Corrective Action Plans

Finding 2024-03: Cash Management Approval Views of Responsible Officials Management agrees with the findings and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the review and approval of cash drawdown requests. Corrective Action Plan Effective July 1, 2024, EVMS merged with ODU and the ODU Research Foundation became the fiscal and administrative agent for EVMS’s transferring sponsored programs on behalf of ODU. As per ODU’s Memorandum of Understanding (MOU) with the ODU Research Foundation, the ODU Research Foundation has policies and processes in place to manage the review and approval of cash drawdown requests. The ODU Research Foundation uses its own system of internal controls for the review and approval of cash drawdown requests with no reliance on ODU systems for those processes and are audited separately. As a corrective action moving forward, ODU management will notify the ODU Research Foundation management of the audit findings, so they are aware of the internal control deficiencies. ODU will request the Research Foundation to provide a copy of their single audit report to monitor continued compliance with Uniform Guidance. The corrective action plan will be completed by March 31, 2025 and the contact person for this finding is Victoria Dean.

Finding 2024-02: Indirect Costs (IDC) Views of Responsible Officials Management agrees with the finding and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the accuracy of the review over indirect costs calculation requirements. Corrective Action Plan Effective July 1, 2024, EVMS merged with ODU and the ODU Research Foundation became the fiscal and administrative agent for EVMS’s transferring sponsored programs on behalf of ODU. As per ODU’s Memorandum of Understanding (MOU) with the ODU Research Foundation, the ODU Research Foundation has policies and processes in place to manage how the indirect costs are calculated. The ODU Research Foundation uses its own system of internal controls for IDC calculation with no reliance on ODU systems for those processes and are audited separately. As a corrective action moving forward, ODU management will notify the ODU Research Foundation management of the audit findings, so they are aware of the internal control deficiencies. ODU will request the Research Foundation to provide a copy of their single audit report to monitor continued compliance with Uniform Guidance. The corrective action plan will be completed by March 31, 2025 and the contact person for this finding is Victoria Dean.

Finding 2024-002 Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Anticipated Completion Date: September 30, 2025 Corrective Action: The City will implement a new policy document specifically for Uniform Grant Compliance to have one document to ensure compliance.

Management’s Response/Corrective Action Plan: Management will reconcile reimbursement requests to general ledger detail and review available grant amounts before submitting the drawdown.

2024-001 Failure to comply with Reporong Requirements The grant was executed in October 2023, making the first reporong period to start January 2024. The City was unable to access the DRGR portal until late April 2024. During this period, the City maintained regular communica􀆟on with the HUD representa􀆟ve . A􀅌er gaining access the data was entered into the portal and the City has remained in communica􀆟ons with HUD representa􀆟ves. While the report was entered, there are addi􀆟onal steps to be able to submit. The City is ac􀆟vely working with DRGR staff to resolve a system issue that is not allowing us to complete the submi􀆫ng process. To date, the City has not received any no􀆟fica􀆟on from HUD indica􀆟ng that the performance reports are overdue, and they have been able to proceed with processing the reimbursement requests. The City has gained beter knowledge in rela􀆟on to the steps for full report submissions on the DRGR website and has strengthened internal controls on repor􀆟ng requirements, and grants management in general to avoid cases like this in the future Contact – Stephanie Hill, Administra􀆟ve Services Director Es􀆟mated Implementa􀆟on – June 30, 2025

Name of Responsible Individual: Marchon Jackson, Associate Vice President of Research; Jaquion Gholston, Assistant Vice President for Post-Award and UARC Operations; Rawle Howard, Assistant Vice President, Procurement Corrective Action: The process to review subrecipient invoices will be improved by requiring the review of supporting documents to ensure expenses are allowable by the Sponsored Program Office (SPO) post award team. This team will thoroughly review supporting documents to ensure expenses are allowable, allocable, reasonable and recorded in the proper period according to university policies and grant terms. Invoices will be reviewed by SPO and will serve as the key control point before transactions are forwarded to accounting to post to sponsored awards. Subrecipient invoices will be paid by Accounts Payable only after approval by SPO and GCA. The Director of Compliance will conduct spot checks on all sponsored transactional activity, especially for high-risk grants to provide an additional layer of oversight. The new review process and training for these responsibilities will be implemented by spring 2025 as part of the broader campus-wide workflow training and staffing up of the new SPO Post-Award office. Anticipated Completion Date: June 30, 2025

Name of Responsible Individual: Ben Carmichael, Associate Director for Compliance, Enrollment Management; Robert Muhammad; Executive Director of Financial Aid; Brenda Willis, Senior Executive Director of Financial Grants & Contracts; Teshome Metaferiya, Director of Reporting Corrective Action: A statement of procedure and workflow will be implemented to formally reconcile FWS - Title IV expenses to the general ledger on a monthly basis to ensure timely draws and adjustments. Adjustments and updates to the FISAP including prior year adjustments will be included in the Title IV reconciliation process and communicated immediately. The reconciliations will require two-tier approvals. Anticipated Completion Date: May 30, 2025

Management accepts this finding and notes there were issues with the disbursement records that prevented them from being sent to COD. Unexpected turnover in the workforce resulted in 25% normal processing capacity during the timeframe in question. Staffing levels in that area have been fully restored with appropriate training to the employees. A formal schedule has been developed whereby records are reconciled and sent to COD on a weekly basis to reduce the risk of late filings. In addition, the University is considering methods of improved redundancy and backup to prevent systemic issues going forward. Anticipated Completion Date December 2024 - completed Responsible Person Nicole Adner, Director of Financial Aid

Corrective Action Plan The University acknowledges this finding and is committed to immediate corrective measures to ensure compliance with federal regulations. The following actions will be undertaken: 1. Enhance Procedures and Internal Controls: The University will strengthen its procedures and internal controls related to the submission of origination and disbursement records to the COD system. This includes implementing stricter monitoring mechanisms to ensure all records are submitted within the required timeframes. 2. Implement Advanced Technology Solutions: To improve the efficiency and accuracy of financial reporting, the University will adopt advanced technology solutions. These tools will facilitate timely and accurate submission of required data to the COD system. The newly established internal audit team will oversee the implementation and management of these corrective actions until the issue is fully resolved. The University is dedicated to enhancing its procedures and internal controls to ensure full compliance with federal origination and disbursement requirements. By taking these steps, the University aims to rectify the identified deficiency and prevent future occurrences, thereby maintaining the integrity of its financial reporting processes. Anticipated Completion Date: September 1, 2025

We acknowledge BDO’s recommendation to ensure consistent approval and retention of timesheets by both employees and supervisors for each pay period requested for reimbursement. However, VOAWW asserts that we have established controls in place to obtain and retain timesheet approvals, and the two instances of missing approvals identified in the audit were due to human error rather than a lack of controls. To prevent such occurrences in the future and reinforce our existing procedures, we will continue implementing and strengthening the following controls: • Proactive Timesheet Approval Monitoring – Reports are regularly run to identify missing timesheet approvals before payroll is processed. Employees and supervisors with outstanding approvals receive reminders to ensure further action as needed, including notifying program directors about missing timesheet submissions or approvals resulting in out-of-compliance with federal awards and Uniform Guidance. • Real-Time Payroll Processing Checks – During payroll processing, additional reminders are sent to employees and supervisors who have not yet approved their timesheets, further reducing the likelihood of omissions. • Additional Approval Outside the System – In response to BDO’s recommendation, we will require managers to email Payroll at the end of every pay period affirming that they have reviewed and approved all timecards. This additional layer of approval ensures that even if a manager forgets to approve a timesheet in the system, there is still documented confirmation of their review. • Post-Payroll Compensating Control Implemented in FY24 – To mitigate any risk of over/undercharging grants due to miscoded time from unapproved timesheets, a compensating control was introduced in FY24. This process requires Program Management to review and approve a post-payroll report identifying any discrepancies in time allocations, ensuring that all time charged to grants is accurate and properly approved. • Documentation and Continuous Improvement – VOAWW provided attestations to BDO where available and acknowledges that the compensating control was not fully implemented during FY23 but was in place for most of FY24. Moving forward, we will ensure that this control is consistently applied across all programs. By maintaining and strengthening these controls, including the additional email approval process, we are confident in our ability to ensure proper timesheet approvals while mitigating any risk of inaccurate grant charging. Responsible Individual: Claire Danielson, Controller Estimated time of completion: June 2025

Audit Recommendation: Procedures should be consistently applied requiring the reconciliation of submitted personnel activity reports to the employees' actual costs allocated and charged to federal and other programs. Planned Corrective Actions: This finding was initially identified during fiscal year 2020, and corrective actions were taken by the School in 2021. To address the issue, the School implemented new procedures that require a monthly review by management, which includes a detailed reconciliation of submitted personnel activity reports to vouchers prepared for federal and other programs. This reconciliation process helps to ensure that payroll cost allocation accurately reflects the submitted personnel activity reports. In addition, the School has made changes to its payroll system to ensure accurate time tracking for its various programs. This includes changing the service provider responsible for voucher submissions. These changes will help to prevent similar issues from occurring in the future and ensure that employee-related costs are accurately allocated to the appropriate programs. As of 2022, the School has successfully implemented these changes and continues to review and monitor its procedures to maintain compliance with federal and other program regulations. Finding was repeated during FY23 and FY24, as the School was in the process of transitioning accountants and implementing control procedures during the period of exceptions noted. Anticipated Completion Date: June 30, 2024 Contact Person: Rita Nolan, Executive Director

2024-001 – Duplicate Invoices Submitted for Reimbursement Cluster: Community Facilities Loan and Grant Cluster Federal Granting Agency: Department of Agriculture Award Name: Rural Housing Service Assistance Listing #: 10.766 Assistance Listing Title: Community Facility Loans and Grants Award Year: July 1, 2023 – June 30, 2024 The Network agrees with the finding, and will make the following enhancements to the process: The current process includes the following: 1. Accounts Payable produces a report for each project listing the invoices, vendor, and amounts. 2. The Vice President of Finance reviews the report and follows-up with Accounts Payable and/or the project manager. 3. Once the reports appear to be accurate, the Vice President of Finance creates subtotals on the file for Construction, FFE, Contingency. These are needed for the USDA Application form with balances remaining calculated. 4. The Administrative Assistant, Finance, prepares the USDA application form and obtains the signature of the Senior Vice President of Finance. 5. The Administrative Assistant, Finance, sends the Application and a copy of the invoices to the USDA Area Specialist for approval. 6. The Application is digitally signed by the Area Specialist, USDA Rural Development, and a copy is sent back to the Administrative Assistant, Finance, to maintain with our records. Enhanced Controls The Senior Financial Analyst will review the Application/Requisition and the individual invoices to verify they were eligible per the letter of conditions. Additionally, she will compare the invoices on the current requisition to the last two requisitions to verify there are no duplicate invoices. Both the Senior Financial Analyst and the Vice President of Finance will sign-off after their review to show evidence of review and approval. For inquiries regarding this finding, please contact Evelyn Diaz, Senior Financial Analyst, and Carl Alberto, Vice President of Finance, who are responsible for the corrective action. Sincerely, Dean Silfies AVP, Financial Accounting & Reporting Services

2024-004. Inadequate Procedures to Identify Healthcare Providers with Expired Licenses State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Out-of-state providers and the provider whose license expired during the PHE. During the PHE an expired license report was not properly monitored. Prospectively, DHHS will ensure license expiration notifications are reviewed on a monthly basis. Additionally, DHHS will work with the PRISM contractor to explore pathways to identify all providers (out-of-state and in-state) whose licenses may have already expired. DHHS will follow the current license expiration process and close those providers as appropriate. Provider initially granted eligibility in the legacy system. In any future event involving data conversion, DHHS will ensure that all relevant data from the existing system is thoroughly collected and reviewed prior to the conversion process. This will help guarantee data integrity and minimize the risk of issues arising during the transition. Implementation Date: July 31, 2025 Contact: Shandi Adamson, Director, Office of Medicaid Operations, shandiadamson@utah.gov

We concur with the auditor’s finding. The University has engaged a third party to review our reconciliation procedures and to make recommendations on improvements to our current policy. The recommendations will also include any additional documentation showing proof that the reconciliation has been completed as timely as required. The Vice President of Business & Finance and the Director of Student Financial Aid will review the reconciliations. Monitoring reports will be completed and shared with senior management and relevant department leaders. Implementation date: Immediately. Persons Responsible: Vice President for Business and Finance, Controller, and Director of Student Financial Aid.

Name of Responsible Individual: Mary Beth Schiller-Schwenke, Chief Financial Officer Corrective Action: The FWS Program instances were the result of retroactive award adjustments that posted subsequent to the federal draws and federal draw reconciliations. To prevent a similar error in the future, the Business Office has modified its draw recordkeeping process to require that the employees that perform the draw requests and the reconciliations review the FWS master worksheet for any pending adjustments. The Federal Pell Grant Program instances resulted from reversals of student awards. The Business Office routinely monitors the general ledger for award transactions, however, reversals of student aid awarded late in the academic term can be missed. The Financial Aid Office will be responsible to notify the Business Office when they initiate award reversals that necessitate a refund. In addition to ongoing monitoring of the related general ledger accounts, the Business Office will also create automated reporting to notify staff of the pending account balances. Anticipated Completion Date: March 31, 2025

Name of Responsible Individual: Controller (Michelle Lane) Corrective Action: The University concurs with the finding. We have made necessary changes in personnel to mitigate the risk of these actions repeating. We have implemented new controls over cash management and implemented additional internal controls. The University will make disbursements as soon as they are available, but no later than the three (3) business days following receipt of funds. University policies and procedures will be followed closely to ensure there is no excess cash. All funds will be returned in a timely manner. Anticipated Completion Date: June 30, 2025

Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will implement policies and procedures to draw down Federal funds only for its immediate Federal program cash needs.

Finding 2024-003 – Fiscal Management (Material Weakness) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Department of Transportation Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: During portions of the fiscal year, the District prepared reimbursement calculations relying on an internally developed spreadsheet tool, rather than using amounts solely obtained from the general ledger and supporting documentation. The reimbursement reports were prepared by management with limited review. Conflicts over review and other monitoring procedures occurred, and were not always resolved. Complete supporting documentation for the claimed costs were not always available. Claims and other financial reports due to ODOT were regularly submitted after the due dates. The late and/or unsubstantiated filings have resulted in lost claims for the District, and potential refunding of reimbursements received. Cause: Internal control procedures assuring timely and accurate preparation of reports and filing of the reimbursement requests were not designed or implemented adequately. Maintaining sufficient and accurate supporting documentation for each report was not possible because original data was not relied upon by management, to complete the reports and reimbursement requests. Effect or Potential Effect: The lack of effective internal control activities over cash management, including financial reporting, allowed for reporting and claims errors, from simple calculation errors to requests for reimbursements of unauthorized purposes. Improper financial reporting to the ODOT occurred regularly. Lack of timely filing of reimbursement requests for amounts claimed, resulted in lost revenues and claims that may be required to be returned. Questioned Cost: No Context: Delays in filing reimbursement claims, delays in filing financial reports to ODOT, and internal disputes regarding completion of grant reimbursement request procedures were evident. Weak or nonexistent controls over cash management, including fiscal management, may result in lost revenues and risks of creating unnecessary liabilities in the form of refunds due to ODOT.  Repeat of a Prior-Year Finding: Yes Recommendation: The District should design and implement internal control policies and procedures for cash management, including fiscal management and financial reporting. Monitoring, information and communication control activities should also be designed and implemented as part of the effort the reduce the risk of continued matters of noncompliance related to cash management. District's Response: The District acknowledges the weaknesses and its intention of correcting weaknesses. Corrective Action Plan: The District’s General Manager resigned effective September 13, 2024. The Board has adopted a plan to procure qualified professional assistance to evaluate and restructure the organization and assist in daily management activities until a new General Manager can be hired and trained. Additional assistance for resolving these deficiencies has been offered by ODOT and accepted by the Board. Planned Implementation Date: October 31, 2024 Responsible Persons: District Board, Umpqua Public Transit District

Condition: During audit procedures, we noted expenditures were charged to the program via adjusting journal entry for which adequate supporting documentation could not be provided. Corrective Actions: Going forward, the Organization will implement procedures requiring supporting documentation for all journal entries made to the program to ensure that amount charged to the program are actual expenses/expenditure of the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025

Condition: During audit procedures, it was noted total reimbursements received exceeded expenditures. The Organization has charged costs to the program and received reimbursement; however, the products cost charged to the program had not been received prior to June 30, 2024. Corrective Actions: Going forward, the Organization will review all vouchers being charged to the program to make sure costs have been incurred before being charged to the program. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: March 31, 2025

Reporting - Cash Management During the testing of the Department's cash management procedures, it was determined that eight out of sixty payments tested were not distributed within 21 days of the draw down of funds. For the items tested, the time elapsed between draw down and payment ranged from 22 to 44 days. Corrective Action Plan:WIC has developed a Quality Control Plan, procedures and a workflow to ensure invoices are timely released to ASO-Fiscal for processing. Implementation Date: April 1, 2025 Responding Official: Melanie Murakami, WIC Branch Chief

2024-003- Medical Assistance (Medicaid School Based Services) Criteria: For an agency to bill Wisconsin Medicaid for School Based Services (SBS), an IEP, and Consent to Bill Wisconsin Medicaid for Medically Related Special Education and Related Services (DPI Form M-5) must be current, signed, and dated by the parent or guardian of a student with an IEP before claims can be submitted. The School District must obtain parental consent before the District accesses Wisconsin Medicaid for the first time. Condition: There were two students tested that did not have signed consent to bill forms on file. The District received reimbursements for services provided to these two students from Medicaid SBS. Without the signed consent to bill forms, theses services are not eligible for reimbursement. Cause: The District had a transition in staffing and the process step to verify signed consent to bill forms was missed. Effect: A reimbursement request was made for services that were not eligible to be reimbursed and did not comply with Medicaid SBS requirements. Auditor's Recommendation: Establish controls to verify all student services billed to Medicaid SBS have a signed consent to bill on file. Grantee Response: The District will review Medicaid SBS consent to bill forms and verify signed copies are on file going forward. Contact Person: Jon Bosworth Anticipated Completion: On-going

View of Responsible Officials - The questioned costs were immaterial and relate to a pay period that was split across the fiscal year (6/26/23 to 7/9/23, with a pay date of 7/14/23). Reports to the funder for the year ending 6/30/23 were due on 7/10/23, before all payroll information and supporting documentation for this pay period was available. Therefore, the full pay period was included in the July reimbursement report. This practice was approved by the funder and the funder will not seek to recoup out of period costs. Moving forward, the Organization will be more cognizant of accrual dates for payroll reporting and submit a true-up as needed to ensure that payroll costs are correctly allocated at the end of the fiscal year

CCS discovered this and self-reported it to the appropriate agencies. The former employee mentioned and his immediate supervisor were terminated by CCS immediately upon its discovery of the conflict of interest and not following CCS’s procurement procedures. CCS refined its Conflict-of-Interest and Procurement procedures. Conflict-of-Interest and procurement policy training sessions were conducted with all levels of staff and will continue to be conducted on a recurring basis. CCS is implementing additional layers of oversight and compliance monitoring. This is the responsibility of the CCS Chief Financial Officer. CCS is committed to continuous improvement, conducting regular internal audits and reviews to verify adherence to federal procurement standards. This is the responsibility of the CCS Revenue Cycle Manager. We are working to ensure that every vendor has a contract on file and all procurement policies are strictly followed. This is the responsibility of the CCS Controller and is expected to be completed by June 30, 2025.

FY24 interest in the amount of$331.01 was returned to USDHHS PS Program Suppmi Center on 1/30/2025. We are keeping a smaller balance in the Federal Funds bank account to lessen the amount of interest earned on the account. Any amount over $500 at the end of the fiscal year will be returned through the same process as prior years. Responsible Person for Correction Action Plan: Deana Rogers, Vice President of Administration & Finance Implementation Date/or Corrective Action Plan: 01/30/25