Corrective Action Plans

FINDING 2023-002 Finding Subject: COVID - 19: Coronavirus State and Local Fiscal Recovery Funds – Reporting – Internal Controls Summary of Finding: The City of Michigan City was not in compliance with effective internal controls related to submitting the P&E reports Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: To bring the City into compliance with effective internal controls to ensure requirements related to the grant agreement and the reporting compliance requirements are satisfied, the City Controller will download from the Treasury website the project detail listing for the Deputy Controller to review and verify prior to submitting the report. Anticipated Completion Date: 08/26/2024

FINDING 2023-001 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements: Suspension and Debarment Contact Person Responsible for Corrective Action: Angela C. Birchmeier, County Auditor Contact Phone Number: (574) 935-8555 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County and Auditor’s office were made aware of the deficiency during the 2022 audit and made changes to the verification of a contractor is not suspended or debarred for any contract over $25,000.00. The Commissioners approved a form for the various departments to have signed by their vendors at the August 21, 2023 meeting. In the interim, we tried to verify contracts by checking the EPLS (Excluded Parties List System) or to identify a clause in the contract. Each individual department is responsible for having the form signed by the vendor to ensure they are not suspended or debarred and that document is included with the claim by the department when entered into the portal for payment. Anticipated Completion Date: We have already implemented this procedure effective April 2023. Angela C. Birchmeier Title: Marshall County Auditor Date: July 26, 2024

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Education The Nauset Regional School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Powers & Sullivan, LLC Audit period: July 1, 2022 through June 30, 2023 The finding from the June 30, 2023, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. DEPARTMENT OF EDUCATION Passed through the Massachusetts Department of Elementary and Secondary Education Special Education Cluster Special Education Grants to States – Federal Assistance Listing Number 84.027 Special Education Preschool Grants – Federal Assistance Listing Number 84.173 COVID-19 Education Stabilization Fund COVID-19 Education Stabilization Fund – Federal Assistance Listing Numbers, 84.425D and 84.425U. 2023-001: Controls for Monitoring Payroll Charged to the Grants Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Compliance and Internal Control Over Compliance – Significant Deficiency Criteria or Specific Requirement: Grantees must provide reasonable assurance that Federal awards are expended only for allowable activities and that the costs of goods and services charged to Federal awards are allowable and in accordance with the applicable cost principles. Condition: Management has established written guidelines and policies outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Such guidelines and policies indicate under what circumstances semi-annual certifications and personnel activity reports (PARS) or time and effort reports are required and when this information must be provided to the school business office. These guidelines and policies were not fully adhered to. Out of a sample of 25 employees selected for testing in relation to the Special Education Cluster, the District was unable to provide time and effort support for 8 selections. Out of a sample of 10 employees selected for testing in relation to the COVID-19 Education Stabilization Fund, the District was unable to provide time and effort support for any of the 10 selections. Context: Payroll expenditures charged to the programs are required to be supported with documentation substantiating that the employees are eligible to be charged to the grant and that the payroll charged relates to time spent accomplishing grant objectives. This supporting documentation should be standardized and should include all required elements in accordance with Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. The District did not have an adequate system of internal controls in place to provide sufficient documentation to demonstrate compliance with federal and state time and effort reporting requirements in accordance with the provisions of Title 2 U.S. Code of Federal Regulations Part 225 Cost Principals for State, Local, and Indian Tribal Governments. Effect: The District has not complied with the federal and state time and effort reporting requirements. Cause: Lack of procedures in place to ensure compliance with time and effort reporting requirements. Questioned Costs: Total payroll charged to the Special Education Cluster in 2023 totaled $540,875. Three of the pay periods were selected for testing, which totaled $63,460 for 25 employees paid out of the grant during those pay periods. From the pay periods selected for testing, $12,616 could not be substantiated through time and effort reports or any similar internal control process. Total payroll charged to the COVID-19 Education Stabilization Fund in 2023 totaled $709,331. 10 employees for three separate pay periods were selected for testing, which totaled $24,894. From the employees and pay periods selected for testing, $24,894 could not be substantiated through time and effort reports or any similar control process. Repeat Finding: This matter was reported as a finding in the previous year as a finding 2022-001. Recommendation: Management should establish procedures to ensure compliance with District guidelines and policies regarding time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Such procedures should indicate under what circumstances semi-annual certifications and personnel activity reports (PARS) or time and effort reports are required and when this information must be provided to the school business office. Management should also implement proper training to ensure that the program managers fully understand the time and effort reporting requirements. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish procedures to ensure compliance with guidelines and policies outlining the time and effort reporting and documentation requirements that department heads must adhere with to ensure compliance with federal and state time and effort reporting requirements. Management will also implement proper training to ensure that the program managers fully understand the time and effort reporting requirements. Management intends to implement these procedures in fiscal 2024. If the Oversight Agency has questions regarding this plan, please call Giovanna Venditti, Director of Finance and Operations of Nauset Regional School District at 508-255-8800. Sincerely yours, Giovanna Venditti Director of Finance and Operations Nauset Regional School District

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage rate requirements. Name, address, and telephone of District contact person: Brenda Trogstad, Assistant Superintendent of Finance and Operations 700 S 1st Street Shelton, WA 98584 360-426-8232 Corrective action the auditee plans to take in response to the finding: If federal funds are used for future construction projects, the Shelton School District will refer to the Davis-Bason Act for specific guidance. The district used the small work roster procedures based on Washington State law because we were not aware of the Davis-Bacon Act. The Director of Facilities and Construction has been given a copy of the Davis-Bacon Act for future reference. This is the first time the Shelton School District has used federal funds for construction in my 34 years in the district. Anticipated date to complete corrective action: Immediately.

The Organization is aware of the requirements and will attempt to compile the information necessary to assure its compliance with this in the future. Responsible Official: Barb Fischer, Executive Director Anticipated Completion Date: The Organization is able to manage the daily compliance requirements for all grants but due to the cost/benefit relationship, the Organization relies upon the auditor for assistance with preparing the schedule.

Following the Auditor's recommendations and as a corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including the reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds. The Finance Department personnel continue to carry out the process of locating the remaining reports and documents as submitted in order to be filed according to the requirements of the grant agreement.

Following the Auditor's recommendations and as a corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including the reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds. The Finance Department personnel continue to carry out the process of locating the remaining reports and documents as submitted in order to be filed according to the requirements of the grant agreement.

There was a lack of documentation for the purchase of program supplies in the amount of $200 charged to federal programs. Recommendation: We recommend The Food Trust review its processes to ensure that all supporting documentation is maintained for federal purchases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will complete a review of its documentation by December 2024. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by December 31, 2024. If the oversight agency has questions regarding this plan, please call Regine Metellus, Vice President of Finance at 215-575-0444 ext. 163.

There was no documentation of review or approval on the calculation for the draw of funding for the program. In addition, draws are not performed in a timely manner after the expenditures are incurred. Recommendation: We recommend The Food Trust implement a clear approval process for the drawing of federal funding. In addition, it is important to establish a clear process and timeline for performing draws. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement an electronic approval system, and draws will be completed within 30 days of month end. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed with the September 2024 month-end close.

The organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement processes and tools to ensure that all employee time and effort charged to federal grants is appropriately documented. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by October 2024.

September 9, 2024 Re: MTBH 2023 Single Audit To Whom it May Concern: In response to our recent MTBH 2023 Single Audit findings related to reimbursement request "KV-4", MTBH will implement a review process for future grant reimbursement requests, effective immediately. I, Jenny Haught, will complete and send the reimbursement requests to Michael Cantrell, President and CEO for review. Upon his review and approval, I will send the reimbursement requests to the appropriate person per the grant agreement for official reimbursement. In response to our recent MTBH 2023 Single Audit findings related to quarterly progress reports, MTBH will implement a review process for future grant reporting, adhering to the grant agreement, effective immediately. Sincerely, Jenny Haught, Vice President of Finance

September 9, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports and timekeeping records to Wade Stables P.C for review. We did not have the grant in our financial software as we were beginning a migration to new software during the early stages of the grant; therefore, we tracked that grant on an excel spreadsheet that annually was provided to our auditors. Most of the staff assigned to the grant were full-time staff, so time allocation was easily tracked. For the few staff that were part-time we had designated codes in our Electronic Medical Record to identify work done on behalf of the grant. In response to Finding 2023-001- B Allowable Costs, we agree with the Statement of Cause citing the exponential growth of the organization regarding preparedness for a first-time grant award of this size being our largest challenge. Initially we were informed we had not received the grant then, due to additional COVID funding, we were invited to participate in the grant with a very short turnaround to finalize budgets and hire staff. Our salaries are consistent with the positions designated in the grant and in a few cases our staff salaries exceeded the allowable costs; therefore, those allowable costs were used to calculate the drawdown. MTBH did not have an established de minimis rate; therefore, we used the 10% designated rate associated with the grant. The interactive Budget Narrative Form template, required per SAMHSA guidelines, had 10% built into the template. If afforded future opportunities to secure a SAMSHA grant, we would be better positioned to execute the financial management in our SAGE software to segregate costs for the purpose of tracking the expenditures associated agency grant operations. Currently all agency expenditures have transferred into SAGE by our Vice President of Finance, Jenny Haught MBA, which would also be the Responsible Official to fiscally manage future grants. Respectfully, Angela Caraway, VP of Clinical Operations

CORRECTIVE ACTION PLAN August 21, 2024 Daniel J. Harshman, Town Mayor respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: June 30, 2023 The findings from the June 30, 2023 Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS -FINANCIAL STATEMENT AUDIT 2023-001: Material Audit Adjustments (Material Weakness) Condition: During the audit, we detected material misstatements in the trial balance. Generally accepted auditing standards dictate that detection of errors in an audit is a strong indicator of a significant deficiency or material weakness. Accordingly, we are required to communicate this finding as such. Recommendation: Material audit adjustments indicate that financial information presented to us for the audit was missing or inaccurate. We recommend that management implement processes to ensure accuracy of accounts. Corrective Action: The Town has engaged work to complete recurring adjustments on an annual basis for financial reporting. Audit adjustments reference work performed to differentiate proposed adjustments from regular entries recorded by the Town. 2023-002: Segregation of Duties (Material Weakness) Condition: Multiple duties in a transaction cycle are performed by the same individual. Consequently, errors or irregularities may occur and not be detected . The Town has segregated certain duties of its employees to help to prevent or promptly detect errors in financial reporting, however, not all areas are properly segregated due to the size of the Town. Recommendation: In an ideal system of internal controls, no individual would perform more than one duty in connection with any transactions or series of transactions. While we understand that limited staff can make this difficult, controls should be in place to mitigate the risk to the best extent possible. Limited use of financial systems, limited access and review of journal entries, and manual tracking of transactions increases risk for small towns. The Town currently does not utilize modified accrua l/accrual accounting financial records outside of the year end reporting process which can improve awareness over funds and liabilities. Corrective Action: This is a work in progress. The Town continues to segregate employee duties as much as possible. The Town Council and Officials are also actively involved in overseeing the Town's financial operations. Financial transactions are processed in public spaces with multiple staff present to increase awareness surrounding the disbursement and receipt of funds for bills and services rendered. FINDINGS AND QUESTIONED COSTS - MAJOR FEDERAL AWARD PROGRAM AUDIT 2023-003: Federal Procurement Policies (Material Weakness) Condition: There are no written procurement policies specific to the federal awards cost principal requirements under Uniform Grant Guidance. Existing procurement policies are minimal and do not meet federal requirements. Recommendation: We recommend the Town develop procurement policies and financial policies that meet federal standards. Corrective Action: The Treasurer has drafted a Procurement Policy for Counci1 to review and approve for implementation. If the Federal Audit Clearinghouse has questions regarding this plan, please call Mandy Roberts, Treasurer at 540-984-8521. Sincerely yours, Daniel J. Harshman Town Mayor Town of Edinburg, Virginia

Finding 2022-05 Misallocation of Grant Funds Condition: The Organization claimed purchases under a reimbursement-based federal grant but then used these supplies for a different grant. This improper use of grant-funded supplies is a violation of the grant’s terms and conditions. Corrective Actions Taken or Planned: The Organizations’ Board and Executive Team consisting of the Chief Executive Officer (CEO) and the Chief Operating Officer (COO) and key Overdose Lifeline (ODL) Staff to include the independent bookkeeper and Grant and Finance Manager recognize the need to further significantly improve on the oversight and reconciliation of supply ordering and inventory. This is already underway with the QB inventory process described previously and an improved process for backup documentation. Additionally key staff will complete of a formal course that covers performing a single audit and engage in consultation with the Independent Public Accounting Firm (Pile CPAs)

Federal Agency Name: Department of Homeland Security Program Name: Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Finding Summary: The Cooperative utilized a fringe benefit spreadsheet provided by FEMA where the information was not calculated correctly. Responsible Individuals: Jeff Birkeland, CEO Corrective Action Plan: The spreadsheet we received from FEMA was protected and we could not verify formulas or make changes. We assumed the spreadsheet to work correctly. Through the audit, however, we found that there is an error in a formula(s) having to do with overheads. We will ensure we are using the most up-to-date spreadsheet for fringe benefits on FEMA projects going forward. Anticipated Completion Date: This has been resolved and Steph went back through and updated the spreadsheets accordingly in August 2024

Corrective Action Plan: In 2023 Grant Accounting implemented the use of labor allocation surveys to ensure that labor costs allocated to programs funded by HUD COC grants provided benefits to those programs. The labor charged to grants is tracked on a spreadsheet Labor Allocation Control. That file listed the overallocation by $792.31 of labor expenses April 2023. The procedure to improve internal control is to check that allocated labor grant expense agrees with the Paycom Labor Distribution Report, before submitting grant draw vouchers. Contact Person Responsible for Corrective Action: Daniel Habbart, Controller Anticipated Completion Date of Corrective Action: August 12, 2024

U.S. Dream Academy, Inc. submits the following corrective action plan for the year ended December 31, 2023. The finding from the schedule of findings and questioned costs dated August 23, 2024 is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 Internal Controls and Compliance over Allowable Costs and Activities - Payroll (Significant Deficiency) Recommendation: We recommend the Academy establish policies and procedures to reconcile the percentage of hours charged on time slips to the budget estimates used to bill the Federal grantor. This should be in conjunction with quarterly billings (or other determined regular interval), at fiscal year end, and at the end of the grant year (if different from the Academy’s fiscal year). Corrective Action: On November 20, 2023, U.S. Dream Academy entered into a contractual agreement with ADP Comprehensive Services to move electronic time cards from Attendance on Demand to ADP Time & Attendance. This change in software will allow program and grant allocations made by employees on time cards to be directly imported into payroll processing as is, eliminating the need to manually enter the summation of all hours worked over the pay period and manually breaking down the allocation for entry into the general ledger. The Time & Attendance software went “live” with the pay period ending May 18, 2024. Each pay period, the Financial Controller will reconcile actual time worked (as per time card) against budgeted salary allocations. The Chief Financial Officer will review these reconciliations prior to grant reporting and at year end closings. Responsible Parties: Phylicia Buie, CFO and Chris Moore, Financial Controller Date Corrected: August 23, 2024 If there are any questions regarding this plan, please contact Phylicia Buie pbuie@usdreamacademy.org or Christine Moore at cmoore@usdreamadacemy.org .

Action Planned/taken in response to the finding: Kewaunee County agrees with the finding. An assessment of all grants, requirements, and related policy and procedures is in progress and will continue to: • Evaluate existing policy and procedures for needed revisions • Document revisions to policy and procedures as necessary • Communicate any new policies to employees responsible for awards • Identify awards covered by the Uniform Guidance • Set and document a schedule for periodic review and revision Policy and procedures, as well as related documentation, are being revised as necessary to ensure compliance with the Uniform Guidance. Progress continues into 2024. The Finance Director will continue to coordinate and provide assistance and guidance to departments receiving grants subject to the Uniform Guidance. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh Planned completion date for corrective action: December 31, 2024

Finding 2023-004:Written Uniform Guidance Policies Responsible Official: Billie Jo Inhofer, Finance Officer Corrective Action Plan: The City is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing

VSS has already updated its financial policies to include electronic approval of expenditures through Bill.com. Bill.com was established for accounts payables mid FY 2024-FY 2025 for credit card payments. VSS has added Bill.com Accounts Payable and credit card services to include approvals required per grant and department.

Boston Fire Department (BFD) incorporated and implemented proper control procedures around all grant related matter; including but not limited to programmatic reporting and oversight. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Fire Department (BFD) has implemented additional procedures to ensure all pay rates are accurate, and evidence of approval exist. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Public Schools (BPS) has revised their policies and procedures for timekeepers to timely report any system issues related to department time summary reporting. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Public Schools (BPS) has updated its’ training and guidance for timekeepers. Timekeepers participated in enhanced trainings during August of 2024 in preparation of the new school year. Anticipated Completion Date: August 31, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov

Boston Public Schools (BPS) has revised its’ consultation process to ensure it happens with fidelity and that records are properly stored. Anticipated Completion Date: June 30, 2024 Responsible Contact Person: Colin Musto, Assistant City Auditor, Grants Monitoring Unit colin.musto@boston.gov