Corrective Action Plans

Material Weakness, Internal Control Over Compliance and Compliance, Allowable Costs and Activities, Reporting Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls related to federal grant allowable costs and activities determinations and reporting requirements and will implement a process that ensures federal expenditure accounting and reports are prepared and then reviewed and approved by a separate employee prior to submission.

Finding No. 2023-005 -Allowable Costs/Cost Principles; Significant Deficiency (#14.896 - Family Self Sufficiency Program) Auditee's Response and Planned Corrective Action The Milton Housing Authority will review FSS program guidelines and reimbursable activities to ensure that it is properly disbursing FSS Funds. To that end, MHA is working closely with HUD officials. Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169

Finding 2023-001 Significant deficiency regarding Allowable Costs/Cost Principles and lack of documentation supporting management’s review control Information on the federal program: Grantor: Department of Agriculture Pass Through Entity: NYS Department of Health Program Name: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing No.: 10.557 Views of responsible officials and planned corrective actions: Management concurs with the audit finding and has implemented a standardized review and approval process that will be performed prior to monthly vouchers being submitted for reimbursement, including verification of allowability of expenditures and appropriate indirect cost and fringe benefit expense rates. Evidence of the monthly review and approval will be retained. Name of responsible official: Bill Dibitetto VP of Finance Projected completion date: October 31, 2024

Management’s Corrective Action Plan For the Year Ended December 31, 2023 Contact Person(s): Sophia Hernandez, Chief Operations Officer Sophia.Hernandez@youthcare.org Amber Aman, Deputy Operations Office - Finance Amber.Aman@youthcare.org Finding Number: 2023 - 002 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective action taken: • Develop a contract expenditure compliance review process created with final review and approval by Deputy Operations Officers. To be established by September 30th, 2024, and implemented in 2025 annual operating plan Anticipated completion date: In Process

Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. Solution: With the guidance and authority outlined in the Department’s internal policies and in accordance with 2 CFR, Part 200, Subpart E, §200.405 Allocable costs, manual adjustments will be defined as reasonable and allocable as defined within existing governing statues, regulations, or terms and conditions of the award. Levels of delegation of staff administering these regulatory activities will utilize the appropriate credentials request cost adjustments and use prudent judgment to determine those costs are necessary and do not deviate from the Department’s established practices and policies. Final review of cost adjustment requests will be reviewed by Department’s OMB and once approved a signature of review and approval will be documented. Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. The Department entered into a professional agreement with Financial Service Advisors, LLC to assess current policies to update standards of management by identifying credentials and experience of senior finance staff who will oversee these activities. Revisions to the policies will provide the Department’s government an extensive manual that will be developed into a fiscal management training. Training will include but not be limited to reviewing procurement methods, fiscal review of ledger activity, and audit responsibility on a quarterly basis and reporting to tribal council. Responsible: Anthony Madera, Chief Financial Officer, Lummi Indian Business Council Anticipated completion date: 06/30/2025

Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will undertake a thorough review and subsequent update of our documented policies and procedures related to federal awards. This review aims to ascertain whether any adjustments are necessary to guarantee that subawarded federal funds are utilized exclusively for their designated purposes. We are dedicated to enhancing our internal controls to adhere to federal regulations concerning the monitoring of our subrecipients. We plan to engage a consultant to help us develop policies and procedures for subrecipient monitoring, as well as to propose an organizational framework for fiscal monitoring that will strengthen our internal controls. We anticipate having the finalized policies, procedures, and training implemented by 12/31/2024. We will develop and implement a risk assessment program for subrecipients, enabling management to monitor the outcomes and demonstrate compliance with federal requirements. Records will be maintained to show that risk assessments were performed. We are dedicated to offering annual training sessions aimed at reinforcing the single audit requirements to our subrecipients. We will establish a subrecipient monitoring/compliance workgroup to define roles and responsibilities for assessing and updating policies and procedures related to subrecipient monitoring and to strengthen internal controls. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO). Planned completion date for corrective action plan: 12/31/2024

Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will review our current policies and procedures in these areas to determine if any changes should be implemented. We will ensure staff responsible for procurement of goods and services are familiar with applicable federal and state laws and policies for awarding and executing contracts. We are deeply committed to the continuous improvement of our purchasing policies and procedures to uphold the highest standards of transparency and accountability. In this regard, procurement policy will be updated to comply with the Uniform Guidance for federal awards. Furthermore, to strengthen our oversight of sole-source contracts awarded with program and non-program funds, we will introduce stringent measures requiring thorough documentation of the vendor’s or contractor’s qualifications. Name(s) of the contact person(s) responsible for corrective action: Department Head, Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO). Planned completion date for corrective action plan: 12/31/2024

Recommendation: We recommend that the Organization implements policies and procedures to properly calculate and allocate payroll benefits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will develop and implement an allocation plan for payroll benefits. We will develop process and procedures where charging of payroll benefits expenses to federal grants includes the written recommendation from compliance team and written approval of the CFO/CEO prior to payroll benefits being charged to federal grants. We will consult with the grantor to discuss whether the questioned costs identified in the audit should be repaid. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO) Planned completion date for corrective action plan: 12/31/2024

Recommendation: We recommend management implement procedures to ensure that unallowable costs are not charged to federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will provide supplementary training focused on the accurate allocation of costs to federal awards, as well as the identification and separation of unallowable costs from allowable costs. We will develop and implement detailed processes and procedures to ensure effective oversight and control of disbursements. These processes will require initial approval from the department head for all disbursements. Subsequently, the compliance team will conduct a secondary review and approval. Finally, all disbursements will necessitate final approval from the CFO/CEO before being processed for payment. This multi-step approval process is designed to ensure proper allocation of costs to federal grants. Name(s) of the contact person(s) responsible for corrective action: Department Head, Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO). Planned completion date for corrective action plan: December 31, 2024

We agree in part to this finding. The deficiency exists with approval of transactional funds that are utilized for the transportation and food voucher programs. Historically, authorization to purchase has been deemed as approval and this year some of those documentation processes were not consistently followed, as mentioned being done verbally or during other discussions that were not documented. We did not make any food voucher purchases without discussion prior to purchasing. That being said, we can formalize an approval process that is documented. Additionally, we will review our transportation program policies to ensure that a proper approval process is in place and continues to be supported by the processes we have in place.

Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent versus actual time spent. ● From a list of 244 clients, 21 client intake forms (used to determine eligibility for services) for Business Growth Services clients were unable to be produced. The auditors recommend the following: 1. Management to implement procedures to ensure all expenditures, including personnel costs, are properly reviewed, approved, and supported with documentation in accordance with federal regulations. SDA Response The SDA accepts the above findings and would like to add the following information for context: ● The requirement to collect T&E forms wasn’t initially established until the completion of the 2022 audit and after the departure of some personnel. Management attempted to collect T&E forms from prior contractors, but was not successful in securing the specific forms identified by the auditors. ● The SDA created a payroll classification document during 2023 which outlined T&E for all W-2 employees at a set rate for the year. This document, however, was not accepted by the auditors as evidence of actual hours expended on each grant, resulting in this finding. ● The SDA onboarded a new Director of Business Growth Services (BGS) in 2023, which led to changes in both the operational structure and the nature of the data collected for BGS activities. During this period, a data migration took place to a newer version of Salesforce that was built specifically for the SDA. Unfortunately, some data was either lost or unmapped during the migration process, leading to discrepancies in the completeness of historical records. SDA Corrective Actions Management is committed to continue training for personnel to ensure timely completion and compliance of hiring as well as time and effort documentation going forward. The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits.

Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures.

LSNYC will ensure that the proper accounting period is selected for all subsidiary ledger entries, as well as all journal entries, before posting is approved into the general ledger. We will also train relevant staff on the importance of recording transactions in the correct period in order to minimize the likelihood of mistakes.

This expense was reallocated to LSC in accordance with LSNYC's Cost Allocation Plan, which was developed to comply with LSC regulations on cost allocations and situations where funders will not cover certain costs. In this situation, the initial funder did not allow capital expenses, which is why the expense was then allocated to LSC. In the future, we will get advance approval for expenses that we know will get allocated to LSC before they are purchased.

Finding No. 2023-001: Fraudulent Payroll Activities Resulting in Theft (Material Weakness) Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: Our fee accountant and payroll consultant will access the payroll process and implement corrective actions, including adding internal controls and training.

View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.

Finding 2023-003 Grantor: Department of Health and Human Services Federal Program: Oral Diseases and Disorders Research Maternal and Child Health Federal Consolidated Programs Assistance Listing #: 93.121 93.110 Title: Effort Certification Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: 1R01DE031756-01A1 2 U03MC28844-09-00 Corrective Action Plan and Anticipate Completion Date • In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has been remediated. Management implemented a new procedure to ensure timely time and effort certification. Management implemented the process for first quarter 2024 to allow time for system updates and training. Responsible person: Aaron Ufferman, Director, Sponsored Projects Completion Date: February 1, 2024

Finding 2023-002 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Fringe Rate Analysis – Formula Error Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: Various Management agrees with the recommendation. However, while there was an error in the underlying data used to evaluate the annual fringe rate, the federal government was not overcharged for fringe benefits. Corrective Action Plan and Anticipate Completion Date Management’s corrective action plan includes: • Management will ensure a more robust review of the underlying formulas. Responsible Person: Natasha Collins, Director of Research Accounting Completion Date: December 31, 2024

Management is committed to enhancing staff knowledge of Uniform Guidance requirements, particularly concerning allowable costs and cost principles. To achieve this, we will implement additional training sessions for all relevant personnel. These sessions will cover key aspects of compliance, ensuring that staff are well-informed about federal regulations and their implications for our grant management processes. The Controller will ensure the calculation of payroll costs are based solely on the actual hours worked and certified by grant personnel. This practice will help maintain accuracy and accountability in our financial reporting. In addition, the Technical and Internal Controls Accountant will conduct quarterly internal reviews to monitor and verify that payroll costs reported on cost reimbursement invoices are consistent with the actual hours certified by grant personnel. These regular reviews will serve as a critical check to uphold the integrity of our financial processes and ensure compliance with federal guidelines. Through these initiatives, management aims to foster a culture of compliance and accountability, equipping our team with the knowledge and tools necessary to effectively manage grant funds.

Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward or downward—to ensure it accurately reflects our current cost structure. To maintain compliance and integrity in our financial processes, the Technical and Internal Controls Accountant will oversee the review of costs included in the indirect cost pool to ensure they meet the criteria for allowability. Additionally, this role will involve verifying that invoices utilize the most current indirect cost recovery rate. Furthermore, management will prepare and submit the required indirect cost proposal to the appropriate cognizant agency to finalize our provisional billing rates used in fiscal year 2023, that aligns with our operational needs and complies with federal guidelines. This proactive approach will strengthen our financial management practices and support our ongoing commitment to transparency and accountability in the administration of federal grants.

US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization requested drawdowns of grant funds in excess of amounts awarded for the grant years ended 10/31/2023 and 10/31/2022 that were denied by the passthrough agency, Omaha Public Schools, resulting in an overstatement in grant revenue and receivables, and federal awards expended included in the schedule of expenditures of federal awards. Corrective Action Plan: Management is in the process of reviewing its accounting policies and procedures over grant monitoring to ensure amounts are tracked appropriately. Management has hired a new fiscal services director to oversee this process. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024

Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hiring will be the responsibility of the grantor. While the grantor placed the instructions for clearances in the scope of work for Safe Passage, it was not clearly outlined in the grant under personnel requirements. Proposed Completion Date August 31, 2024

Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Allowable Costs/Costs Principles Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting Foundation employees’ time and effort reports are submitted monthly to the Director of Finance. The Director of Finance reviews time and effort reports and compiles the data to allocate personnel expenditures, however, the time stamp of approvals was not effectively documented during 2023. The Foundation has implemented procedures to effectively time stamp the review and approval process, each month. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024

The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Human Services department will complete the reconciliation of the service providers costs reports for the fiscal year ended June 30, 2024 before March 2025.