Corrective Action Plans

Management recognizes that there was inadequate documentation from multiple districts to support salary and benefit costs within the Title I Grants to Local Educational Agencies program. Also, Centennial BOCES recognizes, as the fiscal agent, that it is the entity responsible for compliance with the rules and regulations of the program, including for those activities taking place at each district. As a result, the Chief Financial Officer will work with the Grants Accountant that manages this program and the distribution of funds to these districts. Ultimately, corrective action will have several aspects: general training and education, targeted training and education for those districts needing more support, and follow-up with districts to ensure accountability and integrity with the rules and regulations surrounding finding # 2024- 001 cited in this single audit. The first level of corrective action will be sending resources by email to each district in our ESSA consortium. These resources will focus around the requirements of time and effort, in order to support salary and benefit costs charged to federal funds. These resources will contain informational content around time and effort requirements and citations to the Cost Principles, as well as examples and scenarios to guide districts through the proper process of documenting these costs. These emails will be to both the fiscal and program representatives at each district, and will take place in Fall 2025. Targeted support will be provided to those districts cited by the auditors as having insufficient time and effort documentation to support the salary and benefits charged to the Title I Grants to Local Educational Agencies program. In addition to the previously named elements, this will include scheduling meetings with the district fiscal representative, district program representative, CBOCES Chief Financial Officer, and CBOCES Grants Accountant. These meetings will take place either through a phone call, Zoom, or in person. In these meetings we will go over why the district documentation was deemed insufficient, and then have a conversation around the resources provided and how we can help bring the district into compliance and sustain that compliance going forward. These meetings will be scheduled during Fall 2025.As the final element of this corrective plan, CBOCES will ask districts to provide their time and effort documents that appropriately support the salary and benefits being charged during FY26. For districts with adequate documentation, we will ask for time and effort documentation at the end of the fiscal year, to support salary and benefit costs for the fiscal year. For districts with inadequate documentation, we will ask for a sample of two months of time and effort documentation during the fiscal year to monitor progress. If sufficient, no further action will be required of the district. If insufficient, CBOCES will contact the district and work to remediate any inadequacies or questions. These districts will also be required to provide time and effort documentation at the end of the fiscal year, to support salary and benefit costs for the fiscal year. Recognizing the timing of this single audit report, Centennial BOCES will need to address the current time and effort documentation at districts for FY25. Before training activities begin in Fall 2025, CBOCES will ask districts to provide their time and effort documents that appropriately support the salary and benefits being charged during FY25. If found to be insufficient, we will work with applicable districts to correct their documentation and prepare for training activities. This work will be tailored to the specific needs of each district. For future fiscal years beyond FY26, CBOCES will work to maintain compliance by asking each district to provide time and effort documentation at the end of the fiscal year, to support salary and benefit costs for the fiscal year. Also, new fiscal and program representatives at districts will be provided with the training and education documents named in the second paragraph of this action plan.

2024-002 Cash Management Compliance Name of Contact Person: Missy Hyman, CFO Corrective Action: Winn Community Health Center, Inc. will train staff to ensure cash management requirements are followed. This includes tracking the status of the federally funded cash disbursements against the need to draw down funds on related grants. Proposed Completion Date: March 31, 2026

Management concurs with the facts presented by the auditor. However, we do not agree with the conclusion that there is a lack of adequate internal controls in the area of program reports and accounting records. The Bank, as a Subrecipient, performs the closing of the CDBG-DR SBF grants and records each transaction in a system provided by the Recipient and its consultants. The Administrative and Performance Reports referenced by the auditor are automatically generated from the grant management systems provided by the Recipient. The differences reflected between the Bank’s records and these reports result from a system error under the exclusive control of the Recipient and its consultants. These differences were duly reported to the Recipient and its consultants for correction.

2024-006 – WATERSHED REHABILITATION PROGRAM – LACK OF CONTROLS AND IMPROPER PERIOD OF PERFORMANCE – WRD – ALN 10.916 – MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition Pembina County Water Resource District applied costs to the Watershed Rehabilitation Program after the period of performance, which shows a lack of internal controls. The total value of the expenses past the period of performance end date was approximately $170,468 which occurred through September 14, 2024, more than a month past the period of performance end date. Corrective Action Plan: We agree we will ensure costs are in the proper period of performance going forward Anticipated Completion Date: FY2025

2024-003 - IMMUNIZATION COOPERATIVE GRANT AGREEMENTS - INTERNAL CONTROLS - LACK OF SUPPORT FOR PAYROLL APPROVALS - ALN #93.268 - SIGNIFICANT DEFICIENCY FINDING TYPE: SIGNIFICANT DEFICIENCY Finding 2024-003 Federal Program: FAIN: IMMUNIZATION COOPERATIVE AGREEMENT NH23IP922623 ALN: 93.268 Year(s): 2024 Federal Agency: U.S. Department of Health and Human Services Pass Through Agency: North Dakota Department of Health Questioned Cost: $0 Condition: Upper Missouri District Health Unit does not have documented approval of the payroll transactions to ensure that the expenditures are allowable to the Immunization Cooperative Agreements program and are coded to the proper grant. Corrective Action Plan: We agree, UMDHU will be adding proper approval processes regarding payroll transactions. Anticipated Completion Date: FY 2026

1-Develop a reconciliation process for excess cash reserves to ensure compliance with loan agreements 2-Implement procedures to obtain and maintain documentation for qualifying low-income housing individuals. 3-Train staff on compliance requirements for loan agreements and reconciliation processes.

Management will deposit required amounts.

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdown prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will ensure there are proper segregation of duties regarding the cash drawdown process. Name(s) of the contact person(s) responsible for corrective action: Carrie Beithon, Director of Financial Services Planned completion date for corrective action plan: 12/31/2026

Management’s response/corrective action plan: Similarly, YSD acknowledges this deficiency and attributes it to a lack of knowledge of the requirements. Going forward, the School Nutrition Director will present prepared reports, prior to formal submission, to the YSD Business Administrator for supervisory review and reconciliation.

The County Clerk and Treasurer will work with the accounts payable department to update and create spreadsheets and schedule a mid-year review of SEFA funds and grants. Implementation of spreadsheets is in progress and expected to be fully implemented by June 1, 2026.

Condition: Management did not retain evidence of the execution of the Organization’s internal controls over the review and or authorization of the payment or reimbursement of credit card charges during the year. Recommendation: Management should document the review and/or authorization of credit card charges and reimbursement. Views of responsible officials: The Organization will adopt a new policy on corporate credit cards with the following general provisions. Corporate credit cards may only be issued to the Executive Director and, if approved by the Executive Director, to the heads of shelter operations, and the Organization’s Accountant. All charges shall be made solely for goods or services for the use or benefit of the Organization. Use of the credit card for the purchase of gift cards or recurring automatic transactions can only be made by the Executive Director or the Organization’s Accountant after approval by Executive Director. Receipts shall be provided to the internal accountant monthly by the 5th day of the following month. The internal accountant shall prepare a summary of all charges highlighting any 1) that are not supported by a receipt, or 2) appear questionable, and also an allocation of each charge to the appropriate expense category for financial reporting. The summary and the credit card statement shall be provided to the Executive Director for review and approval. The Executive Director will spot check actual receipt documentation for credit card2 purchases of the Organization’s Accountant and the Shelter Director. In the case of the credit card used by the Executive Director, the summary and statement shall be reviewed and approved by the Treasurer or Board President. Any improper or unsupported transaction shall create a reimbursement obligation by the card holder to the Organization. Misuse of the credit card shall be a cause for discipline in accordance with the employment manual.

The payroll procedures in place for processing payroll and paying related liabilities will be reviewed and adjusted to correct the misstatement of payroll expenses and to prevent future overpayments of liabilities. Additionally, the identified overpayments will be reimbursed to the Grantor. This will be accomplished by applying a Head Start 2025 Accounts Payable adjustment and issuing a refund check to the Office of Economic Opportunity (OEO) for the applicable programs. These corrective measures will ensure that all affected program accounts are accurately reconciled and that a zero balance is achieved for finding 2024-001.

Recommendation: CLA recommended that there is an appropriate reviewer of each claim, and expenditure reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: County will have someone other than the preparer review the report prior to submission going forward. Name(s) of the contact person(s) responsible for corrective action: Jason Jerome Planned completion date for corrective action plan: December 31, 2025

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town plans to draft and adopt policies. Anticipated Completion Date: 12/31/2025 Contact: Andrew Alward, Town Administrator

Management’s Response and Corrective Action Plan: MLSC concurs with the audit finding. Management acknowledges that the previous cash disbursement policy did not fully incorporate the requirements outlined in LSC Financial Guide § 3.2.4. MLSC believes that with the implementation of the revised Cash Disbursement Policy and related staff training, all recommendations in the audit finding have been fully addressed. Responsible person: Exec. Director, Lee Pliscou and Chief Fiscal Officer, Jocelyn Mallari Corrective action planned: MLSC has reviewed and revised the policy, and the Board of Directors approved an updated Cash Disbursement policy that fully aligned with the LSC Financial Guide. MLSC staff were trained on the new procedures to ensure full understanding and compliance. The revised policy was shared with all the staff at MLSC’s share drive. Anticipated completion date: Completed

Management’s Response and Corrective Action Plan: MLSC management would like to provide the following clarification regarding the finding that MLSC did not use the prior-year end fund balance before expending the current year’s LSC grant. Just in the first month of 2024, we already have a substantial deficit from the funding that we received. We have started using the fund balance that is in our bank account. There was no other source of funds for us but the fund balance. Being non-profit, whatever is on hand is used first and whatever is received last is the actual cash on hand at the end of the year. It is also important to note that MLSC’s local funder's grants are not received on a regular monthly basis. Some are disbursed quarterly, and FSM is received only once—typically toward the end of the fiscal year. The appearance of using current-year funds first is due to the timing and presentation in the audit schedule, not the actual fund flow. Responsible person: Chief Fiscal Officer, Jocelyn Mallari Corrective action planned: None Anticipated completion date: Completed.

Material Weakness in Internal Control over Compliance and Compliance - Cash Management Federal Program: Major Program- 93.939- HIV Prevention Activities: Non-Governmental Organization Based. Other Program- 16.889- Grants for Outreach and Services to Underserved Populations Federal Agency: Major Program- U.S. Department of Health and Human Services. Other Program- U.S. Department of Justice Award Number: Major Program- NU65PS923746. Other Program- 15JOVW-22-GG-00404-UNDE Fiscal Year: July 1, 2023 – June 30, 2024 Recommendation: We recommend that management ensure drawdowns are strictly aligned with incurred and allowable expenses. This should include: • Pre-drawdown verification of expense documentation. • Monthly reconciliations of drawdown activity to actual expenditures. • Training for staff involved in federal fund management on Uniform Guidance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Procedures related to federal drawdowns were not followed in this case. The finance department will review all procedures and ensure that staff are trained on proper drawdown procedures going forward. Name of the contact person responsible for corrective action: Simon Trowell, Chief Executive Officer. Planned completion date for corrective action plan: December 31, 2025

Views of Responsible Officials: We agree with the auditor’s findings and recommendations. We are going to review, strengthen, and more closely supervise all of our accounting procedures including response time to the Development Team’s requests for reports. We are also engaging in discussions about how and when the Development Team requests information for the needed reports. A Grant Manager has been hired and we hope that Grantseeker, our grant tracking program, can be utilized more effectively which include tracking reporting timelines.

Finding Number: 2024-003 Allowable Costs; Cash Management (Material Weakness) Programs: Unaccompanied Children Program ALN#93.676 Contract#: 90ZU0323 & 90ZU0548 Contract Period: 07/01/23 - 06/30/24 Planned Corrective Action: The auditors noted that certain payroll expenses and other than personnel service (OTPS) expenses are not being charged directly or allocated to the correct cost center in the accounting system monthly. Therefore, the amounts being drawn down during any given month may not be fully supported until the year-end when a reallocation of costs by function occurs. Beginning in FY 2025, personnel costs are being manually recorded to the correct cost centers in Serenic Navigator each month. Additionally, OTPS expenses have been charged directly or allocated to the appropriate cost centers on a monthly basis since January 2025. Person Responsible: The Executive Director and Chief Financial Officer Completion Date: January 2025

Condition and Context: The County does not have a complete set of written cash management policies and procedures required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator

This was corrected during 2024

The manager has assigned the P.O. process to the County Finance Director for records maintenance. The Grants Manager is being placed on a "growth plan" to ensure compliance with records requirements.

Compliance with Cash Management Requirements Planned Corrective Action: Heartland Alliance Health has established a formal Drawdown Policy and Procedure designed to ensure compliance with federal cash management regulations and to prevent premature or excessive drawdowns of grant funds. The policy includes specific requirements for timing, documentation, reconciliation of expenditures to draw requests, and internal approvals prior to submission. The Drawdown Policy and Procedure was reviewed and approved by the Board of Directors in October 2025. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved

Condition: During our audit of the financial management system and cash management practices for the Ryan White Federal Program, we identified the following deficiencies: Transposed Drawdown Amount: A drawdown request submitted to the PMS system for the Ryan White Program had the requested amount transposed with the amount of another federal program. This resulted in an over-request of a material amount on the Ryan White Program. Duplicate Invoice Reimbursement: An invoice was requested and received for reimbursement on a prior drawdown and was subsequently included again in a draw after year-end, resulting in a duplicate reimbursement. Incomplete Expenditure Tracking: The entity did not have a complete system for tracking all expenditures eligible for reimbursement. The drawdown process was limited to cash disbursement and payroll transactions and excluded expenditures incurred and recorded by journal entries. This resulted in the entity having unreimbursed expenditures that could have offset the over-requests noted above. Corrective Action Plan: To correct the deficiency, we are implementing a plan focused on establishing a review and approval process for all drawdown requests and revising our policies to ensure that all eligible incurred expenditures are properly captured and reconciled, thereby assuring strict compliance with federal cash management regulations and preventing federal funds from exceeding our immediate needs. Responsible Party: Austin Maddox, CFO Anticipated Completion Date: December 31, 2025