Corrective Action Plans

Department of Health and Human Services Lutheran Family Services of Virginia, Inc. and Subsidiaries d/b/a enCircle 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. 3906 Electric Road Roanoke, Virginia 24018 Audit Period: Year ending June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. Findings – Financial Statement Audit NONE. Findings – Federal Award Programs Audits Department of Health and Human Services 2023-001: Unaccompanied Alien Children – ALN #93.676, Activities Allowed/Unallowed; Allowable Costs and Period of Performance and controls over Activities Allowed/Unallowed; Allowable Costs and Period of Performance. Significant Deficiency Criteria and Condition: Under the requirements of the Uniform Guidance, the drawdown of federal funds must be based on actual expenditures incurred. Context: We tested twenty-five reimbursed amounts from various awards. We noted two instances where the Organization obtained federal funds without incurring the actual expenditure. We also noted one instance where the expenditure occurred outside of the budget period. Cause: The Organization did not properly allocate expenditures within their general ledger and did not have an adequate review process in place. Effect: The lack of an adequate review process can cause federal funds to be obtained prior to the actual expenditure is incurred. Recommendation: We recommend that the Organization develop a review process to ensure the drawdown of federal funds does not occur before funds are expended and that the Organization submit expenditures incurred in the budget period. Action Taken: Management has implemented enhanced review processes to ensure the drawdown of Federal funds does not occur before funds are expended and that enCircle submits only expenditures incurred during the budget period. Name of Contact Person: David Pruett, Chief Financial Officer

Auditor Description of Condition and Effect. The most recent Gramm Leach Bliley Policy fails to address the assessment of apps that are developed by the institution. As a result of this condition, the College isn't meeting the safeguard requirements necessary to comply with the FTC. In addition, the lack of safeguard controls creates an increased risk to highly sensitive data that is possessed by the College. Auditor Recommendation. We recommend that the College implement procedures to ensure that all Gramm Leach Bliley Policies are met and verified by a second individual. Corrective Action. Currently, the College is reviewing the compliance requirements for Gramm Leach Bliley and will amend the current policy to ensure the assessment of apps developed by the institution is covered within the policy. Responsible Person. Kirk Lehr, Director of IT Anticipated Completion Date. June 30, 2024

U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Foster Care Federal Assistance Listing Number: 93.658 Significant Deficiency and Non-Material Non-Compliance – Allowability and Eligibility Finding 2023-005 Criteria or specific requirement: Per Section 200.303 of the Uniform Grant Guidance, 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. Condition: For one (1) of the 40 participants selected, an amount of $1,004 was requested for reimbursement that was not paid to the third party facility. Questioned Costs: $1,004 and likely questioned costs of 90,594. Effect: By not having the required documentation in the files to support payment for costs recorded, the County may request reimbursement for costs not incurred. Cause: County oversight when performing reviews over payment reimbursements. Recommendation: We recommend the County implement a procedure to ensure all costs being requested within reimbursements have been incurred by the County prior to requesting reimbursement. Views of responsible officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan. Corrective Action Plan: See Corrective Action Plan prepared by the County. The Data Integrity unit within the Finance Department will continue to review invoices, child by child, to verify correct placement information. The Supervisor will review sample of invoices to ensure each Facility is paid the correct amount depending on child placement. Responsible Individual(s): Annette Madden, Management Analyst, Data Integrity Unit, Finance Date of Implementation: 12/31/2023

Corrective Action Plan and Views of Responsible Officials The IT Manager, prior to the filing of any E-Rate or ECF grant documents, have all entries approved by his supervisor. The IT Manager will also set a meeting to review any documentation related to any applications for funding prior to submitting an application to ensure the District is prepared to adequately meet all funding requirements.

Recommendation: We recommend that the Project funds are only used for expenses of the Project. Additionally, we recommend the management company reimburse the operating cash of the Project $16,362 for overpayments. Action Taken: We agree with Finding 2023-001 described in the accompanying schedule of findings and questioned costs. The management company will reimburse the Project operating cash for the overpayments.

2023-001 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles Contact Person Responsible for the Corrective Action Plan: Mary W. Duncan, Finance Director Corrective Action Plan: We have discussed the finding and are currently implementing controls to ensure the timesheets are appropriately reviewed to match with daysheets. Anticipated Completion Date: June 30, 2024

Recommendation: We recommend that management follow its policies and procedures in place to ensure that the residual receipts deposit is made per regulatory guidelines. Action Taken: Management acknowledges that the June 30, 2022 surplus cash was not deposited into the residual receipts account within 90 days of year-end and will provide additional oversight to ensure that the residual receipts deposit is made per regulatory guidelines.

University’s Response/Corrective Action Plan: Upon becoming aware of the issue, the University issued a Stop Work Order to the identified subrecipient to cease all work on the award until such time their invoicing and documentation complies with the terms and conditions of the subrecipient agreement. Since this issue was contained to a single award and a single department the University completed these steps: 1. Performed an audit of the subrecipients on the award to ensure all were following the requirements of the subrecipient award agreement. The audit was complete on October 13, 2023. 2. The Office of Research & Sponsored Programs (ORSP) and Grants Accounting (GA) completed a subrecipient monitoring training for the department to ensure that they were familiar with the requirements of the agreement and revised their processes for appropriate monitoring of subrecipients. This training was completed on November 7, 2023. This training will be made available to all OHIO principal investigators (PI) via the subrecipient webpage on the Office of Research & Sponsored Programs website by November 30, 2023. 3. ORSP and GA worked closely to develop a new checklist that was shared with all PIs on Tuesday, October 24, 2023, that outlines the PI responsibilities for monitoring subrecipients and reviewing any invoices before payment from the subrecipient to ensure that it complies with the subrecipient agreement terms and conditions. This checklist will also be added as resource for PIs as an additional tool for subrecipient monitoring by November 30, 2023. 4. Developed a subrecipient invoice template that includes all required information to comply with the subrecipient agreement. This invoice template will be sent to all subrecipients when the purchase order is issued to the subrecipient. This practice started on October 23, 2023. 5. Responsible Parties: Heidi Whitney, Director of Grants Accounting and Susan Robb, Assistant Vice President for Research & Sponsored Programs

Description of Finding: The District lacked appropriate internal controls to ensure that allowable costs are charged to federal programs in the applicable fiscal year. Statement of Concurrence: The District agrees with this finding. Corrective Action: We will review relevant processes to ensure that there are appropriate controls in place to capture allowable costs within the applicable fiscal period. Projected Completion Date: We expect this matter to be resolved by the end of January 2024.

Condition: During our testing of reimbursements, we noted that the District reported incorrect meal counts on their submitted reimbursement claim forms for the months of October 2022 and May 2023. We tested 2 months of reimbursement claims submitted by the District based on daily attendance records for breakfast and lunch. Of the 4 meal counts tested (2 months of breakfast and 2 months of lunch), we identified three variances where the count claimed for reimbursement did not agree to the underlying records per the school district. Plan: The District will ensure that supporting counts for each months claims are retained and properly reconciled to reimbursement requests. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Dr. Dwayne E. Evans, Superintendent of Schools Management Response: The District is currently strengthening internal control procedures over grant reporting and monitoring.

Corrective Action to be Taken for Finding 2023-002 - Report Deadline Tracking o Catholic Charities will create a shared calendar for use by the Caseworkers, Program Director, Operations Director, and Fiscal Manager to document all deadlines of required reports and staff responsible for completing the reports. o This calendar will be monitored and updated by all staff with new arrival dates, quarterly report deadlines, close of case report dates, billing dates, Match Grant enrollment dates, 180-day budget deadlines, and 240-day budget deadlines. - Trainings o The Program Director will contact the staff of United States Council of Catholic Bishops, here after referred to as USCCB, when an individual begins employment and request a login and password into the USCCB resource website, MRS Connect, which has all USCCB trainings recorded and saved for staff to review. o Within 30 days of an employee’s start date the individual will participate in all approved USCCB training on reporting requirements. - Case File Review o Within the first week of arrival, the Program Director will review a case file. o Thereafter, a weekly case file review to monitor that case files have required documentation in accordance with the federal guidelines will be completed.

Corrective Action to be Taken for Finding 2023-001 - Food Purchases o The practice of purchasing food will be to have the Caseworker for each case take the family shopping to Giant Foods, where there is a Catholic Charities account. The Caseworker should shop with the family and then after the purchase is completed the clients signs the required RF-35 documentation and the receipt is then given to the Program Director to pay within the accounting software. A copy of the signed RF-35 and receipt will be made available for the client case file and for the Fiscal department for billing purposes. o If the option of shopping at Giant Foods is not available due to dietary restrictions or culture requirements, gift cards to these specific grocery stores will be made using a Catholic Charities credit card. The gift card will be given to the family for them to sign the appropriate RF-35. The Caseworker will then take the family shopping to ensure clients spend funds on federally approved food items. A copy of the receipt for the gift card purchases and the signed RF-35 as well will be made available for the client case file and for the Fiscal department for billing purposes. - Rent Payments o The practice will be to have a lease from the Landlord to issue a check for security deposit and rent. On the day of move in, the lease will be signed by the client, the RF-35 will be signed, and then the check will be released to the Landlord. Once the lease is signed, a copy of the lease and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. o The practice when a client is going to be living with their US-tie is that a letter of agreement between the case’s primary applicant and the US-tie will be established explaining the amount the client is responsible for paying for rent and utilities. That agreement will then be signed by the client, the US-tie, and will be witnessed by a third party (Caseworker, Program Director, Operations Director). That agreement will then be utilized as the documentation for requesting rent payments on behalf of the client along with the signed RF-35. A copy of this agreement and signed RF-35s will be made available for the client case file and for the Fiscal department for billing purposes. o The practice when two unrelated clients are going to be living together is as follows: all appropriate required documentation establishing the responsibilities between the two clients will be established. The lease and all agreements will then be signed and will be witnessed by a third party (Caseworker, Program Director, Operations Director). The lease and signed agreement will then be utilized as the documentation for requesting rent payments on behalf of the clients along with the signed RF-35s for each case. A copy of the lease, this agreement, the signed RF-35s will be made available for each of the clients’ case files and for the Fiscal department for billing purposes. o Rent payments made after the initial payment will be made in the amount of the client’s rent according to the lease and will be accompanied by a signed RF-35. A copy of each signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. - Utilities o Educate the clients to turn utility bills into the Caseworker and have the client sign a RF-35 in the amount of the utility bill. The Caseworker then gives the utility bill to the Program Director to enter the invoice into the accounting software for payment. A copy of the utility bill and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes. o If the Landlord pays the utilities and seeks reimbursement, the landlord will provide a copy of an invoice for the client to turn into the Caseworker and have the client sign a RF-35 for the amount of the utility bill. The Caseworker then gives the invoice to the Program Director to enter the invoice into the accounting software for payment. A copy of the invoice and the signed RF-35 will be made available for the client case file and for the Fiscal department for billing purposes.

Finding #2023-002 – Residual Receipts Reserves and Tenant Security Deposits Responsible Individuals: Mary R. Duncan, CPA, CGMA, Chief Financial Officer Corrective Action Plan: The Organization has implemented practices for deposits of residual receipts reserves to be made within 60 days of year-end and proper collection of security deposits, as required by U.S. Department of Housing and Urban Development. Anticipated Completion Date: Fiscal year 2024, as a new Equipment and Facilities Operations Manager was hired.

The District agrees with the finding and will work with TDA to develop a plan to spend the excess fund balance on approved NSBLP expenditures, and maintain an appropriate amount of fund balance in the future.

Management’s Corrective Action Plan Management takes its responsibility to maintain effective internal control over the federal award that provides reasonable assurance that the agency is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the award seriously and gave significant consideration to what additional controls would be effective to ensure the proper amount of indirect costs are charged to all federal grants. To prevent another occurrence, the organization will: On October 17, 2023, the agency refunded the indirect costs that were overbilled in error. By December 31, 2023 and annually thereafter, the Director of Grants Management will provide training and technical assistance to all Grant Specialists and Grant Accountants on allowable costs, including detailed training on proper determination of indirect costs for each grant. This training will also be incorporated into the onboarding process for any new grant staff. Continue its current policy that the Director of Grants Management complete a detailed review of each grant reconciliation monthly, to ensure all costs charged to the grant are reasonable and necessary for the performance of the award. This review will include appropriate tests of indirect costs including ensuring the appropriate indirect cost base is used, all items required to be excluded from the indirect cost base are excluded, and the appropriate indirect cost rate is applied to the indirect cost base. Continue its monthly analytical review to test the reasonableness of grant revenue relative to grant-funded expenditures. At least twice annually, the Controller will complete a second detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. At the end of each award cycle, the CFO will complete a third detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. Going forward, should indirect rates or methodologies change for any award, the CFO will review the grant reconciliation the first month following the effective date of the change to ensure the change has been properly implemented.

Corrective Action Plan The District will implement procedures to ensure planned capital expenditures, using Elementary and Secondary School Emergency Relief Funds, receive approval by either the U.S. Department of Education or the Texas Education Agency prior to the actual purchase. Person(s) Responsible Assistant Superintendent of Business & Finance Anticipated Completion Date Fiscal year 2023-2024

Auditor Recommendation Recommendation: We recommend that the Organization verifies that payments are recorded in the correct period and not changed in the general ledger after the checks are written. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers and Josh Warner (management agent) will establish a review process that will include making sure all payments are recorded within the proper period. 3. Official Responsible for Insuring CAP Sara Wohlers is the official responsible for insuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP Julie Baruch (board chair) and Sara Wohlers will be monitoring this plan.

Auditor Recommendation Recommendation: We recommend that the Organization verifies all requests for reimbursements are received in a timely manner. We also recommend that the Organization verifies that payments are recorded in the correct period and not changed in the general ledger after the checks are written. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers and Josh Warner (management agent) will establish a review process that will include making sure all payments are recorded within the proper period. It will also include ensuring all HUD/HAP funds are received in full during that period and any short falls or overages are identified within the proper period. 3. Official Responsible for Ensuring CAP Sara Wohlers is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2024 audit. 5. Plan to Monitor Completion of CAP John Frank (board chair) and Sara Wohlers will be monitoring this plan.

Finding 2023-004 Name of Responsible Individual: Demetrius Carmichael, AVP Finance and Controller Corrective Action: We understand the requirement of disbursing Title IV funding to eligible students and parents and the requirement to make disbursements as soon as administratively feasible, but no later than 3 business days following the receipt of funds and eliminating excess cash balance within the next 7 calendar days. In this case, the School received funds from the student from unknown sources, and the School submitted the funds to the ED on behalf of the student at the student’s request to lower outstanding educational debt. We discuss the importance of lowering education debt during our debt counseling sessions and encourage students to return funds not needed due to subsequent scholarships or family support. We have not found guidance that will support the requirement to submit funds to the ED within the 3 business days plus 7 calendar days that are earned and provided by the student to submit to the ED under the cash management ruling. Anticipated Completion Date: March 1, 2024

Finding Synopsis: The District has inadequate controls over reviewing and approving quarterly "historical expenditure reports" filed with the Illinois State Board of Education. Action Steps: The District intends to fully implement the recommendation in FY2024, as corrective action was not taken until midway through FY2023.

The Blood Bank added review and approval processes to ensure only allowable charged are included in the MTDC subject to the indirect cost rate.

1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding The Academy will adopt the referenced policies to achieve compliance with Uniform Guidance. 3. Official Responsible Samuel Yigzaw, Executive Director, is the official responsible for ensuring corrective action. 4. Planned Completion Date June 30, 2024 5. Plan to Monitor Completion The Board of Education will be monitoring this Corrective Plan.

Name of Contact Person: David Richmond, Interim Director Corrective Action/Management's Response: In response regarding the above mentioned finding for Moore County Social Services, please see the corrective action plan below: Training: • Accounting will develop and implement annual training for applicable DSS staff in conjunction with State required day sheet training. • This training will also be given to all new applicable staff in the orientation process. • DSS Accounting will maintain a record of all staff completing the training. Internal Reviews/Auditing by Unit Supervisors: • Each biweekly payroll is currently approved by supervisors prior to processing. • After each payroll the day sheets for that biweekly period will be reviewed by the supervisor to ensure proper coding and matching time to the payroll reports for each employee in their unit. • When this process is complete, they will send a report to DSS Accounting with their findings. Internal Reviews/Auditing by DSS Administration • DSS Accounting will monitor each reporting period to ensure each supervisor has submitted their bi-weekly report. • DSS Accounting will maintain files with these reports for additional follow-up as needed. • DSS Accounting and Payroll staff will work with necessary staff that have discrepancies to ensure corrections are completed. • In addition, at the end of each month (prior to submission of the 1571 State reimbursement report) DSS Accounting will spot check 3 random Services records for accuracy. Findings will be reported, and corrections completed/processed by the 15th of the month of review. Proposed Completion Date: The expected completion date to have corrective action implemented is December 15, 2023.

Nutrition Cluster – CFDA Nos. 10.553 and 10.555 Significant Deficiency: See Finding 2023-002

Nutrition Cluster – CFDA Nos. 10.553 and 10.555 Name of contact person – David Gates, Business Manager Recommendation: We recommend the Food Service Director more closely review all meal count information entered for reimbursement prior to submitting each monthly claim to ensure accuracy and consistency with supporting documentation. We recommend that the Food Service Director review all monthly claims filed in fiscal year 2023-24 available for revisions to ensure reports were accurately filed. Further, we recommend that District management periodically monitor claim submissions for accuracy. Action Taken: Management agrees with the recommendations. The Food Service Director has reviewed all monthly claims submitted in school year 2023-24 and found no errors requiring revision. Further, management will implement a plan to periodically review claim submissions for accuracy. Proposed Completion Date: January 31, 2024