Corrective Action Plans

Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time that adequate staffing for review is in place, a member of management or their designee will review claims.

1. Enhance Document Retention Procedures: *We will update our document retention policy to clearly define retention periods for payroll-related records, ensuring compliance with legal and regulatory requirements. This will include retaining all necessary documentation such as payroll reports, tax filings, and third-party payroll contracts. *A secure, organized system will be implemented for storing payroll-related documents, whether physical or digital. This will include utilizing secure cloud storage or an enterprise document management system with restricted access controls. *We will conduct a quarterly review to ensure that documents are being retained for the appropriate time frame and securely disposed of when no longer required. 2. Implement Stronger Controls During Payroll Provider Transitions: *We will formalize and document the process for changing third-party payroll providers. This process will include detailed steps for due diligence, transition planning, data transfer procedures, and ensuring continuous payroll processing during the transition period. *A project team will be assigned for every payroll provider change to ensure proper planning, including backup and contingency plans, data verification, and communication with both internal and external stakeholders. *A comprehensive review of the transition will be conducted after each change, including a reconciliation of payroll records to ensure that all data is accurately transferred, and all systems are functioning properly. 3. Vendor Oversight and Service Level Agreements (SLAs): *We will ensure that future contracts with third-party payroll providers include clear Service Level Agreements (SLAs) outlining the provider's responsibilities in terms of document retention, data security, and transition procedures. This will ensure that providers maintain the necessary standards and practices for managing payroll-related documents.

Condition: During the audit it was noted that, in most of the instances, employee timecards were missing. Plan: The Club will review their monitoring procedures to ensure consistent retention of employee timecards. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Contact Person: Germain Castellanos, CEO Management Response: Since the audit, we have reviewed our monitoring procedures to ensure consistent approval of employees timecards.

Condition: During the audit it was noted that there were twenty-three individuals who did not have documentation of the correct wage that was used on the grant expenditure report. The Club also does not keep any copies of the invoices to back up which expenses are allocated to the grant. Plan: The Club plans to review the issue with its current procedures and revise them as necessary to provide better controls over grant expenditures. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Contact Person: Germain Castellanos, CEO Management Response: Since the audit, we have started to keep the documentation for each salary increase and review in the employee’s personnel files and the supplies that have been purchased.

Condition: During the audit it was noted that instances of wages submitted for reimbursement for two Club employees were more than gross wages that should have been assigned to the grant based on the amount of the paycheck and the percentage allocation. Plan: The Club plans to review the issue with its current procedures and revise them as necessary to provide better controls over grant expenditures. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Contact Person: Germain Castellanos, CEO Management Response: Since the audit, we have evaluated our procedures related to grant reimbursement requests review and we are working on improving our current procedures.

Views of Responsible Officials: SAMU management has ordered that all SAMU staff that corresponds with grantor personnel has to document such correspondence via emails or other means the afreed procedures including those of delayed submission of drawdowns.

Effective October 1, 2023, management implemented extensive accounting and documentation controls to ensure full accounting and reporting compliance on direct costs incurred for all federal grants and expenditures. These controls are reviewed and monitored for compliance by management on a periodic basis during the year.

Finding Number: 2023-003 Allowable Costs; Cash Management (Material Weakness) Programs: Unaccompanied Alien Children Program ALN#93.676 Contract#: 90ZU0323 & 90ZU0548 Contract Period: 07/01/22 - 06/30/23 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. A parallel review of employee setups in ADP, our payroll system, led to the reassignment of staff to appropriate cost centers as needed. Going forward, ADP cost center assignments will be reviewed monthly to reflect any departmental changes. These steps are expected to reduce manual adjustments, improve the accuracy of interim financials, and ensure more precise federal and program drawdowns. Additionally, OTPS expenses have been charged directly or allocated to the appropriate cost centers on a monthly basis since the start of FY 2025. Person Responsible: The Executive Director and Chief Financial Officer Completion Date: April 30, 2025

Federal Award Findings Finding 2023-001 Lack of Internal Controls Over Cash Management Name of Contact Person: Galen Gilbert, First Chief Corrective Action Plan: AVC staff were unable to complete a drawdown for the HUD grants due to a change in staff. AVC is working with HUD to resolve the matter. AVC staff is currently drawing down all other funds in a timely matter. AVC has limited unrestricted cash. AVC is currently looking for opportunities to increase unrestricted cash, such as increasing prices for gas and electric. Proposed Completion Date: July 31, 2024

Material Weakness in Compliance and Internal Control over Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence is retained by ICEDC as proof of oversight of expenditure of federal funds. Additionally, we recommend adding a review and approval process for the ED’s timesheets. There is no disagreement with the audit finding. Action taken in response to finding: ICEDC appreciates CLA’s recommendation to enhance processes concerning the retention of documentary evidence of approvals and importance of maintaining strong oversight of expenditures, especially when handling federal funds. ICEDC will place greater emphasis on obtaining and retaining documentation of approvals related to the expenditure of funds. This documentation will serve as proof of oversight, ensuring compliance with federal regulations and enhancing transparency in fund management. A formal review and approval process will be established for the Executive Director's (ED’s) timesheets. This process will involve periodic reviews by a designated authority and documentation will be retained to maintain a clear audit trail. Name(s) of the contact person(s) responsible for corrective action: Kristina Hines Planned completion date for corrective action plan: 8/31/2025

Corrective Action: The Organization has plans to transition to a new digital software to electronically receive meal counts

Public Health’s Office of AIDS (OA) agrees with the finding and recommendation. OA introduced and fully implemented an internal Secondary Review (SR) process for all AIDS Drug Assistance Program (ADAP) applications in March 2018. This SR process enables ADAP staff to verify that contracted and certified enrollment workers across California are consistently adhering to eligibility and documentation requirements. However, due to staffing challenges caused by the redirection of staff during the state of emergency declared for the COVID-19 pandemic, ADAP faced significant workforce shortages from March 2020 through much of 2023. This caused a backlog in SR processing, which delayed tasks, including the review of this client’s application. The client’s eligibility lapsed after 130 days, before SR could be conducted. The Eligibility Operations Section (EOS) of ADAP which conducts SR, is now fully staffed and has successfully addressed the backlog. As of early 2024, SR processing has returned to normal operations and is current. Estimated Implementation Date: Already implemented as of April 2024 Contact: Joseph Lagrama, ADAP Branch Chief California Department of Public Health

DHCS implemented a process to impose payment withholds for significantly late cost reports, which addresses CSA’s recommendations. As of January 1, 2025, DHCS has issued 26 Notices of Delinquency to contracted counties of Short-Doyle funding (two notices for FY 2015-16, four notices for FY 2016-17, one notice for FY 2018-19, three notices for FY 2019-20, six notices for FY 2020-21, and ten notices for FY 2021-22). DHCS has received positive responses from some of the delinquent counties, stating the cost reports should be submitted shortly. If the counties do not submit their cost reports within 30 calendar days of the delinquency notice, DHCS will send a Notice of Intent to Impose Temporary Withhold of Funds with an option to meet and confer. If a county still has not submitted its cost report within 30 calendar days after Notice of Intent to Impose Temporary Withhold of Funds, the county will be put on Final Notice of Intent to Impose Temporary Withhold of Funds with an effective date of 30 days, at which time a withhold of funds will be processed. Estimated Implementation Date: January 1, 2025 Contact: California Department of Health Care Services • Primary – Ryan Whalen, Behavioral Health Interim Settlement, Section Chief, Audit & Investigations (A&I) Financial Review Outpatient and Behavioral Health Division (FROBHD) • Secondary – Lisa Alder, Behavioral Health Financial Review, Branch Chief, A&I FROBHD • Tertiary – Charles Anders, Behavioral Health Financing Branch, Chief, Local Governmental Financing Division (LGFD)

Allowable Costs Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure the draw down requests and related support are formally reviewed and approved by the Executive Director for allowability before submitting the request to the awarding agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization will put a formal layer of review after preparation of the draw down request and support and before submission to the awarding agency and make sure the approved support is kept on file. Name of the contact person responsible for corrective action: Megan Mattimoe, Executive Director Planned completion date for corrective action plan: June 1, 2025

Cash Management Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure the draw down requests and related support are formally reviewed and approved by the Executive Director before submitting the request to the awarding agency and that the support is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization will put a formal layer of review after preparation of the draw down request and support and before submission to the awarding agency and make sure the approved support is kept on file. Name of the contact person responsible for corrective action: Megan Mattimoe, Executive Director Planned completion date for corrective action plan: June 1, 2025

Criteria: CODE OF FEDERAL REGULATIONS, Title 49 – TRANSPORTATION, Part 18 – UNIFORM ADMINISTRATIVE REQUIREMENTS FOR GRANTS AND COOPERATIVE AGREEMENTS TO STATE AND LOCAL GOVERNMENTS, Subpart C – Post-Award Requirements: 18.41 Financial Report (a) General (4), Due date. When reports are required on a quarterly or semiannual basis, they will be due 30 days after the reporting period. When required on an annual basis, they will be due 90 days after the grant year. Final reports will be due 90 days after the expiration or termination of grant support. 18.58 (a) General. The Federal agency will close out the award when it determines that all applicable administrative actions and all required work of the grant has been completed. 18.50 (b) Reports. Within 90 days after the expiration or termination of the grant, the grantee must submit all financial, performance, and other reports required as a condition of the grant. Upon request by the grantee, Federal agencies may extend this time frame. These may include but are not limited to: (1) Final performance or progress report, (2) Financial Status Report (SF 269) or Outlay Report and Request for Reimbursement for Construction Programs (SF-271) (as applicable), (3) Final request for payment (SF-270) (if applicable), and (4) Invention disclosure (if applicable). U.S. OFFICE OF MANAGEMENT AND BUDGET CIRCULAR A-133—AUDITS OF STATES, LOCAL GOVERNMENTS, AND NON-PROFIT ORGANIZATIONS (OMB Circular A-133), Subpart C— Auditees, Section .300—Auditee Responsibilities (b) Maintain internal control over federal programs that provides reasonable assurance that the auditee is managing federal awards in compliance with laws, regulations, and the provisions of contracts or grant agreements that could have a material effect on each of its federal programs. Condition: For the Airport Improvement Program (AIP), the City did not submit the reports within the required deadline: Report Type Award Number Period Date Due Date Submitted SF-425 Financial 3-06-0034-018-2020 1/1/2022 - 12/31/2022 12/31/2022 Not submitted SF-270 Financial 3-06-0034-018-2020 1/1/2022 - 12/31/2022 12/31/2022 Not submitted FAA Form 5370-1 3-06-0034-018-2020 7/1/2022 - 9/30/2022 10/30/2022 Not submitted FAA Form 5370-1 3-06-0034-018-2020 10/1/2022 - 12/31/2022 1/30/2023 Not submitted FAA Form 5370-1 3-06-0034-018-2020 1/1/2023 - 3/31/2023 4/30/2023 Not submitted FAA Form 5370-1 3-06-0034-018-2020 4/1/2023 - 6/30/2023 7/30/2023 Not submitted Four (4) financial reports were tested and all reports were not submitted by the required deadline. Corrective Action Plan: City management concurs with the auditor’s comments and recommendations. The City will take steps to improve identification and monitoring of required grantor reporting deadlines. Anticipated Completion date: June 30, 2024 Name of Contact Person: Michael Lima, Director of Finance

Condition: The Organization did not have appropriate segregation of duties surrounding the preparation and review of the monthly NIST schedules which accumulate the information necessary to calculate allowable costs and matching for drawdown requests. Further, while the Organization had written procedures over cash management, they were outdated and did not reflect the current staffing model. Planned Corrective Action: Subsequent to year end, the reorganized finance team put new controls and procedures in place. Moving forward the Accounting Supervisor will calculate the NIST MEP monthly program income which is used to determine the monthly award drawdown of cash from the available grant award funds. This is reviewed by the Controller and this report is used to create SF-425. Contact person responsible for corrective action: Alan Kowalewski, Controller Anticipated Completion Date: 07/01/24

Condition: A process was not in place during the year to ensure program income was reported accurately on the SF-425 reports submitted during the year. Planned Corrective Action: Subsequent to year end, the reorganized finance team performed a recalculation and resubmitted corrected SF-425 reports. Moving forward the Accounting Supervisor will calculate the NIST MEP monthly program income which is used to determine the monthly award drawdown of cash from the available grant award funds. This is reviewed by the Controller and this report is used to create SF-425. Contact person responsible for corrective action: Alan Kowalewski, Controller Anticipated Completion Date: 07/01/2024

Instructions were given to the Program staff to ensure that the program income funds will be used for CDBG activities before the withdrawal of CDBG funds.

2022-001: Segregation of Duties Name of contact person: Stacey Holbrook, Executive Director Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregating certain duties is not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.

Uniform Guidance Corrective Action Plan Year ended June 30, 2023 Federal Finding #2023-001 Returns of Title IV funds are required to be deposited or transferred into the student financial assistance account or electronic fund transfers initiated to the Department of Education as soon as possible, but no later than 45 days after the date the institution determines the student withdrew. Quinnipiac University agrees with the finding. For one student who withdrew during the 2022 – 2023 academic year, the Pell funds awarded to that student were not returned to the student financial assistance account within 45 days after the University determined the student withdrew. As a result of this finding, Management has implemented additional steps within the reconciliation process of Title IV awards in order to prioritize the return of any unearned Title IV awards so that they are remitted to the student financial assistance account in a timely manner. If the Office of Management and Budget have questions regarding this plan, please reach out to Stephen Allegretto, the Associate Vice President for Finance and Controller, who is responsible for ensuring this corrective action plan is implemented, at 203-582-7962.

Finding Number: 2023-005 Finding Title: Local Collaborative Time Study (LCTS) Reporting (Cost Schedules DHS-3220) Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Matthew Huddleston, County Administrator Corrective Action Planned: Lake County Public Health and Human Services, acting as the Local Collaborative Time Study Fiscal Reporting and Payment agent, has implemented a process to receive and review all quarterly reports made by collaborative partners to DHS to ensure accurate program reimbursement. Anticipated Completion Date: 12-31-2024

Management is aware of the difficulties relating to the 2023 audit process and has brought in a new finance director as well as a consultant to properly identify expenditures in the general ledger/accounting system that correspond with each drawdown request that occurred during 2024 and forward.

January 6, 2025 The Blackstone – Millville Regional School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Robert E. Brown II, CPA Certified Public Accountant 25 Cemetery Street P.O. Box 230 Mendon, Massachusetts 01756 Audit period: The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule of expenditures of federal awards. Finding 2023-001 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Program Criteria: Grantees must provide reasonable assurance that federal awards are expended only for allowable activities and that the costs of goods and services charged to federal awards are allowable and in accordance with the applicable cost principles. Management of the District is also responsible for establishing and maintaining effective internal control over compliance with federal requirements that have a direct and material effect on a federal program. A deficiency in internal control over compliance exists when the design or operation of a control over compliance does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, noncompliance with a type of compliance requirement of a federal program on a timely basis. Condition and Context: Control deficiencies related to disbursements were noted as a result of the testing of internal controls over payroll. Specifically, a sample of payroll disbursements charged to the major program were tested in order to determine if adequate internal controls were in place. As a result of the testing of payroll disbursements charged to the programs, the employees tested were found to not have adequately approved and or documented employee payroll rate agreements. Cause: BMR experienced limited oversight of detailed financial activities due to the ongoing search for an experienced Director of Finance and Operations. While general budgetary oversight was maintained to ensure the district's overall fiscal health, detailed financial oversight was insufficient during this period. Effect or Potential Effect: Due to the significant deficiencies and noncompliance in internal controls noted above, there is a risk of inappropriate rate of pay and/or wages being paid. Identification as a Repeat Finding: N/A Questioned Costs: Questioned costs could not be determined. Recommendation: The Blackstone – Millville Regional School District should improve the internal controls over Activities Allowed/Allowable Costs by ensuring employee’s payroll rate agreements are approved by an appropriate level of management and in a timely manner. Managements Response: Due to the timing of the grant, we implemented several internal controls beginning at the start of fiscal year 2025 to address the identified findings. Payroll accounts are now reviewed on an ongoing basis to ensure proper coding and accuracy. Additionally, the Grants Manager conducts consistent reviews of expenditures charged to grants to confirm that all costs are allowable under the respective grant guidelines. This review process ensures that any reimbursement requests for expenditures align properly with grant requirements. As part of these reviews, we also verify and confirm the rates used to ensure they comply with the terms of the approved grant funding. These measures, initiated at the beginning of fiscal year 2025, collectively strengthen our internal controls, enhance compliance, and improve the overall accuracy of our financial practices. Responsible for Corrective Plan: Director of Finance and Operations Estimated Completion Date: Beginning of fiscal year 2025 Action Taken: See management response for details of action taken

The enhanced reconciliation process noted above for the Correction Action for Finding 2023-003 will determine the amount of financial aid awarded during the month. Based on the amount awarded, the College will then draw down the amount awarded. Manor believes the monthly reconcilation and drawdown process being implemented by Manor personnel will minimize the risk that student financial aid funds are overdrawn.