Corrective Action Plans

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2023-006 Significant Deficiency: See finding 2024-006. Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to prepare an operating budget by AMP location. Management’s response: The Authority has had some staff turnover over the past several year...
2023-006 Significant Deficiency: See finding 2024-006. Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to prepare an operating budget by AMP location. Management’s response: The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that its budget was not prepare by AMP location. Management engaged the services of a fee-accountant subsequent to year-end who will assist with the budgeting process in the future. The fee engaged was just recently re-engaged subsequent to June 30, 2025 year end. Management is aware that general best practice is to have a budget adopted by the board prior to the beginning of each fiscal year, however since the fee accountant was retained after the beginning of the 2025-2026 fiscal year, the 2025-2026 budget will not be prepared and adopted by the board on a timely basis.
2024-004 Significant Deficiency: See finding 2024-004. Recommendation: We recommend that management of the Authority review its processes for closing out all fully-expended grants with HUD to ensure that, in the future, when grants are fully expended, the close-out process begins shortly thereafter....
2024-004 Significant Deficiency: See finding 2024-004. Recommendation: We recommend that management of the Authority review its processes for closing out all fully-expended grants with HUD to ensure that, in the future, when grants are fully expended, the close-out process begins shortly thereafter. Management’s response: The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that several older grants were still shown as “open” and that the close-out procedures would have to be implemented at some point. Management is evaluating its processes and procedures related to closing out grants and is planning on implementing procedures to ensure grants are properly closed. Management plans on working with the newly hired fee accountant in the future to assist with the close out of grants that have been fully expended.
I. Procurement, Suspension and Debarment Evidence of controls over Suspension and Debarment Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should retain documentation to support complet...
I. Procurement, Suspension and Debarment Evidence of controls over Suspension and Debarment Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should retain documentation to support completeness and accuracy of the vendor list submitted for screening and the results obtained to support the screening process to ensure that no suspended or debarred vendors are utilized by the Corporation prior to entering into transactions. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation will formalize the system of record and end-to-end data flow, implement monthly reconciliations to confirm the completeness of the vendor population submitted for screening, and introduce data validation checks to ensure the accuracy of key vendor information. Supporting documentation will be centrally maintained to evidence control execution, and related policies and procedures will be updated with targeted training to promote consistent and sustainable application. Collectively, these enhancements are designed to mitigate the risk of engaging with suspended or debarred vendors. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Allison Dennison, Director, Compliance Operations, Allison.Dennison@umm.edu
I. Procurement, Suspension and Debarment Incomplete Federal Requirements within Procurement Policies Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its procurement policy ...
I. Procurement, Suspension and Debarment Incomplete Federal Requirements within Procurement Policies Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its procurement policy to include the provisions required by the Uniform Guidance for purchasing goods and/or services with federal funds. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. The ORSPA, Corporate Financial Reporting and Legal drafted a procurement policy for federal awards. The policy is under review by other relevant stakeholders across UMMS. Anticipated Completion Date – August 31, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: Manageme...
A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: Management should reassess the design of its controls to ensure documentation is retained that evidences the review and approval of expenditures submitted to the Department of Treasury 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. The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. ORSPA and Corporate Financial Reporting are developing standard operating procedures for the required review and reconciliation of grant expenditures per the accounting system to the financial submissions to the granting agency, including requirements for maintaining evidence of the review(s). 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
Other finding – SEFA Preparation Preparation of Schedule of Expenditures of Federal Awards Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its policies and procedures and i...
Other finding – SEFA Preparation Preparation of Schedule of Expenditures of Federal Awards Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its policies and procedures and internal controls to ensure accurate reporting of the Schedule as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. The ORSPA department created a standard pre-award approval process for all sponsored proposals prior to submission or award acceptance. The pre-award approval process applies to all federal, state, local, private and commercial funding opportunities across all UMMS entities and covers new, renewal, resubmission and supplemental proposals. The establishment of a central intake process through one department, for all grants across the Corporation, enhances the controls to ensure complete and accurate reporting of the Schedule as required by the Uniform Guidance. Additionally, ORSPA and Corporate Financial Reporting implemented the following controls to ensure all expenditures of federal awards are included on the Schedule. These controls include:  Reconciliation of the grants from the pre-award approval process to the grants tagged in the accounting system;  Use of a specific grant identifier within the accounting system to track expenditures and revenue recognition and tag grants as federal, state or private funded;  Comparison of grant expenditures per the accounting system to the grant agreement;  Comparison of grant expenditures per the accounting system to the financial reporting submissions made to the federal agencies;  Certification from legal entity Finance Executives that the draft Schedule is complete and accurate;  Comparison of the prior year Schedule to the current year Schedule with further investigation around changes in grants and agencies included, and significant changes in the expenditures. 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
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
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
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
The Organization will develop and implement written procurement policies and procedures that comply with Uniform Guidance and ensure consistent application across all procurement activities.
The Organization will develop and implement written procurement policies and procedures that comply with Uniform Guidance and ensure consistent application across all procurement activities.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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.
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.
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.
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
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.
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.
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.
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