Corrective Action Plans

5. Conducted nonprofit cash flow management training for the CEO, Controller, and Board in Q2 FY25.

6. Included cash flow forecasting and liquidity discussions in monthly Finance Committee updates.

7. These improvements were reviewed during the 2025 HRSA Verification Site Visit and contributed to clearance of relevant conditions under Chapter 21 of the HRSA Health Center Compliance Manual.

Corrective Action Plan:

1. Continue weekly updates of the 12-month rolling cash flow forecast.

2. Maintain twice-weekly internal cash reviews to align disbursements with available cash and grant timing.

3. Monitor operating accounts against internal minimum thresholds and refine automated alerts as needed.

4. Reassess account structure annually and maintain contingency agreements with the bank.

5. Require refresher training in cash flow management for new financial staff and Finance Committee members at least once annually.

6. Maintain Finance Committee oversight of liquidity metrics, with trends tracked in monthly dashboards.

7. Review internal controls annually to ensure continued alignment with 45 CFR § 75.302(b)(4) and evolving HRSA guidance.

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of disbursements in its job‐costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job‐costing system. Auditee Response: UICSL has limited access to its accounting system and removed access by outsourced financial management personnel. In addition to better invoicing structure, UICSL also revised its job-costing system to better comply with these requirements. Together, these systems will be used to request only the amount of attributable ot the programs for reimbursement-based grant funding. Corrective Action Plan: All transactions are logged into the accounting system with appropriate respective grant codes and departments. Invoices and transactions will not be processed without approval and proper coding. UICSL has also implemented a new credit card tracking system along with a purchase order system that is active and maintained by Finance and Accounting. Monthly and quarterly invoices will be prepared for grants in compliance with 2 CFR section 200.305(b). Person Responsible: Matt Poss, Executive Director and Mary Louise Santacaterina, Grants Manager Timeline: Already removed accounting system access by prior outsourced financial managemnet personnel. Monthly check-ins and expenditure reports have been implemented with department leads in 2024. Grants Manager tasked along with Director of Finance of reviewing monthly invoices and ensuring each meets grant and expenditure requirements. All invoices reviewed with grant/project leads and logged appropriately. Staff acountant hired in 2024 to help provide oversight.

Management Response and Planned Corrective Action: We concur with the Federal Award Findings outlined above of the auditors and have implemented a corrective action plan, including updating internal control policies and procedures. Views of Responsible Officials and Corrective Actions: The management team of the Council of Western State Foresters believe in the values of transparency, justification, and documentation for transactions made in the course of conducting job related duties. As a small organization with limited staff, suggested reasonable improvements to processes are always welcome. It is in this spirit that the below corrective actions for the compliance issues noted in the findings from the 2023 audit are put forward. 2023-004 Corrective Action Plan: Management acknowledges the need to strengthen procedures related to the preparation and review of SF-270 forms. The review and approval processes for SF-270 submissions have been evaluated and revised to ensure that requests for advances and reimbursements are accurately classified and properly documented. In alignment with 2 CFR § 200.305, all advance requests will be reviewed to ensure they are based on reasonable estimates of direct program costs that are immediately necessary for the applicable period. As part of this process, management will implement a cross-referencing procedure to verify that requests designated as reimbursements or advances are supported by appropriate documentation and accurately reflect the nature of the request. Anticipated Completion: Process revisions and controls have been completed

The Organization initially had difficulty identifying a qualified firm to carry out the Single Audit for the year ended December 31, 2023. During the first half of 2024, the Organization contacted a total of 17 firms to request quotes, in a process that proved especially difficult given that many did not have experience auditing Non-Profit entities or did not respond. The Organization also consulted with peer Non-Profits entities with similar budgets to obtain recommendations, and from all these efforts only one proposal was received. This prolonged search process significantly delayed the start of the audit. Nevertheless, the Organization entered into a formal agreement with a certified public accounting (CPA) firm to perform the Single Audit. In addition, as this was the Organization’s first audit, additional time was required to compile the requested documents. With a clear understanding now of the documentation requirements, the process is expected to be significantly quicker in future audits. Furthermore, the Organization has already agreed with the same firm to perform the Single Audit for subsequent years going forward.

As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final agreement, the budgeted requested salaries were not updated. We will attempt to have the sponsoring office of the federal program to retroactively amend the Assistance Agreement to remove the compensation limitation. The Assistance Agreement has been modified to remove any such limitation prospectively beginning with Modification 0015 April 2024.

FINDING 2023-002 Finding Subject: COVID‐19 ‐ Coronavirus State and Local Fiscal Recovery Funds ‐ Reporting Summary of Finding: The Elkhart County Health Department (Health Department) was awarded the Health Issues and Challenges Grant through the Indiana Department of Health (IDOH) financed through the Coronavirus State and Local Fiscal Recovery Funds The grant was funded through the American Rescue Plan Act that focused on the improvement of chronic disease, and more specifically, elevated blood lead level reduction. The Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS) each month. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels (EBLLs). A Case Manager managed all aspects of an individual patient's care. A home visit and two assessments were completed by the Case Manager and input into the NBS. Once these steps were marked as complete in the NBS, the Clinical Manager reviewed each case and compiled data along with the cost reimbursement amount into a spreadsheet. The Clinical Manager provided the spreadsheet to the Manager of Administration who then completed and submitted the reimbursement invoice to the IDOH. The reimbursement invoice was submitted without a documented oversight, review, or approval process to ensure the accuracy of the data prior to submission. Beginning in October 2022, the Health Department was required to submit program specific metrics and work plan data through RedCap software on a quarterly basis. The Case Manager was responsible for tracking and compiling the necessary information for the quarterly reports. Of the four reports tested, two reports were submitted late. In addition, the quarterly reports were submitted by the Case Manager via the RedCap software without a documented oversight, review, or approval process to ensure timely submission. Recommendation: We recommend the Health Department implement a formal oversight and review process for all data submissions to ensure accuracy and completeness before they are submitted to Indiana Department of Health (IDOH). This would involve a secondary review by a designated individual or team to verify the data. Additionally, improving workflow coordination through clearly defined roles and responsibilities for each team member would help streamline the process and prevent delays. To further improve timeliness, the Health Department should implement a tracking and reminder system for report due dates and reimbursement deadlines to ensure timely submissions. Providing staff with thorough training on reporting protocols and maintaining detailed documentation will help ensure consistent adherence to procedures. Finally, establishing accountability measures through clear roles, deadlines, and regular audits would enhance the efficiency and effectiveness of the reporting process. These steps will help ensure the Health Department meets grant requirements, maintains data accuracy, and avoids potential delays or issues in future submissions. INDIANA STATE BOARD OF ACCOUNTS 29 Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: During the prior audit we were informed of the deficiencies in our controls over the reimbursement requests submitted to the Department of Health. Unfortunately, due to the timing of the finding being brought to our attention near the end of its lifecycle we were unable to implement controls. With only one month remaining between the audit finding results and the grant’s end date, implementing the stated corrective action plan was deemed impractical. The Elkhart County Health Department has internal controls and policies for the grants that are received. This grant was very different from the other grants we have received in the past. Since the Elevated Blood Lead Level Reduction grant differed significantly from previous grants received by the Elkhart County Health Department, moving forward, if the department chooses to pursue and secure another grant with a similar scope, enhanced controls and policies will be implemented to strengthen accuracy and accountability. Specifically, the Health Department will establish a formal data review process. All data submissions will undergo an initial review, followed by a secondary verification conducted by a designated staff member. This dual review procedure will apply to all future grants of a similar nature to ensure the integrity and reliability of submitted information. The goal is to ensure there is an appropriate system of checks and balances, as well as a remediation/correction step, in place for all tasks and documentation related to grant-funded duties and invoicing. Anticipated Completion Date: Effective June 30, 2025 the Elkhart County Department of Health will implement this practice for all newly accepted grants similar in scope to the Elevated Blood Lead Level Reduction.

2023‐008 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working to establish better financial reporting to ensure that costs are appropriately allocated to grants for reimbursement and to establish adequate supporting documentation for all expenditures reimbursed with federal, state, or grant funding. Planned implementation date of corrective action – Calendar year 2025.

VIEWS OF RESPONSIBLE OFFICIALS According to the audit recommendation, it is requested that a written process for reconciling EBT Reconciliation Reports be implemented and developed. Additionally, it is recommended that staff be trained in this matter. The Finance Division will be preparing a task force to assign roles, provide training, and develop a protocol to improve processes and ensure that EBT Reports are reconciled. Manuals will be amended to establish a clearer written procedure. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS The Department of the Family has initiated several corrective actions. Since the first months of Fiscal Year 2024, the Accounting Department has started a review of unliquidated obligations on a monthly basis, canceling any invalid obligations and reporting them in the FY 2024 SSA-4513 report. In fact, Budget and Finance staff had multiple working sessions with PR-DDS personnel to identify and write-off unliquidated obligations that were no longer current. Also, we conducted training for finance and budget staff on accounting controls and administrative cost reporting to ensure compliance with federal regulations. Includes a review of 2 CFR Part 225 on allowable costs (direct allowable and indirect allocable, the difference between direct and indirect costs), reasonable and allocable costs. In addition, we addressed issues of unliquidated obligations (Consultative Examinations (CE) and Medical Evidence of Record (MER), among others). Nevertheless, beginning the first quarter of FY2026, following recent staffing changes in the Finance Department, we are in the process of re-training our team to ensure that unliquidated obligations are reviewed every month and invalid commitments are promptly canceled. To reinforce these practices, the Department of the Family will also deliver a series of new workshops to relevant staff outlining the procedures and best practices for SSA-4513 preparation and POMS compliance. IMPLEMENTATION DATE September 2025 RESPONSIBLE PERSON Office of the Secretariat

VIEWS OF RESPONSIBLE OFFICIALS Based on the audit report submitted, it is recommended that the Cash Management Section Procedures Manual be amended, and that the segregation of employee duties be identified. To this end, work has begun on reading and amending the Manual. It will be updated considering both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)

Planned Corrective Action: We will ensure that all drawdown is supported by data directly from the financial system. We will also develop a drawdown checklist with approval workflow to ensure that there is adequate review and approval over the monthly drawdowns. Name of Contact Person: Ruth Cable, CFO Anticipated completion date: September 30, 2025

During our Mississippi Department of Education (MDE) Administrative Review, auditors provided technical assistance on using the Edit Check Report in Mosaic to avoid underreporting or overreporting meals. Since that review, we have implemented the use of the Edit Check Report to enter reimbursable meals in the MARS system instead of the Claim Report. This change improves the accuracy of meal counts and reimbursement claims. Additionally, we will establish a formal review process whereby a second staff member verifies montly claims before submission to further ensure accuracy and compliance.

Finding Summary: The District was required to have their first single audit for the year ending June 30, 2023. They did not submit its audited financial statements and federal program data to the Federal Audit Clearinghouse by the due date of March 31, 2024. Responsible Individuals: Peter McElroy, Director. Corrective Action Plan: The District has experienced significant turnover in management positions. They have recently employed a new Director. As a result, the District will have more timely filings going forward, if required.