Corrective Action Plans

Finding 1205396 (2024-003)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management

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

H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that the Corporation works with the funding agency to remedy the period of performance noncompliance. In addition, we recommend that the Corporation reassess the design of its period of performance controls to identify where enhancement or additional controls are needed over liquidation of financial obligations subsequent to the end of a grant award. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue to educate all grant managers on (1) the reporting capabilities within the system that can be utilized in the execution of monitoring payment status on individual invoices that have been submitted to granting agencies for reimbursement, and (2) the requirement to use their grant specific general ledger coding when orders are placed with vendors that are set up under the Corporation’s group purchasing process. For the specific vendor noted in Finding 2024-003, a grant number input field has been added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants and the monitoring of payment of those expenditures. The use of the accurate grant general ledger coding by grant managers when orders are placed will reduce the time between placement of order and payment of the invoice. The grant manager responsible for oversight of BHSB grants will work with BHSB to remedy the period of performance noncompliance noted in Finding 2024-003. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397083

Finding 1205395 (2024-002)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles Cash Management Reporting

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

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

View Audit 397083

Finding 1205394 (2024-001)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles

A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Purchase Orders Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management shou...

A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Purchase Orders Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should obtain documentation that evidences the review and approval of expenditures submitted to Behavioral Health System Baltimore (BHSB). Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on system capabilities that can be utilized in the execution of review and approval of grant expenditures prior to submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as retain their review and approval evidence. For the specific vendor noted in Finding 2024-001, a grant input field was added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants. Additionally, management worked with the vendor to ensure the requisition and approval configuration is properly maintained to prevent an approver from approving their own requisitions. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397083

Finding 1205246 (2024-006)

Material Weakness 2024

Save the Michael's of the World

NY

Procurement, Suspension & Debarment § 200.318 § 200.326

The Organization will develop and implement written procurement policies and procedures that comply with Uniform Guidance and ensure consistent application across all procurement activities.

View Audit 396940

Finding 1205245 (2024-005)

Material Weakness 2024

Save the Michael's of the World

NY

Reporting

The Organization has engaged an audit firm to complete the 2024 audit and is implementing procedures to ensure the Single Audit is completed and submitted in a timely manner in future years.

View Audit 396940

Finding 1205244 (2024-004)

Material Weakness 2024

Save the Michael's of the World

NY

Beginning in 2024, the Organization transitioned its time-tracking process to QuickBooks Time, which integrates directly with its accounting system. In addition, the Organization will formally document all future pay rate authorizations in writing, including approvals by the employee and the applica...

Beginning in 2024, the Organization transitioned its time-tracking process to QuickBooks Time, which integrates directly with its accounting system. In addition, the Organization will formally document all future pay rate authorizations in writing, including approvals by the employee and the applicable manager or supervisor. This documentation will be retained in each employee’s personnel file to substantiate authorized pay rates going forward.

View Audit 396940

Finding 1205243 (2024-003)

Material Weakness 2024

Save the Michael's of the World

NY

Equipment & Real Property Management

The Organization will implement procedures to ensure a physical inventory of all federally funded fixed assets is performed at least every two years and reconciled to the fixed asset records. Newly acquired fixed assets will be tagged upon purchase, and written policies will be updated to assign res...

The Organization will implement procedures to ensure a physical inventory of all federally funded fixed assets is performed at least every two years and reconciled to the fixed asset records. Newly acquired fixed assets will be tagged upon purchase, and written policies will be updated to assign responsibility and ensure ongoing compliance.

View Audit 396940

Finding 1205186 (2024-003)

Material Weakness 2024

Morgan County

OH

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.202 § 200.208 § 200.301 § 200.328

The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accor...

The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accordance with those requirements.

View Audit 396842

Finding 1205047 (2024-001)

Material Weakness 2024

Detroit Police Athletic League, Inc.

MI

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management is committed to strengthening how we track and allocate hours to grant-funded projects to ensure full compliance with 2 CFR 200.430. Going forward, the organization will implement a time study approach to support the allocation of personnel costs to federal grants. Employees working across multiple funding sources will participate in periodic time studies designed to reasonably estimate the distribution of their time based on actual activities performed. The results of these time studies will be used as the basis for allocating payroll costs to the appropriate grants, and will be supported by documentation and supervisory review. We will also implement consistent tools and processes to ensure allocations are applied systematically across all funding sources. On a monthly basis, the finance team will review and reconcile payroll allocations to ensure they align with the established methodology. In addition, we will provide training and ongoing oversight to reinforce compliance and prevent similar Issues In the future.

View Audit 396692

Finding 1205009 (2024-004)

Material Weakness 2024

Innovative Health Solutions

CA

Reporting Cash Management Program Income

Finding 2024-04 Schedule of Expenditures of Federal Awards. Management concurs with the finding. IHS will be working with the new outside CPA firm to develop a grant bridging report beginning FY2025/26.

View Audit 396668

Finding 1205008 (2024-003)

Material Weakness 2024

Innovative Health Solutions

CA

Cash Management Significant Deficiency

Finding 2024-03 Filing of Single Audit Reports. Management concurs with the finding. Beginning July 1, 2025, IHS will be transitioning some of its financial reporting and audit support functions to an outside CPA firm specializing in nonprofit services. It is anticipated that this transition will he...

Finding 2024-03 Filing of Single Audit Reports. Management concurs with the finding. Beginning July 1, 2025, IHS will be transitioning some of its financial reporting and audit support functions to an outside CPA firm specializing in nonprofit services. It is anticipated that this transition will help assist in meeting the single audit filing deadline.

View Audit 396668

Finding 1205007 (2024-002)

Material Weakness 2024

Innovative Health Solutions

CA

Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements

View Audit 396668

Finding 1205006 (2024-001)

Material Weakness 2024

Innovative Health Solutions

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recogniti...

Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recognition criteria for various revenue streams. IHS will continue to review and refine its accounting policies and procedures as it transitions some of its financial reporting and audit support functions to a new outside CPA firm specializing in nonprofit services beginning July 1, 2025.

View Audit 396668

Finding 1205004 (2024-007)

Material Weakness 2024

The City of Frederick, Maryland

MD

Subrecipient Monitoring § 200.331 § 200.332

Finding reference: 2024-007 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Unifor...

Finding reference: 2024-007 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Uniform Guidance, as noted in Section 200.331(a). Additionally, program management should develop standardized procedures for selecting and granting subawards. These procedures should be formalized and maintained for future reference. Brief minutes of progress meetings should be taken to show that monitoring is taking place. All reporting by the subrecipient should be reviewed by management of the program. Action taken: The HHS Department will outline the selection process within the Notice of Funding Availability. Furthermore, a monitoring schedule will be created and program staff are required to review all reports submitted by the subrecipient.

View Audit 396662

Finding 1205003 (2024-006)

Material Weakness 2024

The City of Frederick, Maryland

MD

Subrecipient Monitoring Reporting Material Weakness

Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In ad...

Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In addition to hiring a grant manager to oversee compliance, the City has purchased OpenGov grant software to ensure compliance, monitoring and the insurance of timely submissions in accordance with the grant. This system is designed to send notifications of reporting requirements prior to the due date.

View Audit 396662

Finding 1205002 (2024-005)

Material Weakness 2024

The City of Frederick, Maryland

MD

Reporting

Finding reference: 2024-005- 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Reporting – Financial Report Recommendation: Program management and the Finance Department should maintain a schedule of required reporting with correspondi...

Finding reference: 2024-005- 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Reporting – Financial Report Recommendation: Program management and the Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Action taken: In addition to hiring a grant manager, the City has purchased OpenGov grant software to ensure compliance, monitoring and the insurance of timely submissions in accordance with the grant

View Audit 396662

Finding 1205001 (2024-004)

Material Weakness 2024

The City of Frederick, Maryland

MD

Cash Management § 200.302

Finding reference: 2024-004 - 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Cash Management Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the gen...

Finding reference: 2024-004 - 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Cash Management Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Action taken: With the hiring of our grant accountant, the policy is that all drawdowns are to be reconciled to general ledger prior to submitting.

View Audit 396662

Finding 1205000 (2024-010)

Material Weakness 2024

The City of Frederick, Maryland

MD

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on t...

Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Action taken: All elements required for the sliding fee discount are being properly maintained. All employees have been properly trained in software.

View Audit 396662

Finding 1204999 (2024-009)

Material Weakness 2024

The City of Frederick, Maryland

MD

Cash Management § 200.302

Finding reference: 2024-009 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Cash Management Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed a...

Finding reference: 2024-009 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Cash Management Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Action taken: With the hiring of our grant accountant, the policy is that all drawdowns are to be reconciled to general ledger prior to submitting.

View Audit 396662

Finding 1204998 (2024-008)

Material Weakness 2024

The City of Frederick, Maryland

MD

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding reference: 2024-008 - 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for...

Finding reference: 2024-008 - 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Action taken: The City has moved to personnel activity reports (PARS) for timesheet reporting to ensure the allocation of the number of hours performed on each program is accurate. The only exception is an employee that works 100% on one grant. Total working hours are recorded to the grant for this individual.

View Audit 396662

Finding 1204988 (2024-003)

Material Weakness 2024

The City of Frederick, Maryland

MD

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding reference: 2024-003 - 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for emp...

Finding reference: 2024-003 - 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Action taken: The City has moved to personnel activity reports (PARS) for timesheet reporting to ensure the allocation of the number of hours performed on each program is accurate. The only exception is when an employee works 100% on one grant. Then all working hours are recorded to the grant.

View Audit 396662

Finding 1204879 (2024-002)

Material Weakness 2024

Village of Glenmont

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Period of Performance § 200.329

The Fiscal Officer will improve tracking and reporting procedures by requesting a clear outline from all funding and liaising parties at the start of all future projects. As well as making sure all reporting and procedures are adhered to by those parties.

View Audit 396497

Finding 1204855 (2024-004)

Material Weakness 2024

Mountain State Centers for Independent Living, Inc.

WV

Internal Control / Segregation of Duties

Indirect cost proposal. MSCIL acknowledges the need to maintain compliance wi th fed eral reporting requirements and has taken steps to ensure timely submission going forward. Management will complete and submit the indirect cost proposal immediately upon finalization of the audited financial statem...

Indirect cost proposal. MSCIL acknowledges the need to maintain compliance wi th fed eral reporting requirements and has taken steps to ensure timely submission going forward. Management will complete and submit the indirect cost proposal immediately upon finalization of the audited financial statements. Responsibility for preparing future proposals will be assigned to a designated staff member, with oversight from the President/CEO to ensure deadlines are met. MSCIL is also refining its reporting schedule and review procedures to support timely and accurate filings in future years. The Fyffe Jones Group will assist with filing needs as necessary to support compliance and ensure accuracy of submissions. These steps will help e nsure tha t indirect cost proposals are submitted timely in accordance with federal requirements.

View Audit 396485

Finding 1204853 (2024-003)

Material Weakness 2024

Mountain State Centers for Independent Living, Inc.

WV

Program disbursements lacked proper documented support. MSCIL recognizes the importance of maintaining proper authorization and documentation for all federally funded expenditures and has taken steps to strengthen these practices. Management is improving its internal and program review systems to en...

Program disbursements lacked proper documented support. MSCIL recognizes the importance of maintaining proper authorization and documentation for all federally funded expenditures and has taken steps to strengthen these practices. Management is improving its internal and program review systems to ensure that disbursements are properly reviewed and handled in accordance with grant requirements . Program disbursements will be stored within MSCIL's accounting software to improve consistency across departments. The Administrative Coordinator will assist in monitoring program documentation, and The Fyffe Jones Group will review these processes as part of their monthly reconciliation procedures to identify areas of improvement. These modification s will help ensure that MSCIL's reporting aligns with federal expectations.

View Audit 396485

Finding 1203104 (2024-001)

Material Weakness 2024

Town of Oak Bluffs

MA

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

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C....

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C. 53 State Street, 17th Floor Boston, MA 02109 Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Financial Statement Finding 2024-001 – Document Policies and Procedures Over Federal Awards Condition: During our audit, we noted that the Town did not have formal policies and procedures in place covering the requirements of Uniform Guidance as specified in 2 CFR Part 200. Certain elements, such as procurement standards, subrecipient monitoring, internal control, and other compliance areas, were not addressed in written policies or documented procedures. Criteria: Uniform Guidance (2 CFR Part 200) requires non-federal entities administering federal awards to establish and maintain written policies and procedures to address all requirements specified in the regulations, including but not limited to internal controls, determination of allowable costs, procurement, subrecipient monitoring, financial management, and reporting. Cause: The Town has not developed comprehensive written policies and procedures to address all compliance requirements under Uniform Guidance. Effect: The absence of written policies and procedures increases the risk of noncompliance with federal requirements, reduces consistency in federal program administration, and limits transparency and accountability. Recommendation The Town should develop and implement comprehensive written policies and procedures that address all major compliance requirements under Uniform Guidance (2 CFR Part 200). Periodic review and updates should be performed to ensure ongoing compliance. Views of Responsible Officials: We have been reviewing existing workflows, and unwritten procedures, relative to our management and oversight of federal awards either received directly from the federal or from another intermediary pass-through agency. Once our review is complete, we will commit those procedures to writing and present them to the Select Boad for approval. The anticipation is that we will have documented policies and procedures, that are compliant with the Uniform Guidance, in time for the FY2026 audit.

View Audit 396313

Corrective Action Plans

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