Corrective Action Plans

Subject: Hennepin County’s 2023 Corrective Action Plan Finding# 2023-007 Eligibility Program: Medical Assistance Program (ALN 93.778) Type of Finding: Material Weakness in Internal Control over Compliance; Other Matter Compliance Finding Condition: During our testing, we noted the following 8 instances of noncompliance in the sample of 120 case files tested: • Five MAXIS (eligibility determination system) case files had different bases of eligibility in MAXIS and MMIS (payment system). For three of the five cases, MAXIS indicated the beneficiary was “EX” (age 65 or older) while MMIS indicated the beneficiary was “DX” (disabled). For one of the five cases, MAXIS indicated the beneficiary was “1619(b)” (people who no longer receive an SSI cash benefit and maintain their disability status) while MMIS indicated the beneficiary was “DX” (disabled) and the final case indicated the beneficiary was “DC” (disabled child 18-20) in MAXIS while MMIS indicated the beneficiary was “DT” (disabled child under TEFRA option). • Two MAXIS case files did not have a signed application on file. • One MAXIS case file did not have citizenship verified. In addition, the County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the two eligibility determination systems, MAXIS and METS. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered and the information required by the contract is retained in the County’s records. Hennepin County Employee Responsible for the CAP: Vickie Goulette Planned Completion Date for CAP: December 31, 2024

Criteria The Entity is required to maintain residual receipts in an interest-bearing account. Condition The Entity’s residual receipts were not maintained in an interest-bearing account. Cause The interest rate on the account was changed by the bank, which was not noticed by management personnel before the year end. Context When performing out audit, we noted that the Entity's residual receipts did not earn interest in 2023. Questioned Costs none noted. Effect The Entity was not in compliance with the requirement to maintain its residual receipts in an account that bears interest. Recommendation We recommend the Entity contact the bank to correct the interest rate on the account or move the balance to an interest-bearing account. Views of the Responsible Official See Corrective Action Plan

Corrective Action Plan for Audit Finding Town of Litchfield Corrective Plan Information: Audit Finding Number: 2023-001 Finding: Document Policies and Procedures over Federal Awards Type of Finding: Compliance Criteria: OMB's Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (UG) established significant requirements related to federal awards. The requirements stipulate that federal award recipients must document their policies and procedures over certain aspects of financial program management. Specifically, written policies are required for the following: • Cash management • Determination of allowable costs • Employee travel • Procurement • Conflicts of interest • Subrecipient monitoring and management Corrective Action Taken Adoption of Policy "Federal Grant Acceptance and or to be Taken: Compliance Policy" by the Board of Selectmen and implementation across all departments. See attached Date of Completion or Policy Federal Grant Acceptance and Compliance Policy" estimated Date of Adopted by the Board of Selectmen August 12, 2024 Completion: Issued to all department heads 8/13/2024 Shared drive for grant documentation created and shared with department heads Town Purchasing Policy amended to include reference to Grant policy 8/12/2024. Policies updated on Town website - 8/14/2024 Management The Town of Litchfield agrees with the finding as no Response: formalized Policy or Procedures existed at the time of Audit. Town Contact Kim Kleiner Responsible for Town Administrator Corrective Action: 2 Liberty Way, Litchfield, NH 03052 603-424-4046 x1250 Email: kkleiner@litchfieldnh.gov

Finding No. 2023-002: Audit and SEFA Adjustments Responsible Officials: Angela Wilkerson, Mayor Corrective Action Plan: The City will make every effort to make accurate accounting adjustments throughout the year. When recording a journal entry that is unfamiliar, the Finance Officer will inquire on how to make the correct entry. The Finance Officer will make every effort to make sure the accounting adjustments are made correctly. Capital assets will be reviewed monthly by the Finance Officer and capitalized in a timely manner. Some of the ambulance receivables will be analyzed and adjusted by Accounting Clerk on a monthly basis. Anticipated Completion Date: Ongoing

2023-002 U.S. Department of Housing and Urban Development– Assistance Listing # 14.239 Home Investment Partnerships Program Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The condition reported as item 2023-001 above also applies to the Township’s internal control over compliance with the requirements of federal programs. Planned Corrective Action: The Township acknowledges the potential effects of this condition. However, for such a small organization as we are, the Township believes that it would not be cost beneficial to hire additional personnel to provide for adequate segregation of duties at this time. The Board of Supervisors continues to closely monitor the financial transaction processes and has several control procedures in place to provided for as much segregation of duties as possible given the size of the Township’s staff. The following are the control procedures over federal programs that the Township currently has in place: • One Township supervisor is involved in the day-to-day activities of the federal program as he serves as the project manager for all Township projects. • The three Township supervisors personally review and formally approve the list of all bills proposed for payment (including those for federal programs and projects) at their monthly public meetings. In addition, the Township has a requirement that all checks require two authorized signatures, one of which must be a Township supervisor. • Each month’s complete financial statements are reviewed by the three supervisors at the monthly public meetings, and grant activities and updates are presented and discussed as well.

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

Views of Responsible Officials: IJD acknowledges that it is holding federal funds in excess of immediate operational need. The funds were drawn down to finance IJD’s Reporters Shield initiative, so that IJD could establish the risk pool to provide legal protection to investigative journalism organizations; without the cash in place to finance the risk pool, IJD cannot credibly offer to protect investigative journalism organizations from legal threat. The drawdown of federal funds was exactly in line with the proposal originally submitted to the federal funder (USAID), and the funds were drawn down with the agreement and understanding of the USAID program officer responsible for the grant. We note that IJD is in a chicken-and-egg situation, since without the funds first being in place, it will not be possible to recruit new members to join the risk pool. The corrective plan is to grow the membership pool as quickly as possible, so that the funds are used for their intended purpose, i.e. protecting journalists. Name and Title of Responsible Official: Clothilde Redfern, Executive Director International Journalism Defense Anticipated Completion Date: Not applicable

Management concurs with the recommendation as proposed and is implementing policies and procedures to provide for proper segregation of duties over grant activities. This has been implemented effective immediately.

For the Year Ended December 31, 2023 Finding Number 2023-001 Contact Person(s): Cynthia Sikina, Interim CFO Wendy Perry, Director of Budget & Contracts Corrective Action Planned: Contract terms will be reviewed to ensure understanding of the billing terms and will be documented in the contract management system in accordance with the Samaritas contract approval procedure. Cash draws will be aligned with actual cash expenditures for any cost reimbursement contract/grant to limit draws to immediate cash needs in accordance with Title 2 U.S. Code of Federal Regulations Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards (the Uniform Guidance), Subpart D – Post Federal Award Requirements, Section 200.305 Federal Payment. Anticipated Completion Date: Date completed June 30, 2023

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expenditures. Management will also reinforce the importance of employees providing the appropriate invoices or supporting documentation for all expenditures submitted for payment. Expenditures will not be paid without the appropriate supporting documentation. All approvals will be tracked through an online system. In addition, management will reinforce the importance of reviewing the timing of when expenditures are incurred, to ensure they are recorded in the appropriate fiscal year. Anticipated completion date: Implemented November 2023

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Management is in the process of implementing Bill.com, which will require review and approval by a direct supervisor or higher, to ensure proper segregation of duties for approval of expenditures. Management will also reinforce the importance of employees providing the appropriate invoices or supporting documentation for all expenditures submitted for payment. Expenditures will not be paid without the appropriate supporting documentation. All approvals will be tracked through an online system. In addition, management will reinforce the importance of reviewing the timing of when expenditures are incurred, to ensure they are recorded in the appropriate fiscal year. Anticipated completion date: Implemented November 2023

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Prior to any cost reimbursement invoices submitted, the invoices will be reviewed and approved by the State Manager or a Director of State Engagement to ensure amounts requested for reimbursement were incurred prior to the reimbursement request and are related to costs that were properly allocated to the federal program. Anticipated completion date: Implemented October 2023

Name of Auditee’s Contact Person Responsible for Corrective Action: Molly Gravholt Corrective Action Planned: Prior to any cost reimbursement invoices submitted, the invoices will be reviewed and approved by the State Manager or a Director of State Engagement to ensure amounts requested for reimbursement were incurred prior to the reimbursement request and are related to costs that were properly allocated to the federal program. Anticipated completion date: Implemented October 2023

Historic Hudson Valley will adopt written policies and procedures, and standards of conduct as required by 2 CFR 200, Subparts D and E.

Finding: Management did not have an internal control in place to review the allowability of the expenses to be allocated to the Congressional Directives grant. Corrective Action Plan: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to determining expenses that are eligible for federal grant reimbursement. Responsible Party: Vice President Finance Completion Date: November 30, 2024

WIA management will implement the following corrective action plan: In order to ensure compliance with the timeliness of disbursements of federal funds contemplated under 2 CFR 200.305(b), WIA will implement the following additional procedures for federally-funded expenses. A detailed evaluation of project deliverables and timelines will be conducted by the Project Manager and Project Director for any program subject to compliance with Federal guidelines. The timelines, deliverables and affected funding mechanism(s) will be aligned to determine if there may be a delay beyond a reasonable period which would impact the submission and processing of payments to subcontractors. If it is determined that a delay is possible or likely, consideration will be given to contract amendments which better support the processing of payments aligned with 2 CFR 200.305(b). Further, the Finance team member assigned to the associated program will provide regular guidance to the project team which may include a detailed briefing on the CFR and any relevant concerns with cash management. Disbursements of federal funds will be issued in a timely manner in all instances. The additional set of procedures described above will be implemented in September 2024. In addition, we are currently working through finalizing the contract for Phase 2 of the specific contract related to this finding. We anticipate these negotiations will be completed by October 31st, 2024. Once the Phase 2 agreement has been reached, we will immediately release the Phase 1 funds to the vendor and obtain guidance from The Ohio State University as to the proper disposition of any interest that has been earned by WIA from the withheld Phase 1 payment. Marta Sokol, Chief Financial Officer is the individual responsible for oversight of this corrective action plan. Mrs. Sokol can be reached at 703.535.7447 or Marta.Sokol@wia.org.

Type of Finding: Significant Deficiency in Internal Control over Compliance - Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Aging Cluster Assistance Listing Number; 93.044 / 93.045 / 93.053 Federal Award Identification Number and Year: DA23-1109-2023 Pass-Through Agency: City of Seattle Pass-Through Number(s): DA23-1109 Award Period: January 1, 2023 through December 31, 2023 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-Federal entity must “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non- Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring the Organization of the Treadway Commission (COSO).” Condition: During testing of reporting, it was noted that, for one sample, documentation was not retained of approval of financial reporting. Questioned Costs: None Context: A sample of 9 financial reports was made from a population of 54 total reports. Of the 9 sampled, 1 was missing evidence of authorized personnel review and approval. Cause: In this one instance, verbal approval was given rather than emailed approval. Effect: Without adequate documentation and controls in place to ensure costs are reasonable and intended for the program charged, Sound Generations could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that Sound Generations is entitled to under the terms of the grant. Repeat Finding: No. Recommendation: CLA recommends that documentation is retained as proof of authorized personnel review. Views of responsible officials and planned corrective actions: Sound Generations agrees with the finding. Sound Generations has revised its approval process to include digital signatures with time stamps by authorized personnel on all documentation rather than emailed approvals. Responsible Official: Carlos Rojas, Chief Financial Officer; Christina Hannan, Controller Anticipated Completion Date: March 31, 2024

Conservation Research and Development Program – Assistance Listing #81.086 Plan completion date for corrective action plan: October 31, 2024 Recommendation: The Organization should establish written policies and procedures regarding invoicing for cost- reimbursement related to federal grants which include proper segregation of duties. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments, and the following actions have been or will be taken to improve the situation. We hired a Grants Accountant in 2024 to take over the responsibility of preparing invoices for cost-reimbursement. This allows for the additional control of the Senior Finance Manager reviewing the invoices. This review is now being documented in writing. Additionally, there are procedures in place to ensure if the Senior Finance Manager prepares the invoice, the Director of Finance & Operations reviews and documents approval of the invoice. We will establish written policies and procedures to document this process by October 31, 2024. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Ronald Tran, Senior Finance Manager

The City of Charleston will implement internal controls and procedures to ensure all required reports are prepared, reviewed, and submitted within the program’s required timeframes, and with the correct amounts.

Recommendation UVNR should implement procedures to ensure thorough monitoring and accurate accounting of all subrecipient expenditures. Subrecipients should be required to submit properly supported invoices with their reimbursement requests. It is also recommended that authorized grant personnel diligently review and approve these invoices to ensure that reimbursements are made only for actual expenditures. Management Response Corrective Action: 1. Meet with subrecipient to clarify compliance issues with 2023 disbursements and to discuss plans of action for 2024 through grant period end (occurred on 9/10/24). 2. Subrecipient will invoice monthly providing grant personnel with an invoice and general ledger of expenses. 3. Grant personnel will adopt a policy of reviewing subrecipient’s monthly invoices and supporting documents, including adding a requirement for grant personnel to approve and sign subrecipient invoices before drawing down from the federal award’s payment management system. 4. Signed and approved grant invoices and supporting documentation will also be shared with accounts for approval before drawing down from the federal award’s payment management system. 5. Grant personnel will meet regularly with accountants for thorough and continuous monitoring of the award, including accurate accounting of subrecipient funds Due Date of Completion: September 30, 2024 - ongoing Responsible Party(ies): Co-Executive Directors

Condition: During compliance testing, it was identified that an employee's wages were being charged to the grant after the employee was terminated. Corrective Action Taken or Planned: Management noted there was turnover in fiscal year 2023 which led to lack of some reviews. Controls have been put in place to ensure all worksheets are viewed for accuracy by the CFO prior to requesting drawdown amount. Name(s) of Contact Person(s) Responsible for Corrective Action Coleen Elias, Chief Executive Officer, Community Clinical Services. Anticipated Completion Date: Controls have been implemented as of the date of the audit report.

Contact Person: Tracy Carr, Andrew Hall Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: Monthly grant reimbursement reports have a limited window before the due date. Additional requirements have added time to properly prepare reimbursement reports. Gathering all supporting documentation before submission has increased the time needed before the complete reimbursement request package is ready. Each member of the finance team is sharing in the responsibilities to meet the deadline. Completion Date: Beginning September 1, 2024 and thereafter.

The Authority has reviewed the facts surrounding the draw down of funds not expended within a reasonable time and will review 2 CFR Part 225, Subtitle A, Part 85.20 to familiarize themselves with the regulations.

Congregation Oros Bais Yaakov of Lakewood, Inc, respectfully submits the following corrective action plans for the year ended December 31, 2023. Finding 23-1: The school’s net cash resources exceeded three months average expenditures are the end of the year. Recommendation: To keep monitoring the net cash resources throughout the year to ensure it doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue, the School’s administrator has begun to routinely monitor the net cash resources to ensure it does not exceed three months of average expenditures. As such, the required correction actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of July 19, 2024. Person Responsible for Implementation: Nechama Prager, the Administrator, is the responsible party for implementation of the CAP. Telephone Number: 732-730-6049

Significant Deficiency in Internal Control over Compliance, Other Matters 2023-002 Reporting Recommendation: We recommend the County review its processes and implement controls to formally review these quarterly reports and that they are compared and reconciled to the general ledger. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County is planning a more in-depth checklist of accounts to be reconciled and journal entries to be made along with regular check in and team meetings to meet the deadlines. Name(s) of the contact person(s) responsible for corrective action: Michelle Uitenbroek, Finance Director Planned completion date for corrective action plan: December 31, 2024 If the granting agencies have questions regarding this plan, please call Michelle Uitenbroek, Finance Director at 920-832-1674.