Corrective Action Plans

Activities Allowed or Unallowed, Allowable Cost/Cost Principles, and Reporting Finding 2023-003 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: activities. The Authority claimed expenses attributable to coronavirus but did not reduce such expense by the amounts Medicare reimburses or is obligated to reimburse the Authority. Corrective Action Plan: The Authority has enhanced the internal controls to ensure underlying supporting records agree to the final reports submitted to HHS, including a review and approval by someone different than the individual inputting the report data. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: May 2024

inding 2023-007: lnterfund Balance Corrective Action: The software conversion to PHA-Web caused tremendous confusion and along with the inexperience of the prior fee accountants. This will be researched and corrected during FY 2024. Date Due: 6/30/2024 Person Responsible: Angela Farrish

The Organization has implemented a reivew of summary reimbursement reports

The Sr. Accounting Manager who oversees the requests for reimbursement process will discuss the finding with the team and emphasize the importance of retaining evidence of approval consistently. All requests for reimbursement from FY2024 will be reviewed to ensure they were approved and that the evidence of approval is properly retained. The target completion date of this correction action is September 30, 2024. The contact person for the corrective action is Debra St. Onge, Sr. Accounting Manager.

2023-004 U.S. Department of Education, Assistance Listing Number 84.425 – Education Stabilization Fund Condition: A portion of the grant expenditures claimed under this grant have been claimed twice. Questioned Costs: $9,275 Criteria: A reconciliation of the District’s grant project detail to the grant claims should be performed. Supporting documentation should be maintained with grant claims. Cause: The grant expenditures claimed were not reconciled so some expenditures were reimbursed twice. Effect: Excess reimbursement amounts requested may be disallowed and be returned to the federal agency. Auditor’s Recommendation: We recommend that the District reconcile grant claims with the general ledger. Grantee Response: The District will reconcile grant claims with the general ledger as recommended by the auditor. Contact Person: Jessica Lien Anticipated Completion: June 30, 2024

The District will utilize DESE's Federal & State Grant Manual document as a guide to ensure compliance with grant management.

Finding Summary: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023. Responsible Individuals: Andre Stringfellow, CFO Corrective Action Plan: Management has contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of grant‐related expenditures. Also, the Organization is in the process of creating the administrative infrastructure which includes new staff, new workflow and processes that are designed to report grant activity monthly which includes the timely submission of all grant related reports Anticipated Completion Date: August 2024

Personnel Responsible for the Corrective Action: Steven Rosenzweig, Chief Financial Officer Anticipated Completion Date: Periodically throughout the next federal grant program, prior to each drawdown request Corrective Action Plan: Senior leadership will work with the grant manager to review the federal grant program expenditures periodically during the grant period, in order to determine the appropriate corresponding grant drawdown requests. Written documentation of these reviews and approvals of the periodic drawdown requests will be maintained.

Findings – Federal Award Programs Audit Department of Agriculture 2023-001 Child Nutrition Cluster Program Deficiencies: See Finding 2023-001 Recommendation: Machne Rav Tov will ensure that meal counters are present at the start of each meal service. All required records will be maintained and posted as necessary. The Organization will have proper site supervision during meal services to ensure that meals are served at the approved time, consist of all required components, and are consumed on site. Action Taken: Since the date of the exit conference, we have implemented the above-mentioned comprehensive plan of corrective action. Mrs. Rotenberg, the site supervisor, is designated as being responsible to ensure timely and efficient meal service, and consumption of meals on site. Meal servers will receive relevant training for proper service of meals, including required meal components. An additional site supervisor, Mr. Isaac Ferentz, was hired and trained and will be present on site before the start of each meal time. The supervisors will ensure that meal pattern requirements are met and proper meal counts and food safety procedures are followed. Mrs. M. Stasel is designated as overseeing proper meal counting. Click counters will be used for accurate counting and documenting. Additional training was given to all SFSP staff. We have designated Mr. Hershey Rosenberg as being responsible to oversee the implementation of our plan of corrective action for these findings. Completion Date: May 21, 2024

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University has formalized and documented financial processes to establish internal controls in order to ensure accurate, timely and consistent reporting. In addition, this has created a reasonable transition plan during employee turnover, as well as ensures proper and timely filings. The corrective action involves drawing down the funds from the G5 federal website and issuing refunds to students that day. There is a checks and balance process built in so multiple staff members are involved with the process. The financial aid department calculates the amount of a federal drawdown and relays that information to the business department. The senior accountant draws down the appropriate amount of federal financial aid. The student accounts billing coordinator applies the aid to the various student accounts in the software. After the aid has been applied, the student account billing coordinator determines if a refund is due to the students. Any students that are entitled to a refund will be cut a refund check that day. The students will then have a window of opportunity of to come pick up the refund checks. Within 2 business period, any students who have not picked up their refund checks will have them mailed to their address on file with the University. This process has been developed to ensure that students receive their refunds in a timely and accurate manner. Anticipated Completion Date: A new process has been in place Since February 2024 and is ongoing.

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the internal controls surrounding the cash management of the Federal Research and Development Programs was not in compliance for federal standards. The University is in the process of enhancing the internal controls and cash management procedures to prevent this from happening in the future. Going forward all federal grant funds that are allocated for the Challenger Learning Center will go directly into the appropriate bank account and will be drawn down and spent in the correct time frame. When operating expenses are incurred for the Challenger Learning Center the payment will be processed from the University’s general checking and the federal grant funds will reimburse the University that day. The same is also true for the payroll expenses incurred by the Challenger Learning Center. Wages will be paid out of the university’s general checking account and then reimbursed to the university from the bank account that hold the federal grant funds. Anticipated Completion Date: June 2024

As communicated in the District’s response to the prior audit finding, the District does not concur with the SAO’s interpretation of unmet need in the 2021-2022 audit nor does it concur with the same finding for the audit of the 2022-2023 fiscal year. We believe all Chromebook purchases were allowable and devices were only provided to those with an unmet need. We concur with SAO that we did not retain adequate documentation indicating which staff and students received hotspots and appreciate that SAO noted that there was an urgent need to distribute hotspot internet services to students in order that they could participate in remote learning, and that this urgency and extenuating circumstances resulted in this situation. We recognize there was an error associated with vendor credits in the amount of $2,751.10 but did not claim reimbursement for the other credits totaling $8,898.90 as indicated in the audit finding. We will work to improve our process regarding credits on future invoices. The District will continue to work with the FCC to resolve this finding.

Grant Reimbursement Requests (Indirect Costs and Cash Management) Recommendation: We recommend that the Organization follow the current policies and procedures over grant reimbursement transactions to maintain documentation supporting the request. This should include all supporting documentation and back-up, and preparer and reviewer sign-offs and dates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Society was short of trained billing staff due to employee leave and has provided training to additional back-up staff for future use. Name(s) of the contact person(s) responsible for corrective action: Kelly Moritz, Vice President of Finance and Contracts Planned completion date for corrective action plan: December 31, 2024

Finding 2023-003 Corrective Action Plan The College acknowledges that there are unspent funds in this subprogram as of August 31, 2023. The College will return these unspent funds to the U.S. Department of Education before the close of the program’s fiscal quarter. The College’s management notes that these Federal programs have expired and does not anticipate further funding related to the Education Stabilization Fund. Anticipated Completion Date The College anticipates completion of this corrective action on or before July 10, 2024. Name of Contact Person Responsible for Corrective Action Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities

Finding 2023-002 Corrective Action Plan The College acknowledges that funds withdrawn for these subprograms were not disbursed in a timely manner. The College notes that although the funds were disbursed after the period required by the program (within 3 days of withdrawal for non-student aid expenses), the expenses paid were allowable under the guidance of the program. The College’s staff and management developed a checklist in response to Finding 2022-005 from the prior year to ensure that reporting, filing, and disbursement requirements for all grants will be met. The College’s management notes that these Federal programs have expired and does not anticipate further funding related to the Education Stabilization Fund. Anticipated Completion Date The College anticipates completion of this corrective action on or before August 31, 2024. Name of Contact People Responsible for Corrective Action Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Ross Holgado – Manager of Financial Reporting

The District does not concur with the audit finding or the $858,725 of questioned costs. This finding is the same as reported in the 21/22 audit. The District still contends that the costs were allowable. The issues regarding internal controls and reporting were not brought to the District’s attention until 10 months into the 22/23 audit period, leaving no time for discussion or changes in interpretation and process. The audit’s condition states that our internal controls were ineffective for ensuring we requested reimbursement only for students and staff with a documented unmet need and that our internal controls were ineffective for demonstrating per location and per user limitations. Based on guidance from the Federal Communications Commission (excerpted below), the District contends we have spent all funds for allowable costs, that those costs were reasonable and necessary, and for students and staff with unmet needs. Districts were able to determine whether students and staff had unmet needs. For our district this meant addressing instances where students may have shared a home device with other siblings; student or staff devices were too old or slow to function properly when running multiple required applications; and / or student owned devices did not have the appropriate security in place to protect students during remote learning (especially from unauthorized websites). Home drives, where all educational digital resources were stored, couldn’t be accessed unless using a district issued device. Additionally, the district’s technical support could not access personally owned devices to provide for thousands of trouble tickets and support issues students faced during remote learning. Based on these factors, unmet need was defined broadly, but within allowed parameters and inventory records were kept, albeit, not perfectly. Devices for remote learning could also be used at school. During the pandemic in Washington State we experienced times when classrooms, schools and or districts were closed by the health department and state regulations because of outbreaks. Districts had to be prepared to support remote learning each day with constantly changing guidance on who was allowed to be in person. Seattle Public Schools followed guidance from the Federal Communications Commission outlined in a document titled: . “Emergency Connectivity Fund Common Misconceptions”, “Misconception #2: If schools have returned to in-class instruction for the upcoming school year, they are not eligible to participate. Answer: This is false. Equipment and services provided to students or school staff who would otherwise lack sufficient access to connected devices, and/or broadband internet access connection while off campus is eligible for Emergency Connectivity Fund Support.” Additionally, from the Federal Communications Commission Order FCC-CIRC21-93-043021, question 77: “We think schools are in the best position to determine whether their students and staff have devices and broadband services sufficient to meet their remote learning needs, and we recognize that they are making such decisions in the midst of a pandemic. We, therefore, will not impose any specific metrics or process requirements on those determinations.” And from question 51: “…we are sensitive to the need to provide some flexibility during this uncertain time. If those connected devices were purchased for the purpose of providing students…with devices for off-campus use consistent with the rules we adopt today, we will not prohibit such on-campus use.” Finally, SAO did not apply any reasonable measure to reduce questioned costs but did state they know that at least some of the equipment addressed unmet needs, while still choosing to question all costs. That is clearly out of alignment with the FCC guidance. There are no corrective actions to take at this time as the funding source has been exhausted and the timeline has passed.

Corrective Action Plan: We have held recent discussions with the City of Houston regarding the Fiscal Report. As a result, it has been agreed that we will submit the Fiscal Report within the required timeframe. The Home will develop a process to ensure that once the Board of Directors has approved the quarterly financial information, the previously submitted Fiscal Reports will be reviewed for consistency. If differences exist, The Home will submit an amended Fiscal Report to the City of Houston for the applicable quarter. Contact Person Responsible for Corrective Action: Ms. Anna Coffey, Chief Executive Officer. Anticipated Completion Date: This was completed in conjunction with the filing of the Fiscal Report for March 31, 2024.

2023-001 FINDING: Deficit Fund Balances Questioned Costs: None noted. Recommendation: We recommend the School continue to implement their plan to liquidate all remaining debt from the general fund. We also recommend they continue a vigilant oversight of all budgets of the School. Response: The current Business Manager is enforcing the CHS Policies that do not permit expenditures in excess of the approved budget without Board approval. In addition, the current Business Manager does not include any carryover from prior budgets in the existing budget until the audit is completed and the financial statements are reconciled. The Business Manager has restricted use of General Fund revenues to remedy the deficit, including income received by the School that is non-program income, and the School Board is responsible for monitoring expenditures monthly. ANTICIPATED COMPLETION DATE: June 30, 2025 PERSON(S) RESPONSIBLE: Leslie Cuny, Business Manager

Finding 2023-004: 2023-004 - Significant Deficiency in Internal Control over Compliance and Noncompliance – Cash Management Contact: Michael Bailey, Chief Financial Officer Corrective Action Plan: The Accounting department at Alaska Behavioral Health has stabilized staffing in accounting personnel, including the replacement of the Chief Financial Officer. The CFO will develop and maintain a Master Grants tracking system that identifies cumulative allowable expenditures, determining the maximum cash drawdown of Federal Funds for the appropriate reporting time period and assuring that drawdowns are made in a timely manner. Proposed Completion Date: 09/30/2024

The Northeast Texas Public Health District (NET Health) will take steps to ensure overall effective grant monitoring and to increase communications between NET Health Grant Managers and the Chief Financial Officer and Chief Executive Officer. The NET Health Leadership Team will discuss any issues during our weekly Leadership Team meetings to ensure compliance. These weekly meetings will address costs expended within the grant parameters and ensure grant funds will be more evenly expended during the year as appropriate. NET Heatlh will continue to develop effective methods of grant oversight as it finds weaknesses in its processes. To ensure compliance with the period of performance requirements, NET Health will change its processes effectively immediately. Going forward checks will only be prepared, dated, signed, and mailed to vendors after work is completed or items are received. There will be enhanced internal controls by establishing procedures to monitor and ensure timely payment of accrued expenditures, such as regularly accounting for any outstanding checks and actively communicating with vendors on performance requirements. In addition, we will enhance communication and coordination among relevant departments to expedite the payment process while maintaining compliance with grant regulations. George T. Roberts, CEO, and Lawanda Owens, CFO, are the persons responsible for this action plan going forward. NET Health is expected to have this action plan implemented by May 1, 2024.

NCC conducted staff training to reinforce requirements for the return of funds within 240 days for all federal award checks returned uncashed. Effective November 2023, we implemented an automated process to assist with identifying federal funds that need to be returned.

Finding Number: 2023-001 Condition: Two reimbursement requests submitted during 2023 did not have documentation available to indicate that the reimbursement request was reviewed by a supervisor for accuracy before submission. Planned Corrective Action: Staff turnover in early 2023 resulted in a temporary lapse of documentation proving that the internal control process was followed. The Society follows its internal review process and is maintaining documentation that appropriate approvals are in place. Contact person responsible for corrective action: Dharshni Sabapathy, Senior Director of Accounting Anticipated Completion Date: April 25, 2024

CORRECTIVE ACTION FINDING 2023-003 -- CASH MANAGEMENT Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the material weakness identified in our cash management practices related to federal grant programs. To address this, we will enhance internal controls and allocate additional resources to support grant management activities. Improved communication between departments involved in grant management and reducing reliance on interfund borrowings through better cash flow forecasting will be prioritized. Establishing regular monitoring and reporting systems will provide visibility into grant fund status and facilitate smoother accounting processes. These actions aim to strengthen our cash management practices and ensure timely drawdowns and reporting for federal grant programs, ultimately optimizing the utilization of grant funds for program expenditures.

CORRECTIVE ACTION FINDING 2023-002 - TIMELY DRAWDOWN GRANT REIMBURSEMENTS Anticipated Date of Completion: June 1, 2024 Name of Contact Person: Robin Vail, Business Manager Management Response: Management acknowledges the finding regarding delays in performing drawdowns and reporting for federal grant programs. To address this, we will implement a control process for timely drawdowns and reporting, ensuring adequate resource allocation and support for the Business Manager. Responsibilities will be delegated among the business office staff, and regular monthly reports on drawdown status will be provided to enhance transparency and accountability. These actions aim to improve the District's grant administration processes and ensure timely reimbursement for program expenditures.

In Finding 2023-003, the Organization made one draw of federal funds that was not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes. The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization.