Corrective Action Plans

Finding No.: 2023-003 Condi􀆟on: SEDOL submited grant expenditure reports for reimbursement without having sufficient support for expenditures claimed, resul􀆟ng in reimbursements greater than allowable costs. Plan: Management will implement a process to properly budget, track and monitor grant expenditures and create an improved review and oversight process. An􀆟cipated Date of Comple􀆟on: 6/30/2026 Name of Contact Person: Dr. Stephen Johns, Co-Interim Assistant Superintendent

Cash Management Planned Corrective Action: The reconciliation process will be reviewed and any deficiencies will be corrected to assure funding is drawn and disbursed within three days of receipt. Student disbursement reports will be reviewed to determine drawdown amounts before making draws from G5. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

Contact Information: Sharon Hunt, Interim Chief Financial Officer, Dallam Hartley Counties Hospital District Audit Finding Reference Number: 2023-003 Planned Corrective Action: DHCHD has contracted with another payroll provider. Human Resources staff will work with the payroll provider to ensure that appropriate documentation regarding pay amounts and other essential payroll and personnel data is maintained on each employee. Anticipated Completion Date: Completed as of October 1, 2024

I. VIA HOPE 2023 MANAGEMENT CORRECTIVE ACTION PLAN: ► BACKGROUND: CONTINUATION, ADDRESS MULTI-YEAR FRAUD: STRENGTHEN INTERNAL CONTROLS: Management and staff continue to work with the insurance carrier and local law enforcement agencies to restore funds and strengthen its internal controls. ► Update: History and Board Actions: In FY 2021, Via Hope experienced a significant loss of revenue due to the ending of contracts from its two primary funding streams – the Health and Human Services Commission and the Hogg Foundation for Mental Health. This loss of revenue resulted in the Board recommending and approving the reduction of staff and the departure of the CEO. In FY 2022, the Board recommended and approved the termination of its Accounts Manager and the former Board Chairman stepped in to voluntarily manage the finances until the organization could make other arrangements. The former chairman stepped down from his role and an election of officers was held to install a new Chair. By January 2022, with new revenue coming into the organization, the Board selected a new CEO and in December 2022, a new accounts manager was hired. Once the new accounts manager began reconciling the accounts, a pattern of questionable expenditures became evident with PayPal and other accounts. The CEO and staff informed the Board of what appeared to have happened and recognizing its fiduciary responsibility, the Board approved the engagement of a forensic audit by an external audit firm, The Wesley Peachtree Group (WPG) of Atlanta, Georgia. The forensic audit resulted in findings that fraudulent activity in the amount of $233,000 was likely to have occurred. As a result, the CEO was instructed to file an insurance claim with Frost Insurance. To process the claim, Frost required the involvement of law enforcement which was approved by the Board. Formal investigations were launched and remain ongoing with the Austin Police Department and the Travis County District Attorney's office. Recently, law enforcement met with the Board and provided an update on the investigation. Subsequently, the CEO was requested to follow up with the insurance carrier and state regulatory agencies to ensure the prompt receipt of its insurance claim from PayPal and other potential sources. II. FINDINGS AND RECOMMENDATIONS: Finding 2023-001 - Internal Control Deficiencies (Material Weakness) a) Time and Effort, Payroll and Human Resource Forms and Contracts - In response to the finding, Management will require monthly Time and Effort reports for each employee, develop new human resource forms, and update staff contracts at the beginning of the fiscal year. b) Drawdowns and Written Approvals - With the addition of the new Finance staff member in January 2025, management will initiate a written approval process. All payroll adjustments, drawdowns, credit card purchases, and payments will require invoices, receipts, and written approvals before payment is made. The Accounting Manager will also work with the CEO to ensure that staff provide receipts promptly and that journal entries are recorded on a monthly basis. c) Receipts, Written Approvals, PP&E Schedule - Receipts and written approvals were addressed in Response (C). While the organization maintains an equipment log, we will establish a formal Property, Plant, and Equipment Schedule (PP&E), particularly noting equipment purchased with federal funds. d) Segregation of Duties - Management has begun the process of interviewing qualified staff to segregate duties in the Finance office. This will ensure that one individual will no longer be responsible for handling funds, payments, reconciliations, and General Ledger (GL) postings. The individual will be in place by January 2025.

2023-011 Excess Food Service Fund Balance (Material Weakness) Management’s Response: We completed and Excess Balance Use of Funds report and worked with the State to understand exactly the parameters of this/ The funds were spent down and we are working hard to make sure to stay under the three months of expenses as worded in CFR Title 7, 210.14(b). Again management is trying to take on a bigger role as this monitoring was not considered prior to COVID. Fund Balances at year end averaged no more than $10,000. Name of Contact Person and Completion Date: Toni Butterfield Anticipated Completion Date - Immediately

Finding Number: 2023-005 Finding Title: Reporting – PR29 – CDBG Cash on Hand Quarterly and Federal Funding and Accountability and Transparency Act Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Max Holdhusen, Deputy Director of Community and Economic Development Corrective Action Planned: 1) Ramsey County will implement internal procedures to complete PR29 quarterly reports as required by HUD and ensure the correct accounting basis and accounts are being utilized. 2) Ramsey County will implement procedures to complete reports on FSRS required by FFATA. 3) Ramsey County will develop/update our agency’s written grants administration policies and procedures to align with current practices and applicable rules. 4) Ramsey County will conduct regular trainings of policies and procedures for staff involved with CDBG grants administration. Anticipated Completion Date: July 15, 2025

Child Nutrition – Report Testing Recommendation: We recommend that the District reviews its procedures and controls over reporting for the Child Nutrition Cluster program to ensure all reports are accurately reporting information and are reviewed by someone other than the preparer and that review is documented prior to submission of the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will review its procedures over its reporting of claims to MDE to ensure claims made to MDE is properly supported by the District's meals count. Name(s) of the contact person(s) responsible for corrective action: Tariro Chapinduka, Director of Business Services Planned completion date for corrective action plan: June 30, 2025

As noted in the finding, the significant staff turnover and financial constraints during the audit period caused some disruption in our ability to provide the necessary documentation for certain transactions. In light of this, we have developed and implemented a corrective action plan to ensure full compliance with 2 CFR 200, grant agreements, and cost principles going forward. 1. Strengthening Documentation Procedures: o Community Resource Center, Inc. has committed to implementing a process in which all transactions will be supported by actual invoices and all reimbursement requests will be submitted with corresponding supporting documentation. This will include both the original invoices and any other necessary backup materials. o Community Resource Center, Inc. is working with a financial consultant (start date on November 1, 2024), to audit and refine the financial systems, with particular emphasis on improving the accuracy and transparency of our documentation processes. The financial consultant will also assist in ensuring that all future costs align with the requirements of the funding agency and the OMB guidelines. 2. Review and Update of Internal Controls: o In response to the finding, Community Resource Center, Inc. has begun revising internal controls to ensure that adequate checks and balances are in place, especially in times of staff turnover. This includes designing more robust systems for tracking and documenting all costs related to grants, ensuring that all documentation is easily accessible for audit and review purposes. o A dedicated team will be assigned to monitor compliance with the internal control processes, and we will conduct regular internal reviews to verify that supporting documentation for all transactions is complete, timely, and accurate. 3. Contingency Planning for Staff Turnover: o Recognizing the impact of turnover, Community Resource Center, Inc. is formalizing a contingency plan for future staff changes. This plan will include clear guidance on the retention and transfer of all financial records, as well as designating backup staff with sufficient training and authority to oversee and maintain compliance with all financial requirements. We will also implement cross-training for key financial personnel to ensure continuity and consistency in the event of unexpected departures. 4. Ongoing Staff Training: o Community Resource Center, Inc. is committed to providing ongoing training to staff responsible for financial reporting and compliance. This will ensure that all staff involved in grant transactions understand the requirements set forth in 2 CFR 200 and other applicable regulations. Community Resource Center, Inc. will also work with the financial consultant to identify and address any skill gaps within the team. 5. Monitoring and Audit of Corrective Actions: o Community Resource Center, Inc. will establish regular internal monitoring and audits of these corrective actions to ensure they are being followed effectively. This will include periodic spot-checks of transaction documentation to ensure completeness and accuracy, as well as regular reviews of our internal controls and procedures to ensure their ongoing effectiveness.

NIYC has developed new policies and procedures around the requests for reimbursement from federal grantors. This will ensure that all requests for reimbursement are reviewed and approved before the request is submitted. It further requires sufficient supporting documentation for each request to be attached to aid in review and documentation.

Condition: As a result of transition in the finance department and lack of formal filing procedures, we noted an instance in which the support for a portion of an authorized voucher could not be located. Corrective Action Taken or Planned: In conjunction with the hiring of a professional services firm for accounting and finance support, PHIMC will evaluate current record keeping system and ensure supporting information for submitted vouchers is maintained and accessible. Anticipated Date of Completion: December 31, 2025 Name of Contact Person: Karen Reitan, President and Chief Executive Officer Management Response: Management concurs with the finding.

We concur with the auditor's findings. We submitted the annual financial report during the period expense reimbursement was received instead of submitting it for the budget periods that ended. We are developing and implementing a grant reporting calendar listing federal financial report (FFR) due dates for all federal grants. We will use the automated alerts from the grants management system to track and remind staff of upcoming reporting deadlines. Lastly, we will maintain audit-ready documentation of each FFR submission.

FINDING 2023-009 Finding Subject: Child Nutrition Cluster – Non-Profit School Food Service Accounts Summary of Finding: Receipts for the grant were posted to the ledger by one individual without an oversight or review process in place to ensure the remitter, amount, fund, and receipt classification were accurate. Additionally, the same individual received the ACH notifications when monies from monthly meal reimbursements were credited to the School Corporation's bank account and performed the bank reconciliations. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Food Service Director and Business Manager hold a monthly financial meeting to review the food service finances. A report listing all receipts for the previous month to the food service fund will be reviewed at this meeting. This item will be added to the agenda. Anticipated Completion Date: March 31, 2024

FINDING 2023-007 Finding Subject: Child Nutrition Cluster - Reporting Summary of Finding: Monthly reimbursement claims for breakfast and lunch meals served are prepared and submitted without documented review or approval by a second individual not involved in the preparation of the reimbursement claim. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will calculate the monthly claims to be submitted to the DOE/CNP and email this information to the Business Manager for review before submittal. Anticipated Completion Date: March 31, 2024

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation stated that 100% of Free/Reduced lunch applications were reviewed during the audit period. However, testing of controls indicated that 100% of Free/Reduced lunch applications were not being reviewed by an individual other than the individual making the initial determination. As a result, three of forty sampled students received the incorrect eligibility status in the system software when compared to supporting documentation (Direct Certifications and/or income-based applications). Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently all income based applications for free/reduced lunch status are processed by Pam Frost and then reviewed by the Business Manager. Beginning in the 2024-2025 school year Direct Certification students will also be reviewed by the Business Manager. Anticipated Completion Date: August 31, 2024

FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Business Manager and Food Service Director hold a monthly financial meeting to review the status of finances for the Food Service. A review of the payroll distribution reports for the previous month will be added to the agenda of this meeting. Anticipated Completion Date: March 31, 2024

Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all draw down requests are reviewed and approved to ensure costs were accurately reported and paid before requesting reimbursement. Grantee Response and Corrective Action Plan 2023-001: We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. Previously draw down documentation was uploaded to a shared folder, in which the CEO and Fiscal Manager had access. In 2024, we implemented additional procedures to document review of drawdowns and supporting documentation. Additionally, documentation includes attaining the CEO signature on draw down documentation before the draw down is made. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

Plan of Action: A New Cash Management Procedure was implemented on 5/5/24. We have also developed a tracking system in Microsoft Forms for the Project Director or Authorizing Officer to request and approve funds.

We will reconcile all of 2024 accounts to ensure accuracy. Expenditure and reimbursement of all federal funds will be recorded timely and accurately.

Finding Reference Number: 2023-002 Description of Finding: The security deposits, residual receipts, and replacement reserve were not properly established in separate bank accounts, and the required monthly deposits to the replacement reserve were not made. Statement of Concurrence or Nonconcurrence: Management agrees with this finding. Corrective Action: Management has set up separate bank accounts and continues to make the required deposits. Name of Contact Person: Kimalee Williams, CEO - Faith Asset Management, LLC, (860) 528-5000, kimalee@faithassetmgt.com Projected Completion Date: December 15, 2024

COVID-1 9 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21 .027 Recommendation: We recommend the District design controls to ensure an adequate review process over the invoices recorded and presented on the schedule of expenditures of federal awards to determine compliance with the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District’s policies will be updated and approved if needed to conform to federal guidance. Name(s) of the contact person(s) responsible for corrective action: Ron McEachern, General Manager or Delia Stoor, Accounting Manger Planned completion date for corrective action plan: September 30, 2024

Name of Contact Person: Veronica Williams, Interim Executive DirectorCorrective Action:KHMA’s Board has approved new written policies and procedures and are in place now.Appropriate staff have begun taking proper safeguards for Capital Fund Program management to ensure proper accountability. This includes the oversight of processing payments of CFP expenditures, which includes the following procedures for: 1) payment of invoices; 2) requisition of funds; 3) monitoring; and 4) reporting of CFP funds.payment of InvoicesAll CFP invoices will be reviewed and clearly marked as approved and documented to show that the source of funds for payment are CFP grant funds by the Executive Director prior to payment. The Executive Director will specify the general ledger code, including the BLI account to be used for payment processing on the invoice before providing the invoice to the accounts payable clerk.Under no circumstances will a payment be made if KMHA has not drawdown and received the respective CFP funds.With the exception of funds associated with BLI 1406 “Operations”, PHAs have three (3) business days to issue and mail the check once the CFP funds are received.The Executive Director/accounts payable clerk will specify the BLI account and CFP grant year on the check voucher prior to sending the check voucher to the fee accountant for financial statement processing.Requisition of FundsFor each drawdown, the Executive Director will print the associated eLOCCS Voucher Payment form from the eLOCCS system.The Executive Director will document the check number(s) and vendor(s) associated with each CFP draw (i.e., the eLOCCS Voucher Payment form). In addition, each individual draw shall be numbered for reference purposes.A copy of each draw shall be submitted to the fee accountant to ensure proper reporting of the grant drawdown.With the exception of funds associated with BLI 1406 “Operations”, in no case shall a draw be made without the proper approved invoices.MonitoringThe fee accountant's monthly financial statements will include a CFP report for each grant which will be reviewed by the Executive Director for proper coding and accuracy.Folder has been created to track all required information in the management of a CFP grant to include correspondence to and from HUD, expenses, grant reimbursements, budgets, closeout documentation and EPIC management.Proposed Completion Date: Immediately

Management agrees with the finding and has developed and implemented the appropriate policies and procedures effective September 2024.

In alignment with this audit finding, Illuminate Colorado has implemented processes to improve working capital and address cash flow challenges, including:  improved invoicing procedures to ensure timely submission of invoices to minimize time elapsed between submission of invoices to funders and reimbursement of those invoices, and  seeking increased working capital via a larger line of credit or other source (foundation, corporate, or individual donations) In addition, Illuminate Colorado is in process of developing a Standard Operating Procedure to ensure consistent identification of vendors utilized for direct Federal assistance programs in order to prioritize payment of those vendors with federal drawdown receipts. Standard Operating Procedure will include:  Process to identify vendors paid with federal funds  Process to monitor invoice timelines of vendors paid with federal funds  Process to prioritize payments of vendors paid with federal funds following federal drawdowns  Process for internal review of payment timelines

Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: Management was unable to reproduce a detailed listing of expenses incurred that agreed to the amounts submitted under the federal award for reimbursement. Planned Corrective Action: Management agrees with the finding and will review its policies and procedures to ensure that a detailed listing of expenses submitted for reimbursement is maintained. Planned Completion Date: Ongoing Person Responsible: Mary Young, Director of Operations

2023‐009 Reporting Annual Project and Expenditures Report (Material Weakness): The City did complete the Project and Expenditures Report but just not timely as a result of staff turnover during the actual fiscal year. Since taking office in fiscal year 2024, the current Finance Director has prioritized compliance with federal reporting requirements. As of fiscal year 2025, all required project and expenditures reporting has been completed and submitted in accordance with U.S. Department of Treasury guidelines. To prevent future occurrences, the Finance Department has implemented internal controls ensuring multiple staff members are responsible for federal reporting. Specifically, both the Finance Director and the Financial Analyst now share the responsibility and authority to complete and submit these annual reports. This new process ensures continuity in reporting, even in the event of staff turnover, and strengthens the City’s commitment to compliance with federal funding requirements. In addition, The City’s Procurement officer now maintains responsibility for grants from award to reversion date. A tracking file is maintained for all active grants at the point it is awarded, expended, and reimbursement received to ensure this process is properly managed. Additionally, the Finance Director oversees this responsibility so there are now multiple controls to ensure timely completion.