Corrective Action Plans

Finding 544065 (2024-004)

Significant Deficiency 2024

ND

Allowable Costs / Cost Principles

Contact Person: Business Manager and Human Resource Manager Planned Corrective Action: The District currently does have processes and controls in place to ensure grant expenditures have been approved. Specific to this audit finding of missing salary authorization forms, the Business Manager will...

Contact Person: Business Manager and Human Resource Manager Planned Corrective Action: The District currently does have processes and controls in place to ensure grant expenditures have been approved. Specific to this audit finding of missing salary authorization forms, the Business Manager will meet with the Human Resource Manager to review the current control and approval processes for employee salaries and make changes as appropriate. Planned Completion Date: January 2025 and ongoing

View Audit 350871

Finding 544063 (2024-001)

Material Weakness 2024

Brandywine Community Resource Council Dba Claymont Community Center

DE

Reporting Internal Control / Segregation of Duties

Management acknowledges the recommendation and has begun considering controls consistent with the recommendation. Appropriate year-end closing procedures will be written to document required reconciliations and related internal controls over completeness and accuracy.

View Audit 350868

Finding 544060 (2024-003)

Significant Deficiency 2024

Intecare, INC

IN

Procurement, Suspension & Debarment

2024-003 Supportive Services for Veteran Families – Assistance Listing No. 63.033 Recommendation: CLA recommends InteCare, Inc. develops a comprehensive procurement policy that complies with the federal regulations. CLA also recommends InteCare, Inc. enhances controls to ensure an adequate process ...

2024-003 Supportive Services for Veteran Families – Assistance Listing No. 63.033 Recommendation: CLA recommends InteCare, Inc. develops a comprehensive procurement policy that complies with the federal regulations. CLA also recommends InteCare, Inc. enhances controls to ensure an adequate process is in place to review potential vendors to determine they are not suspended or debarred and to ensure documentation to support this is maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A procurement policy that matches the federal regulation will be added. Moving forward, documentation will be retained when checking a vendor’s status on SAM.gov. Name(s) of the contact person(s) responsible for corrective action: Lara Williams Planned completion date for corrective action plan: 4/1/2025

View Audit 350867

Finding 544057 (2024-002)

Significant Deficiency 2024

Intecare, INC

IN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Significant Deficiency

2024-002 Supportive Services for Veteran Families – Assistance Listing No. 63.033 Recommendation: CLA recommends the control process be reviewed and enhanced to ensure consistency in obtaining proper approvals. Explanation of disagreement with audit finding: There is no disagreement with the audit...

2024-002 Supportive Services for Veteran Families – Assistance Listing No. 63.033 Recommendation: CLA recommends the control process be reviewed and enhanced to ensure consistency in obtaining proper approvals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Adjusted who was responsible for payroll approvals. Name(s) of the contact person(s) responsible for corrective action: Lara Williams Planned completion date for corrective action plan: 11/1/2024

View Audit 350867

Finding 544054 (2024-001)

Significant Deficiency 2024

Intecare, INC

IN

Reporting Significant Deficiency Internal Control / Segregation of Duties

SIGNIFICANT DEFICIENCY 2024-01 Financial Reporting Recommendation: The organization should ensure: • Internal controls are in place and performed throughout the year to enable an efficient year end closing process. • Documentation of the performance of internal reviews over reconciliations and jour...

SIGNIFICANT DEFICIENCY 2024-01 Financial Reporting Recommendation: The organization should ensure: • Internal controls are in place and performed throughout the year to enable an efficient year end closing process. • Documentation of the performance of internal reviews over reconciliations and journal entries is retained and is readily available. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An external application is now being used to track reviews of journal entries and reconciliations to make up for this being a missing feature in the accounting system. Name(s) of the contact person(s) responsible for corrective action: Noah Masson Planned completion date for corrective action plan: 8/1/2024

View Audit 350867

Finding 544052 (2024-004)

Significant Deficiency 2024

The Pennsylvania State University

PA

Procurement, Suspension & Debarment

Finding Number: 2024-004, R&D Procurement Suspension and Debarment Checks Condition: The University’s policy is to check sam.gov for exclusions prior to entering into transactions that are subject to 2 CFR 180.300. During the year, there were certain contractors that the University paid (using feder...

Finding Number: 2024-004, R&D Procurement Suspension and Debarment Checks Condition: The University’s policy is to check sam.gov for exclusions prior to entering into transactions that are subject to 2 CFR 180.300. During the year, there were certain contractors that the University paid (using federal funds) in advance of the sam.gov check being completed. Planned Corrective Action: To prevent future exceptions, the University’s Office of Central Procurement has implemented, and will continue to provide, semi-annual refresher training for all buyers. This training reinforces the importance of vendor checks and proper retention of documentation within the purchase order files. The initial refresher session was conducted in March 2025. Contact person responsible for corrective action: Duane Elmore, Chief Procurement Officer Anticipated Completion Date: March 31, 2025

View Audit 350858

Finding 544047 (2024-003)

Significant Deficiency 2024

The Pennsylvania State University

PA

Subrecipient Monitoring Internal Control / Segregation of Duties Cash Management § 200.305

Finding Number: 2024-003, Subrecipient Payments Condition: The University did not have adequate controls in place to ensure invoices to subrecipients were paid timely within the 30-calendar-day requirement. Planned Corrective Action: Penn State has created a new Subaward Administration and Complian...

Finding Number: 2024-003, Subrecipient Payments Condition: The University did not have adequate controls in place to ensure invoices to subrecipients were paid timely within the 30-calendar-day requirement. Planned Corrective Action: Penn State has created a new Subaward Administration and Compliance Office (SACO), which is part of the new Post Award Contractual Compliance Office. The SACO is led by its own director and will provide central oversight over key subaward compliance processes, such as subrecipient payments, and provide training to campus on subrecipient processes. This function has previously not existed in a central office at Penn State. The creation of this office demonstrates Penn State’s commitment to compliance for subaward activities. Contact person responsible for corrective action: John Hanold, Associate Vice President for Research; Director, Office of Research Administrative Services Anticipated Completion Date: June 30, 2025

View Audit 350858

Finding 542032 (2024-002)

Significant Deficiency 2024

The Pennsylvania State University

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Finding Number: 2024-002, Effort Certification Condition: One of the internal controls that the University has designed related to ensuring that personnel expenses charged to federal grants were accurate is an effort certification that is completed at least annually. This control was not operating ...

Finding Number: 2024-002, Effort Certification Condition: One of the internal controls that the University has designed related to ensuring that personnel expenses charged to federal grants were accurate is an effort certification that is completed at least annually. This control was not operating effectively during the year ended June 30, 2024, as certain effort certifications were not completed timely. Planned Corrective Action: Penn State raised awareness of the late effort certification issue at various committee and council meetings during Fall 2024 and enforced compliance with our existing policy. These meetings involve research leadership at all colleges, such as Associate Deans for Research, College Research Administration Officers, and College Financial Officers. Penn State followed its policy on overdue effort certifications, and we have implemented additional internal controls in the process. The University’s Office of the Senior Vice President for Research has restructured oversight of effort certification, along with many other post award financial matters, to a newly created office, Post Award Contractual Compliance (PACC). This office includes the existing Research Accounting Office (which was part of the Office of Budget and Finance prior to July 1, 2024), and Penn State has hired an Assistant Vice President to oversee this team. A new suboffice, led by a new director, within PACC is the Financial Analysis and Compliance Office (FACO), which is responsible for central oversight and training over the effort certification process. This office has recently created a new dashboard to monitor the completion of effort certifications and works closely with business units within Penn State to ensure timely completion via sending out reminders, holding meetings, and providing training on the process. Contact person responsible for corrective action: John Hanold, Associate Vice President for Research; Director, Office of Research Administrative Services Anticipated Completion Date: June 30, 2025

View Audit 350858

Finding 542031 (2024-001)

Material Weakness 2024

The Pennsylvania State University

PA

Procurement, Suspension & Debarment

Finding Number: 2024-001, 93.323 Procurement Suspension and Debarment Checks Condition: The University’s policy is to check sam.gov for exclusions prior to entering into transactions that are subject to 2 CFR 180.300. During the year, there were certain contractors that the University paid (using fe...

Finding Number: 2024-001, 93.323 Procurement Suspension and Debarment Checks Condition: The University’s policy is to check sam.gov for exclusions prior to entering into transactions that are subject to 2 CFR 180.300. During the year, there were certain contractors that the University paid (using federal funds) in advance of the sam.gov check being completed. Planned Corrective Action: The College of Medicine’s procurement operations will perform compliance checks to ensure vendors are reviewed in SAM.gov prior to processing transactions subject to 2 CFR 180.300. The College of Medicine will implement a procedure requiring vendor checks in SAM.gov during the purchase requisition phase for applicable transactions. Once the purchase requisition identifies grant funding, the procurement office will ensure venders are reviewed in SAM.gov prior to processing. These checks will be documented and retained with the corresponding purchase requisition files before submission to the Office of Budget and Finance for payment. For new vendors, before being created in Penn State’s Financial ERP system, a check will be made in SAM.gov to ensure compliance. Contact person responsible for corrective action: Sharon Sowers, Financial Manager Anticipated Completion Date: June 30, 2025

View Audit 350858

Finding 542030 (2024-002)

Significant Deficiency 2024

University of Pikeville

KY

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

Federal Program: U.S. Department of Education Federal Direct Loan Program, Federal Assistance Listing 84.268 Criteria: The University is required to comply with 36 CFR Section 685.309(b). Condition: During our testing of 40 students for eligibility, we noted three students in which the students' ...

Federal Program: U.S. Department of Education Federal Direct Loan Program, Federal Assistance Listing 84.268 Criteria: The University is required to comply with 36 CFR Section 685.309(b). Condition: During our testing of 40 students for eligibility, we noted three students in which the students' status change was not timely reported to the National Student Loan Database System (NSLDS). Corrective Actions Taken or Planned: For the year ended June 30, 2024, three students were reported late to NSLDS. Each student, after being identified, were then reported to NSLDS with the correct status and date. The Office of Institutional Research will work with the Registrar’s Office to ensure that students are reported in a timely manner. The Director of Institutional Research has provided the following steps that will be taken when a student is reported as withdrawn: 1. View the student's transcript in Ellucian to see if he/she withdrew or is back-dated as never enrolling. 2. Update Excel file for the term enrollment accordingly. 3. Update National Student Clearinghouse (NSC) file that will be submitted on the next due date. 4. Manually update the student's enrollment in National Student Clearinghouse 5. Manually update the student's enrollment in NSLDS Name of Responsible Person: Daniel Donner, Director of Financial Aid Completion Date: August 13, 2024

View Audit 350857

Finding 542029 (2024-001)

Significant Deficiency 2024

University of Pikeville

KY

Questioned Costs Student Financial Aid Eligibility

Finding 2024-001 Federal Program: U.S. Department of Education Federal Pell Grant Program, Federal Assistance Listing 84.063 Criteria: The University must comply with 34 CFR 690.61(a)(1). Condition: During our testing of 40 students for eligibility, we noted one student who was eligible for a Pel...

Finding 2024-001 Federal Program: U.S. Department of Education Federal Pell Grant Program, Federal Assistance Listing 84.063 Criteria: The University must comply with 34 CFR 690.61(a)(1). Condition: During our testing of 40 students for eligibility, we noted one student who was eligible for a Pell grant, but was not awarded nor disbursed a Pell grant. Upon further analysis, there were four additional students that were eligible for a Pell grant and were not awarded nor disbursed a Pell grant. Corrective Actions Taken or Planned: For the year ended June 30, 2024, it was found that some students were not awarded eligible Pell grants. After the initial students were discovered, the University reviewed all students that were active for the 2023-2024 award year and reviewed their most current Institutional Student Information Record (ISIR) to determine which students may not have been awarded Pell grants correctly. Affected students were then awarded as needed and funds applied to their account. Going forward, the University will review subsequent student ISIRs and run additional reports to ensure students are awarded the correct amount of Pell grants. This additional review will capture those who would have previously been missed. Name of Responsible Person: Daniel Donner, Director of Financial Aid Completion Date: August 13, 2024

View Audit 350857 Questioned Costs: $1

Finding 542026 (2024-002)

Significant Deficiency 2024

Energy Coordinating Agency of Philadelphia, Inc.

PA

Questioned Costs

ECA agrees with this finding. This particular event was a result of human error and ultimately an “extra” zero was added into the system by mistake. ECA hired a Chief Operating Officer in July 2024, who will ultimately be responsible for creating a new policy for all grant billing that must be enter...

ECA agrees with this finding. This particular event was a result of human error and ultimately an “extra” zero was added into the system by mistake. ECA hired a Chief Operating Officer in July 2024, who will ultimately be responsible for creating a new policy for all grant billing that must be entered into a third-party software that will include adequate reviews

View Audit 350855 Questioned Costs: $1

Finding 542023 (2024-101)

Significant Deficiency 2024

Yuma Private Industry Council

AZ

Cash Management

YPIC will post the $194,602 audit adjustment to correctly reverse the overstatement of grants receivable and grant revenue in the accounting records by April 30,2025. YPIC will also implement a monthly reconciliation process to review grant expenditures and ensure that amounts reported align with ac...

YPIC will post the $194,602 audit adjustment to correctly reverse the overstatement of grants receivable and grant revenue in the accounting records by April 30,2025. YPIC will also implement a monthly reconciliation process to review grant expenditures and ensure that amounts reported align with actual expenditures. Additionally, YPIC will develop a Financial Reporting Checklist to ensure all adjustments are posted timely.

View Audit 350846

Finding 542019 (2024-002)

Significant Deficiency 2024

Urban League of Portland

OR

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Contact Person NAME: Julia Delgado PHONE: (503) 280-2600 E-Mail: jdelgado@ulpdx.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned Urban League of Portland shall review an...

Contact Person NAME: Julia Delgado PHONE: (503) 280-2600 E-Mail: jdelgado@ulpdx.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned Urban League of Portland shall review and revise the current policy to enhance recommendations that assure rent reasonableness procedures are instituted. Further training shall be provided to Program Managers to support a due diligent interim review of Master Leases. Anticipated Complete Date: 05/01/2024

View Audit 350845 Questioned Costs: $1

Finding 542015 (2024-001)

Material Weakness 2024

Urban League of Portland

OR

Questioned Costs Allowable Costs / Cost Principles Period of Performance

Contact Person NAME: Julia Delgado PHONE: (503) 280-2600 E-Mail: jdelgado@ulpdx.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned The Urban League of Portland is committe...

Contact Person NAME: Julia Delgado PHONE: (503) 280-2600 E-Mail: jdelgado@ulpdx.org Explanation and Specific Reasons for Disagreement with the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned The Urban League of Portland is committed to an environment of continuous improvement. Further training shall be provided to Program Managers regarding the organizations’ documented internal controls and the importance of adhering to the established approval process. Urban League has currently hired a seasoned Controller and is in the process of hiring an experienced Accounting Manager. Tracking expiring grants more thoroughly and having further reviews in place to assure transactions are recorded within the grant’s agreed upon period of performance shall provide confidence expenses are recorded properly. Anticipated Completion Date: 05/01/2024

View Audit 350845 Questioned Costs: $1

Finding 542010 (2024-005)

Significant Deficiency 2024

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.306 § 200.403

Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of match expenditures, testing noted 5.15 hours identified as Medicaid hours for one employee were not removed from...

Matching Federal Agency Name: Department of Health and Human Services FFAL #93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of match expenditures, testing noted 5.15 hours identified as Medicaid hours for one employee were not removed from the employee’s total hours when calculating the amount of match for the federal program. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could claim as match disallowed costs under the federal award and would not be able to detect and correct noncompliance in a timely manner. The employee’s Medicaid hours were not properly included within a revenues report due to the employee’s provider number not being included within the report parameters. Responsible Individuals: CEO (Dan Ries) Corrective Action Plan: CEO will double check and confirm that all revenue reports run have data for the correct staff to ensure that the accurate information is being used to calculate match hours. Anticipated Completion Date: September 2024.

View Audit 350836 Questioned Costs: $1

Finding 542009 (2024-004)

Significant Deficiency 2024

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.430

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.696 Program Name: Certified Community Behavior Health Clinic Expansion Grants Finding Summary: During testing of expenditures, the following was identified: a) ClickTime timecard, which trac...

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL #93.696 Program Name: Certified Community Behavior Health Clinic Expansion Grants Finding Summary: During testing of expenditures, the following was identified: a) ClickTime timecard, which tracks federal and nonfederal hours for employees, did not properly reflect the employees total federal and nonfederal hours being paid within the payroll register (1 instance). b) Calculation errors for expenses allocated to the grant (3 instances). c) Employee tracked 2.7 hours under the federal program and a nonfederal program line in ClickTime (1 instance) causing it to be double counted. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. An employee entered 8 hours of PTO into ClickTime for two days each; however, the employee was only paid for 4 hours of PTO for each day. The calculation errors were due to the use of a wrong employee’s allocation percentage and a keying error for payroll expenses for an employee. The secondary review of the employee ClickTime timecards did not identify the incorrectly tracked hours and double tracked time. Also, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. Responsible Individuals: Project Directors (Rebecca McCrackin, Missy Martini), Project Accounts Manager (Marsha Bomgaars) and CEO (Dan Ries) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare and reconcile all ClickTime reports with payroll reports using an Excel spreadsheet to identify discrepancies and to ensure the ClickTime timecards and the payroll registers match and all hours are accurately reported. Anticipated Completion Date: September 2024.

View Audit 350836 Questioned Costs: $1

Finding 542008 (2024-003)

Significant Deficiency 2024

Northwest Iowa Mental Health Center D/b/a Seasons Center for Community

IA

Questioned Costs Allowable Costs / Cost Principles § 200.303

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL#93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of expenditures, the auditor’s noted calculation errors when allocating payroll expens...

Activities Allowed and Allowable Costs Federal Agency Name: Department of Health and Human Services FFAL#93.087 Program Name: Enhance Safety of Children Affected by Substance Abuse Finding Summary: During testing of expenditures, the auditor’s noted calculation errors when allocating payroll expenses to the federal grant. The Center’s controls did not detect or correct the errors identified, which results in a reasonable possibility that the Center could submit disallowed costs under the federal awards and would not be able to detect and correct noncompliance in a timely manner. The calculation errors were due to the use of a wrong employee’s allocation percentage, a keying error for the amount of payroll taxes for an employee, and not properly updating the calculation of worker’s compensation based upon the new percentage effective January 1, 2024 for the state of Iowa. In addition, the secondary review of federal grant expenditure tracking spreadsheet did not identify the calculation errors. Responsible Individuals: Staff Supervisors (Sarah Heinrichs) and Project Accounts Manager (Marsha Bomgaars) Corrective Action Plan: Staff supervisors are to compare ClickTime entries with payroll system entries to ensure they match. The Project Accounts Manager will compare and reconcile all ClickTime reports with payroll reports using an Excel spreadsheet to identify discrepancies and to ensure the ClickTime timecards and the payroll registers match and all hours are accurately reported. Anticipated Completion Date: September 2024.

View Audit 350836 Questioned Costs: $1

Finding 542006 (2024-003)

Material Weakness 2024

Planned Parenthood Keystone

PA

Procurement, Suspension & Debarment

Material Weakness in Internal Control over Compliance of Procurement, Suspension and Debarment Other Matters Recommendation: We recommend that management continue to develop policies and procedures to ensure an adequate review process is in place to monitor new and potential contractors to determi...

Material Weakness in Internal Control over Compliance of Procurement, Suspension and Debarment Other Matters Recommendation: We recommend that management continue to develop policies and procedures to ensure an adequate review process is in place to monitor new and potential contractors to determine whether a conflict of interest exists and that the procurement, suspension, and debarment procedures are being followed in accordance with Uniform Grant Guidance. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: This finding was specifically about laboratory services, which have very limited options when it comes to vendor selection due to health plan participation and geography. To mitigate this finding, the procurement policy will be updated to incorporate these requirements including documentation; if necessary, we will obtain further training from our auditors to ensure our policy and procedures are appropriate and compliant. Name of the contact person responsible for corrective action: Melissa Reed, President/CEO Planned completion date for corrective action plan: June 30, 2025

View Audit 350834

Finding 542005 (2024-003)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Questioned Costs Subrecipient Monitoring Procurement, Suspension & Debarment

2024-003 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 th...

2024-003 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 recommendations. 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. Additionally, management will develop a federal grant policy that covers all requirements for compliance and internal controls for federal grants. 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 350833 Questioned Costs: $1

Finding 542004 (2024-002)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles Cash Management Reporting

2024-002 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 Recommen...

2024-002 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 recommendations. 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 will develop a federal grant policy that includes the requirements for compliance and internal controls for federal grants. The policy 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, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 350833

Finding 542003 (2024-001)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2024 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) considers the implementation and monitoring of effective internal controls to be one of its most i...

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2024 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities. The Corporation respectfully submits the following corrective action plan regarding the Schedule of Findings and Questioned Costs for the year ended June 30, 2024. Audit period: July 1, 2023 to June 30, 2024 FINDINGS—FEDERAL AWARD PROGRAMS AUDITS 2024-001 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 recommendations. 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 has been added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants. Additionally, management is working with the vendor to ensure the requisition and approval configuration is properly maintained to prevent an approver in the 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 350833

Finding 542001 (2024-002)

Significant Deficiency 2024

Nami Chicago

IL

Allowable Costs / Cost Principles § 200.303

Fiscal Policies and Procedure Alignment with Uniform Guidance Management at NAMI Chicago agrees with this finding and has already taken steps to address this recommendation through the following: • The implementation of expense management platform, Ramp to track and electronically maintain a system...

Fiscal Policies and Procedure Alignment with Uniform Guidance Management at NAMI Chicago agrees with this finding and has already taken steps to address this recommendation through the following: • The implementation of expense management platform, Ramp to track and electronically maintain a system of authorization and approval for all expenses. This system was piloted from September 1, 2024 – December 31, 2024 and implemented as of January 1, 2025. • The hiring of new fiscal staff with expertise in nonprofit financial management and standards, completed by June 30, 2024. • Updates to our fiscal policies and procedures to ensure alignment with Uniform Guidance requirements completed on December 1, 2024.

View Audit 350830

Finding 542000 (2024-001)

Material Weakness 2024

Washington State Potato Commission

WA

Procurement, Suspension & Debarment

Finding ref number: 2024-001 Finding caption: The Potato Commission lacked adequate internal controls over and did not comply with federal suspension and debarment requirements. Name, address, and telephone of Commission contact person: Brandy Tucker Washington State Potato Commission 108 ...

Finding ref number: 2024-001 Finding caption: The Potato Commission lacked adequate internal controls over and did not comply with federal suspension and debarment requirements. Name, address, and telephone of Commission contact person: Brandy Tucker Washington State Potato Commission 108 Interlake Rd Moses Lake, WA 98837 509-765-8845 Corrective action the auditee plans to take in response to the finding: The Washington State Potato Commission (WSPC) acknowledges the audit finding and appreciates the recommendations provided by the auditors. Moving forward, we are committed to ensuring full compliance with federal requirements for the Specialty Crop Block Grant Program (SCBGP). To address this issue, the WSPC will implement stronger internal controls to verify that all contractors paid $25,000 or more, either fully or partially with federal funds, are not suspended or debarred from federal programs prior to entering into contracts. This will include: - Regularly checking exclusion records in the U.S. General Services Administration’s System for Award Management (SAM.gov) before performing work with contractors included in SCBGP contracts. By adopting these measures, we are confident in preventing any future noncompliance and ensuring proper stewardship of federal funds. Anticipated date to complete the corrective action: We have already taken action and reviewed our current contractors and plan to do so after each annual report is submitted to WSDA/USDA to ensure they are still not suspended or debarred from federal programs.

View Audit 350829

Finding 541997 (2024-001)

Significant Deficiency 2024

Grand Street Settlement Senior

NY

HUD Housing Programs Period of Performance Reporting

2024-001: Financial Reporting Management agrees with the finding and has taken immediate steps to address the issue and ensure timely submissions. Grand Street Settlement and BTQ Financial, Inc. will jointly oversee and ensure the timely submission of all progress reports. All agreements will be re...

2024-001: Financial Reporting Management agrees with the finding and has taken immediate steps to address the issue and ensure timely submissions. Grand Street Settlement and BTQ Financial, Inc. will jointly oversee and ensure the timely submission of all progress reports. All agreements will be reviewed in detail to fully understand compliance and reporting requirements, ensuring that all conditions are met, and submissions are made on time. A detailed timeline will be established for each reporting period, with regular check-ins to ensure that progress reports are completed and submitted on schedule. All deadlines will be closely monitored to prevent any future delays. Status of Finding: Management is expected to resolve the finding during fiscal year 2025 and will continue to work on resolving the finding. Managements Response: Management agrees with the finding. The issue will be corrected and resolved by the Grand Street Settlement Director of Administration, Program Director, and BTQ Financial during the fiscal year 2025.

View Audit 350812

Corrective Action Plans

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