418 (2024-001)

Material Weakness 2024

Fort Lee Housing Authority

NJ

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Views of Responsible Officials and Planned Corrective Action: The Authority contracted with an Agency which performed all rent reasonableness calculations, however, a copy of the calculations could not be located at the time of audit. The Authority has implemented a process whereby all completed ren...

Views of Responsible Officials and Planned Corrective Action: The Authority contracted with an Agency which performed all rent reasonableness calculations, however, a copy of the calculations could not be located at the time of audit. The Authority has implemented a process whereby all completed rent reasonableness calculations will be stored in the related tenant file. Terrence Corriston, Executive Director, is responsible for implementing this corrective action by December 31, 2025.

View Audit 370143

Finding 1159417 (2024-004)

Material Weakness 2024

Supports to Encourage Low Income Families INC

OH

Reporting Internal Control / Segregation of Duties

In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiate...

In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiated. The new policy was approved shortly thereafter by the organization’s board. SELF also contracted with a digital security company to train all employees about digital threat awareness including fraud and phishing attempts, specifically via email. As part of these new practices, all employees are required to participate in monthly training.

View Audit 370141

Finding 1159416 (2024-002)

Material Weakness 2024

Gowest Foundation

WA

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303 § 200.518

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

View Audit 370140 Questioned Costs: $1

Finding 1159415 (2024-001)

Material Weakness 2024

Gowest Foundation

WA

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.

View Audit 370140 Questioned Costs: $1

Finding 1159414 (2024-002)

Material Weakness 2024

Heart of Ohio Family Health Centers

OH

Reporting

Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. ...

Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Additionally, the Organization will implement policies and procedures surrounding file retention of the underlying data that supports federal reports submitted. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Angelita Thomas, Chief Financial Officer

View Audit 370139

Finding 1159411 (2024-001)

Material Weakness 2024

Center for Asbestos Related Disease

MT

Reporting § 200.516

Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm...

Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Rudd & Company, PLLC 3805 Valley Commons Drive, Ste. 7 Bozeman, MT 59718 Audit Period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below: Federal Award Findings and Questioned Costs Finding 2024-001 Department of Health and Human Services Libby, Montana’s Public Health Emergency, Asbestos Health Screening, CFDA #93.534 5NU61TS000295-05 Finding Summary: Final Financial report for the grant period end was not submitted by the due date. Responsible Individuals: Executive Director, Tracy McNew and Financial Officer, Janine Price Corrective Action Plan: Management has added all report due dates to their calendars beginning two weeks before the due dates to ensure reports are filed in a timely manner even if difficulties are encountered with the filing process. In addition, case numbers with PMS’s help desk will be recorded and other communications will be saved to ensure that proper documentation is maintained for any reports rejected and refiled at a later date. Anticipated Completion Date: Ongoing

View Audit 370138

Finding 1159410 (2024-001)

Material Weakness 2024

Grady Memorial Hospital Corporation

GA

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting

View Audit 370132

Finding 1159406 (2024-008)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, Nati...

Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, National Science Foundation, Department of Veteran Affairs, Environment Protection Agency, Department of Energy, Department of Health and Human Services, U.S. Agency for International Development Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. Due to a system failure, vendor payment files from January through September 2024 were not transmitted to Mount Sinai’s sanction screening vendor. Mount Sinai has taken corrective actions to address this issue. All current vendors in our vendor master file, as well as all new vendors added through our new vendor credentialing process, are now processed through our sanction screening vendor on a monthly basis. In addition, a new manual control has been implemented to review, confirm, and reconcile to ensure that the vendor master file has been transmitted successfully, and all vendors are screened for sanctions, and a report thereof is provided each month. Our process will also document and maintain evidence that unverified vendors or those that were indicated as excluded were investigated and evaluated by the Health System. We will also periodically perform independent sanction screening checks on a sample of our vendors to validate the accuracy of the results of our third-party sanction screening vendor. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: Our vendor credentialing process was establishing with our ERP implementation on October 7, 2024. Our enhanced procedures to reconcile our file transmissions to our independent third-party and perform screening checks on samples of vendors verified by our independent third-party is expected to be implemented by December 31, 2025.

View Audit 370128 Questioned Costs: $1

Finding 1158856 (2024-007)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Questioned Costs Procurement, Suspension & Debarment

Finding 2024-007 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, Nati...

Finding 2024-007 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, National Science Foundation, Department of Veteran Affairs, Environment Protection Agency, Department of Energy, Department of Health and Human Services, U.S. Agency for International Development Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. In October 2024, Mount Sinai transitioned to Oracle Cloud for its Enterprise Resource Planning (ERP) and general ledger system. During this transition, Deputy Buyer transactions of $10,000 and above were not routed to the Purchasing Team for review, allowing purchase orders to be completed without the required documentation, including Sole Source Justifications, Directed Source Justifications, or multiple quotes as required under Uniform Guidance. Corrective actions, including a system enhancement, have been implemented to remediate this issue. Mount Sinai’s enhanced process ensures Deputy Buyer transactions of $10,000 and above are routed appropriately to the Purchasing Team for validation and documentation review. In addition, a quarterly manual review process, supported by reports developed in partnership with Mount Sinai’s technology team, will be fully implemented as a compensating control in the fourth quarter of 2025. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: Our enhanced procedures for ensuring the necessary documentation is completed on Deputy Buyer transactions of $10,000 and above is expected to be implemented by December 31, 2025.

View Audit 370128 Questioned Costs: $1

Finding 1158306 (2024-006)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Student Financial Aid Allowable Costs / Cost Principles Reporting

Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not c...

Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not correctly populated. Management has since corrected the data and submitted a revised FISAP. Management notes there was turnover in the PSON’s Office of Student Financial Aid during the year and an employee was not properly trained on the FISAP preparation. Training has since been implemented and new employees in the department will be trained accordingly. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158301 (2024-005)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Student Financial Aid

Finding 2024-005 N. Special Tests and Provisions - Disbursement to or on Behalf of Students Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective ac...

Finding 2024-005 N. Special Tests and Provisions - Disbursement to or on Behalf of Students Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that certain credit refunds were not issued timely. PSON and ISMMS’ Offices of Student Financial will implement a control that ensures communication related to refunds is enhanced when a student withdraws. ISMMS has ensured compliance with the Department of Education’s 14-day credit balance requirement by contracting with Nelnet, an external financial management vendor, to administer the credit refund process, supported by ongoing monitoring and periodic internal reviews. The control will ensure that all credit refunds are issued timely. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org LaVerne Walker Director of Student Financial Services, Icahn School of Medicine at Mount Sinai Laverne.walker@mssm.edu Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158296 (2024-004)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions

Finding 2024-004 N. Special Tests and Provisions - Enrollment Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management ag...

Finding 2024-004 N. Special Tests and Provisions - Enrollment Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON and ISSMS’ Offices of Student Financial will ensure that all NSLDS submissions are made timely and with the correct status of each student. The respective Offices are implementing enhanced monitoring, staff training, and periodic internal reviews to confirm compliance. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org LaVerne Walker Director of Student Financial Services, Icahn School of Medicine at Mount Sinai Laverne.walker@mssm.edu Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158291 (2024-003)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Student Financial Aid

Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees wit...

Finding 2024-003 N. Special Tests and Provisions - Verification Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON’s Office of Student Financial Aid will implement a process that ensures all required documentation is retained. Employees of the Student Financial Aid Office will be trained and PSON will be in compliance with the requirements in the Federal Student Aid Handbook. Name of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158286 (2024-005)

Material Weakness 2024

Providence St. Joseph Health

WA

Subrecipient Monitoring § 200.208 § 200.303 § 200.328 § 200.329

Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely subm...

Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely submission and retention of supporting documentation for required sponsor reporting. This process will be implemented by December 31, 2025.

View Audit 370126

Finding 1158252 (2024-004)

Material Weakness 2024

Providence St. Joseph Health

WA

Reporting Special Tests & Provisions

Management acknowledges the audit finding regarding deficiencies in the reporting of student status changes to COD. These discrepancies were primarily due to limitations in our staffing and review procedures. We are revising our enrollment reporting policies to clearly define roles, responsibilities...

Management acknowledges the audit finding regarding deficiencies in the reporting of student status changes to COD. These discrepancies were primarily due to limitations in our staffing and review procedures. We are revising our enrollment reporting policies to clearly define roles, responsibilities, and timelines for processing student status changes. This includes an additional layer of review to verify the accuracy of effective dates prior to COD submission. These additional policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Corrective Action Plans

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