Corrective Action Plans

Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-005 Reporting Condition: The CMHSP did not reconcile financial expenditures shown in the Federal Financial Report to the total disbursement and charges in PMS. Planned Corrective Action: The CFO or Finance Manager will ensure that the financial expenditures shown in the Federal Financial Report reconciles to the total disbursement and charges in PMS. Contact Person: Kevin Hartley, CFO 231.633.2171 Kevin.hartley@nlcmh.org Anticipated Completion Date: 10-1-24

Prior Period Restatement – My Project USA acknowledges the importance of accurately reporting transactions within the appropriate accounting periods and recognizes the internal control weaknesses that contributed to this finding. To address this issue, Uzair Qidwai, Ramy El-Asal, and Executive Director Zerqa Abid will review the organization's processes and internal controls to ensure they are up-to-date and robust enough to instill full confidence in the organization's ability to report transactions in a timely and accurate manner. Additionally, new measures will be implemented to provide a comprehensive overview of all grants, thereby enhancing the understanding of the overall grant environment.

Finding 2023-001: Internal Control Over Financial Reporting Management’s Response Mid Michigan CAA has a long-standing history of exemplary stewardship of federal, state, and local funds. The significant delay in preparation and subsequent completion of the FY2023 audit is directly related to staffing issues within the agency’s finance department. To prevent recurrence of this issue, Mid Michigan CAA is implementing the following corrective actions: 1. Revised Internal Timeline: We have established an internal audit preparation calendar with clearly defined deadlines to ensure timely completion and submission of future audits. 2. Enhanced Oversight: The Finance Committee of the Board will now receive monthly updates on audit progress during the audit cycle to ensure accountability and timely resolution of any issues. 3. Staff Engagement: Key finance staff are provided with more context and information on the audit process so that they can be more engaged and able to assist in the data gathering process. Contact Person Responsible for Corrective Action: Mark Polega, Executive Director Anticipated Completion Date: February 2025 – September 2025

N/A - The Healthy Start Program transitioned to another local non-profit October 31, 2023. The Council will no longer have direct control over their corrective action plan.

Department of Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Finding 2023-003 – Education Stabilization Fund – ESSER III AL No. 84.425U Condition: During our test of controls over compliance it was noted that there are expenditures charged to the Education Stabilization Fund – ESSER III for services outside of the period of performance as set forth by the Massachusetts Department of Elementary and Secondary Education. Criteria: The Period of Performance for the Education Stabilization Fund – ESSER III was October 4, 2021 through September 30, 2024. Context: During our test of expenditures and review of the general ledger against the Education Stabilization Fund – ESSER III grant as it is related to compliance it was noted that the School paid in full a four year lease from 3/1/23 to 2/28/27 and charged 10/1/23 to 2/28/27 to the Education Stabilization Fund – ESSER III grant in the amount of $190,869 and thus the period from 10/1/24 to 2/28/27 would be outside the period of performance and thus would not be an allowable cost. Effect: Assabet Valley RTHS was not in compliance with the period of performance requirement as set forth by the Massachusetts Department of Elementary and Secondary Education. Questioned Costs: Questioned costs charged to the Education Stabilization Fund – ESSER III grant whose service period was beyond the grant end date of September 30, 2024 was in the amount of $135,005. Cause: Grant should have been amended Identification as a Repeat Finding: N/A Recommendation: We recommend the Assabet Valley RTHS follow procedures to ensure that expenditures charged to the grant is within the period of performance as set forth by the Massachusetts Department of Elementary and Secondary Education. Responsible for Corrective Plan: Maria Silva, Director of Business Operations Estimated Completion Date: 12/31/2024 Action Taken: The District agrees with the recommendation and will work with those writing the grants.

FINDING 2023-004 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Mindy McGee Contact Phone Number and Email Address: 812-265-8300, mmcgee@madison-in.gov Views of Responsible Officials: We concur with the finding regarding errors in Coronavirus Fund reporting. Description of Corrective Action Plan: Historically, the city has not had a centralized position who would be responsible for grant compliance and reporting. Individual department heads were responsible for comp0lying with each awarded grant for their own area of responsibility. In spring of 2025, a new Project & Grant Manager position was created and filled by a qualified individual. The responsibilities of the position include data collection and analysis, project management, grant coordination, information management and compliance monitoring and reporting. Anticipated Completion Date: The new position referenced above has been filled and is in operation as of April 8th 2025.

Corrective Action Plan: 1. Proper identification and segregation of restricted revenue: Created spreadsheet that tracks restricted revenue, expenses, and balance remaining for each fund or restriction. This helps with both internal and external reporting requirements. 2. Matching Expenditures to Restrictions: As expenditures related to restricted funds are incurred (e.g., paying for program services or project costs), ensure these expenses are recorded against the same fund or tracking code used for the revenue. This ensures that all expenditures meet the requirements of the restriction and provides proper documentation for audit purposes. 3. Continuous monitoring and analysis to ensure accurate recording in the general ledger: Restricted funding will be reviewed at monthly Development meetings to ensure that revenue and expenses are appropriately recorded and that the remaining balance matches the restrictions. 4. Regular reviews and reconciliation of restricted funds to ensure compliance with restrictions. 5. Clear reporting to stakeholders and proper disclosure in financial statements. Anticipated completion date: 1. Completed 2. Ongoing 3. Starting February 10, 2025 4. Ongoing 5. Ongoing

Corrective Action Plan: 1. Standardize financial reporting procedures: • Accountant and ED will meet bi-weekly to review revenue and expenses • Accountant will meet with Donor Operations Manager monthly to confirm fund development revenue and expenses are properly allocated to the correct GL code • Accountant will send monthly financials to ED first for review • Once approved, ED will send monthly financials to Finance Committee Chair and BOD President • Finance Committee Chair will send to full board • Any questions will be addressed to the Finance Committee Chair • Budget will be reviewed at monthly leadership meetings • Regularly assess and refine, as applicable, financial reporting and closing processes to improve efficiency and accuracy 2. Finance Committee • Effective 9/2023, the finance committee was re-instituted to review financials and to implement stronger financial safeguards for TBS • Monthly meetings are held where financial performance and reports are reviewed in depth • Any anticipated risks will be reviewed • Finance Committee prepares annual budget with input from ED and BOD President 3. Board reporting • BOD members will receive monthly financial packet from Finance Committee Chair for review • Any questions will be directed to the Finance Committee Chair • Each quarterly board meeting will include a budget review highlighting projections and actuals vs budgeted • First board meeting of year will include comprehensive review of previous year Anticipated completion date: 1. Ongoing 2. Ongoing 3. Ongoing

Corrective Action Plan: 1. Review and update credit card and expense policies making it clear that receipts and invoices are mandatory for all purchases. Share this updated policy with all staff. 2. At the end of each month, staff members who have credit cards will submit their receipts along with their credit card statement to the Administrator. The Administrator will be responsible for reviewing and ensuring that all of the receipts are in hand. If any are missing, the Administrator will work with the staff member to get a copy. If no copy is available, the staff member will write a statement explaining they are missing a receipt and what it was for. Document will be signed by the staff member and the Executive Director. 3. We will conduct quarterly reviews of expense documentation to ensure consistent compliance with policies. This will be reviewed during our quarterly Quality Improvement Program (QIP) meeting. Anticipated Completion Date: 1. Within 30 days 2. Within 30 days 3. Quarterly starting on February 10

Finding 2023-003 Material Weakness in Internal Control Over Special Tests and Provisions Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2023 Criteria FFHC is responsible for keeping adequate supporting documentation of the calculation of patient service fees for those patients who qualify for discounted fees based on family size and household income. FFHC is also required to apply discounted fees accurately based on an approved sliding fee scale that meets federal compliance requirements. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2023, to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2023 to remediate the finding and address the cause of the finding. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. • FFHC will enforce its current policy and related internal control procedures to ensure that supporting documentation of family size and household income is maintained for all patients that receive discounted patient service fees in relation to the Health Centers Program and Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program. • FFHC will enforce its current policy and related internal control procedures to ensure that discounted patient service fees are properly calculated and charged based on the applicable approved sliding fee scale. The target date for full implementation of these corrective actions is December 30, 2025. The person responsible for the planned resources will be Raheel Shahzad, Chief Financial Officer (847) 957-6244. Our address is 340 E. 51st St., Chicago, IL 60615.

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers and Mainstream Vouchers Federal Assistance Listing Numbers: 14.871 and 14.879 Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Special Tests and Provisions Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Thirty-two (32) names were selected from the new move-in list and those names were to be traced to the waiting list to verify new move-ins were chosen in an order that was in accordance with the Authority’s policy. It was determined that six (6) out of thirty-two (32) new move-ins selected could not be traced with any certainty back to the Authority's waiting list. Known Questioned Costs: 14.871 - Section 8 Housing Choice Vouchers - $35,098 14.879 - Mainstream Vouchers - $13,796 Cause: There is a material weakness in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Section 8 Housing Choice Vouchers and Mainstream Vouchers programs are in material non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the material weakness in the Section 8 Housing Choice Vouchers and Mainstream Vouchers programs and will implement internal control procedures that will ensure compliance with federal regulations. Shannon Koenig, executive director and CEO, is responsible for implementing this corrective action by December 31, 2024.

Finding 2023-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871, 14.879, and 14.EHV Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility. Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 6,531 units. Of a sample size of seventy-seven (77) tenant files, the following was noted: - Section 214 citizen declaration form missing in 15 files - HUD 9887 consent to release information form missing in 2 files - Original application missing in 1 file - Annual inspection missing in 1 file - Lead based paint form missing in 4 files - Verification of income missing in 6 files Our sample size is statistically valid. Known Questioned Costs: 14.871 - Section 8 Housing Choice Vouchers - $36,728 14.879 - Mainstream Vouchers - $13,028 14.EHV - Emergency Housing Vouchers - $1,272 Cause: There is a material weakness in the Housing Voucher Cluster in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor, and will make the several changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement). Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Shannon Koenig, executive director and CEO, is responsible for implementing this corrective action by December 31, 2024.

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2023 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended December 31, 2023. Finding 2023-001 Responsible Party Name: Gina Rice Position: Director of Accounting Telephone Number: 816-238-4511 ext 131 Federal Agency U.S. Department of Agriculture Federal Program Emergency Food Assistance Program (Food Commodities) Compliance Requirements E - Eligibility Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action We will establish a process to ensure required eligibility documentation is maintained in accordance with federal program requirements which will include periodic monitoring and review performed by personnel not directly involved with program administration. Anticipated Completion Date June 2025

2023-001 Reporting – Late REAC Submission and Late OMB Data Collection Form Submission Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 – Housing Choice Vouchers Material Weakness in Internal Control, Material Noncompliance Condition: The Authority’s audited Financial Data Schedule (“FDS”) filing was not submitted within the timeframes specified by HUD. The FDS filing was due by June 30, 2024, but the financials were not issued until June 3, 2025. The Authority was also required to submit the OMB Data Collection Form to the Federal Audit Clearinghouse (“FAC”) by June 30, 2024, but was not filed timely as the audit was completed on June 3, 2025. Recommendation: The Authority should ensure that they retain support for all required documentation and that it is organized and readily accessible. Storing documents electronically with frequent backups would help prevent loss of data from damage to any one location. Furthermore, the Authority should ensure that staff receives necessary training for proper document retention. Action Taken: To address the identified deficiencies and restore compliance with HUD requirements and the Trouble Recovery Agreement, the Authority will implement the following corrective actions: 1. Leadership and Governance Stabilization: Ensure that the new CEO is briefed on all relevant programs, financial updates, management, and strategic planning initiatives. Ensure that the Finance Committee, within the Board of Commissioners, continues to hold monthly meetings before all regular board meetings and monitors financial reporting, budget adherence, and audit readiness. Ensure that the Administrative Plan for the HCV Program is comprehensively updated to reflect current HUD regulations and strategies for program optimization. 2. Financial Staffing and Capacity Building: Maintain continuity in financial leadership by supporting the Interim CFO and ensuring adequate staffing, such as the new Staff Accountant in the Finance Department, to support audit preparation and HUD reporting. Develop a financial onboarding and training program for all new finance staff, with a focus on HUD systems (FDS, VMS, EPIC, LOCCS) and internal budget protocols. Ensure that Program and Finance Management staff of the HCV Program attend the HCV Financial Management and HCV Financial Accounting and Reporting sessions. 3. Budget Training and Accountability: Implement mandatory budget training for the Finance Department and the HCV Program Department, covering: Budget development and forecasting; Budget-to-actual variance analysis; HUD funding streams and eligible uses; Internal budget controls and documentation standards; Voucher Management System, FDS policies, and SOPs. Create an Accountability Chart for the Program and Financial Management of the HCV Program, outlining roles, responsibilities, and procedures for budget planning, monitoring, and reporting. Require monthly or biweekly meetings with budget reviews by department heads and mid-level managers, with variance explanations submitted to the CFO and CEO, and shared with the Board. 4. Fee Accountant Reinstatement and Optimize HCV Program Finances: Reinstate and formalize the partnership with BDO PHA Finance to support audit preparation, financial reporting, and staff training. Establish financial performance tracking, standard operating procedures (SOPs), contract compliance monitoring, and payment authorization protocols. 5. Technology and Data Management Improvements: Prepare the Chart of Accounts, Procure to Pay, and Voucher Management System (VMS), as well as the Two-Year Tool (TYT), and take other necessary financial steps to ensure a seamless transition from SACS to Reframe. Implement cloud-based storage and digital backup protocols to safeguard financial records and ensure continuity in the event of future disruptions. Establish a centralized digital archive for all financial documents, including budgets, invoices, contracts, and audit work papers. 6. Audit Readiness and Compliance Monitoring: Create an annual audit preparation calendar with clear deadlines for data collection, reconciliations, and internal reviews. Conduct monthly and quarterly internal audits to assess financial controls, procurement compliance, and budget adherence. Submit monthly and quarterly progress reports to HUD and the Board as part of the Troubled Recovery Agreement and internal HUD Recovery Strategic Plan, documenting improvements in financial management and audit readiness. 7. Transparency and Communication: Present monthly financial reports to the Board of Commissioners, including budget-to-actual comparisons and audit status updates. Publish an annual financial summary on the Authority’s website to promote transparency and public accountability

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: We will review items not fully implemented. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

Return of Title IV (R2T4) Planned Corrective Action: A process will be implemented to run a 0-credit report at the end of each semester. This will ensure withdrawals are followed up on and that R2T4s are completed timely, if required. A process will be implanted to track student attendance in classes. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

Incorrect Pell Calculations Planned Corrective Action: A process will be implemented to verify Pell is correctly awarded before disbursements are made. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

Enrollment Reporting to NSLDS Planned Corrective Action: A process will be created to ensure enrollment is reported timely and accurately. Spot checks of NSLDS will be performed on enrollment status throughout the year. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

ISIR Comment Resolution Planned Corrective Action: All ISIR comment codes will be resolved before disbursement of federal aid to students. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

Lack of Administrative Capability Planned Corrective Action: The financial aid officer will participate in trainings specific to knowledge gaps. In addition, monthly entries will be made in the general ledger for financial aid activity and monthly balances will be reconciled between the general ledger and financial aid software. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

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 No . 2023-002: Annual Audit Submission Assistance Listing Program Title and Number: All Federal Agency: All Pass-through Entity: All Description of Finding: As per the Code of Federal Regulations, Section 200.512 - Report Submission, the audit must be completed and the Data Collection Form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the end of the audit period. The due date for the audit and reporting package submission was March 31, 2024. Statement of Concurrence or Nonconcurrence: The State Education Resource Center agrees with this finding. SERC experienced staffing shortages and related difficulties during the fiscal year. As such, SERC was not able to prepare timely for the audit for the Uniform Guidance, Data Collection Form, and reporting package to be filed by the due date. Corrective Action: In May of 2024, the State Education Resource Center hired a new Chief Financial Officer whose focus is to bring the organization up to date on all audits and reporting and to ensure that the Fiscal team has the proper tools and guidance to perform their tasks and to improve policy and process for the department. This will also aid in ensuring all necessary efforts will be taken to ensure timely submission of the audit, Data Collection Form, and reporting packages. Name of Contact Person: Jim Fried, Chief Financial Officer, 860-740-4263, fried@ctserc.org will be responsible for completing the corrective action plan. Projected Completion Date: The anticipated date for completing the corrective action plan is June 30, 2025. The action plan will be monitored on a bi-annual basis to ensure ongoing compliance.