Corrective Action Plans

Finding 2024-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Federal Grantor: United States Department of Homeland Security Assistance Listing No.: Assistance Listing 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Grantor: Indiana Department of Homeland Security Federal Award Period of Performance: March 1, 2020 – May 11, 2023 A material weakness was identified related to internal controls over payroll expenses charged to FEMA funds, subject to the Uniform Guidance (UG) audit. This guidance requires internal controls to comply with the terms of the federal award as well as with the "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control—Integrated Framework" issued by COSO. The finding was a compliance matter and did not result in any questioned costs. Community Foundation of Northwest Indiana, Inc. and Subsidiaries (CFNI) acknowledges the finding related to the lack of documented review and approval of all timecards for payroll expenses charged to federally funded programs. In line with industry standards, CFNI prioritizes timely payroll processing and does not delay payroll for outstanding timecard approvals. While this is not a recurring issue and did not result in any questioned costs, CFNI recognizes the importance of ensuring compliance with all federal requirements. To address this finding and prevent recurrence, CFNI is implementing a comprehensive policy that mandates timely review and approval of all timecards associated with payroll expenses charged to federal grants. Additionally, CFNI is establishing a formal process to monitor adherence to this policy, including regular audits and detailed documentation of the review process. CFNI is committed to strengthening internal controls, improving oversight, and ensuring full compliance with federal grant requirements. Responsible Official: Pamela Pokropinski, VP Finance Status of finding: Completion expected June 2025

Finding 2024-004 Federal Agency Name: Department of Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Period of Performance Finding Summary: Some expenditures were not fully supported by underlying documentation. In addition, some of the expenditures tested did not have documentation of the review and approval of the allocation of the expenditure to the federal program. The Clinic also calculated their indirect cost rate based on the total grant budget and claimed an equal amount of indirect costs per month instead of calculating the indirect cost rate per direct expenditures for each month. Responsible Individuals: Kayla Trent, Finance Director Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we have implemented procedures to retain expenditure listings and other support for federal awards as well as the related review. The Clinic began retaining expense reconciliations for all Grants. Anticipated Completion Date: July 1, 2024

Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were incurred). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor’s Controllers office provides training on accrual basis of accounting at year-end training. All personnel related to recording the expenditures related to this program will be required to attend the meeting. In addition, the Auditor’s office will require all department heads and chief fiscal officers to sign off on the accuracy and completeness of their revenue and expenditures prior to closing each fiscal year going forward. Names of the contact persons responsible for corrective action: Aimee Espinoza, Auditor-Controller and Alonzo Solis, AC Senior Accountant. Planned completion date for corrective action plan: June 30, 2025, is not feasible due to the issuance date so expected completion date to June 30, 2026.

Block Grants for Community Mental Health Services - Assistance Listing No. 93.958 Recommendation: We recommend the County to conduct training with its various departments to instruct them on how to compile expenditures based on the accrual basis of accounting (when the expenditures were incurred). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Auditor’s Controllers office provides training on accrual basis of accounting at year-end training. All personnel related to recording the expenditures related to this program will be required to attend the meeting. In addition, the Auditor’s office will require all department heads and chief fiscal officers to sign off on the accuracy and completeness of their revenue and expenditures prior to closing each fiscal year going forward. Names of the contact persons responsible for corrective action: Aimee Espinoza, Auditor-Controller and Alonzo Solis, AC Senior Accountant. Planned completion date for corrective action plan: June 30, 2025, is not feasible due to the issuance date so expected completion date to June 30, 2026.

Finding 2024-027 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-023 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

The Institution acknowledges the finding regarding the late submission of the No Cost Extension (NCE) for HEERF Student Aid funds, which resulted in the ED not approving the extension and subsequently categorizing the $41,146 in distributions to 13 students as unallowed activities. The delay in submitting the NCE request was due to limited guidance and a lack of awareness regarding the June 30, 2023, filing deadline. The Institution relied heavily on the Program Management Analyst for HEERF-related guidance, and amid the evolving nature of HEERF regulations, the deadline was not effectively communicated or acted upon in time. We accept responsibility for this oversight and are committed to ensuring full compliance with all future grant-related requirements. 1. Coordination with ED for Resolution & Fund Return Process: The Institution will proactively engage with the U.S. Department of Education (ED) to determine the proper process for returning the $41,146 in overdistributed HEERF Student Aid funds. We will promptly comply with any official request from ED regarding the return of funds, ensuring timely resolution of this issue. A designated financial aid compliance officer will oversee communication with ED to track all requirements and submission deadlines. 2. Strengthening Grant Compliance Procedures: A compliance checklist will be introduced for all future grant performance period extensions to ensure deadlines are met well in advance. The Institution will implement a Grant Compliance Tracking System to monitor: a. Key deadlines for grant extensions, reporting, and compliance filings. b. Required actions for all active federal grant awards to ensure timely submissions. 3. Enhanced Staff Training & Internal Oversight: The Institution will provide training to financial aid and grant management staff on: a. Federal grant regulations and performance period compliance. b. How to track and process NCE filings in a timely manner. c. Best practices for engaging with ED to ensure compliance and funding oversight. Staff will also undergo annual refresher training on Title IV and HEERF grant compliance. 4. Improved External Communication & Regulatory Monitoring a. The Institution will establish direct communication channels with ED representatives and external regulatory advisors to ensure awareness of any changes in grant policies, extensions, and reporting requirements. b. Monthly compliance review meetings will be held internally to verify that all federal grant deadlines are on track. By implementing these corrective actions, the Institution is confident that future federal grant extensions and reporting requirements will be met on time, ensuring continued compliance with all federal funding regulations. We appreciate the recommendations provided and are committed to maintaining strong financial oversight and accountability. Personnel Responsible for Implementation: Danielle Skinner Position of Responsible Personnel: President Expected Date of Implementation: Immediate

1. Corrections to NSLDS Program-Level and Campus-Level Data Reporting: The Institution has conducted a full review of its NSLDS records and is correcting all program-level data discrepancies, including the published program length for the Machine Tool Technology/Machinist program. We are updating the "Weeks in Title IV Academic Year" field to ensure that NSLDS correctly calculates program length. A dedicated NSLDS Compliance Checklist will be implemented to ensure that all program-level and campus-level data is aligned with institutional records before submission. 2. Strengthening Accuracy in Campus-Level Enrollment Reporting: A mandatory second-level review process will be implemented for all graduation and withdrawal status updates to prevent misreported enrollment dates or statuses. NSLDS data will be cross-checked monthly against the Institution’s internal student records to proactively detect and correct any discrepancies. 3. Improving Timeliness in Certification of Enrollment Status: The Institution will implement a structured 60-day certification schedule to ensure that all enrollment changes are reported to NSLDS within federal timeframes. A compliance tracking system will be introduced to flag students requiring enrollment status updates, allowing for proactive monitoring and timely submission 4. Staff Training and Process Improvement: The Institution will train financial aid and student records personnel on NSLDS reporting standards, including: a) Accurate program length calculations and Title IV academic year reporting. b) Timely certification of enrollment changes to remain within the 60-day requirement. c) Common reporting errors and best practices for NSLDS data management. Annual refresher training sessions will be held to ensure staff remain up to date on NSLDS reporting regulations and procedural improvements. 5. Internal Compliance Monitoring & Quality Assurance: A quarterly audit of NSLDS reporting will be conducted by a designated compliance officer to identify and correct discrepancies before regulatory deadlines. The Institution will establish internal controls and reporting checklists to ensure consistency, accuracy, and compliance with federal requirements. Personnel Responsible for Implementation: Danielle Skinner Position of Responsible Personnel: President Expected Date of Implementation: Immediate

2024-001 Reporting (Financial) Student Financial Assistance Cluster: U.S. Department of Education Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers and Years: P268K240460, (9/1/2023-8/31/2024) Finding Type: Material Weakness and Noncompliance Responsible personnel: Alyssa Timko, Director of Financial Aid, act2156@tc.columbia.edu, 212 678-3654 Corrective Action Plan: In September 2023, the College identified a technical issue with the manual reporting process for student loan disbursements to COD and determined the existing solution was only partially functioning at that time. While some loan activity was timely and properly reported to COD, other student disbursement transactions were stalled and reported after the 15-calendar day requirement. At that time, the College’s ERP, Banner, job submission process for disbursement reporting to COD was manually initiated by the Office of Financial Aid. The resulting reports were then uploaded through the DOE’s EDconnect, a Windows based software application, using WinSCP file transfer (the same process was used for return files from COD). After an evaluation, it was determined that a new solution and process was required to ensure proper, complete and timely reporting under the regulations. The reporting process was redesigned in October 2023 as part of a plan to automate loan origination and now functions through Automic, a workload automation software. Instead of manually generated files and upload / receipt through EDconnect, student loan disbursement records are now automated to/from COD using TDClient, which is a command software for sending and receiving student aid related information through the DOE’s Student Aid Internet Gateway (SAIG). The new process regularly transfers loan disbursement data to COD. However, the College also determined that a prescheduled pause in the Automic loan origination process at the end of the fiscal year 2024 academic year (in August 2024), which was established in accordance with the regulations, also inadvertently paused loan disbursement reporting and resulted in late submissions. The Office of Financial Aid has also remedied this issue by adding non-standard reporting days to the standard calendar. Along with more frequent and recurring reconciliations of Banner to COD loan disbursement data and ensuring the continuation of disbursement reporting after loan originations are paused at the end the academic year, the College does not anticipate any further late reporting matters and expects all future disbursement data to be reported within 15 calendar days.

Finding #2024-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, HIV Prevention Activities Non-Governmental Organizational Based, Assistance Listing #93.939, Contract #6NU62PS924649-03-03, Contract year: 07/01/23 – 06/30/24, Contract #5NU62PS924649-04-00, Contract year: 07/01/24 – 06/30/25. U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA210403-03-03, Contract year: 08/27/23 – 08/26/24, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Children’s Health Insurance Program, Assistance Listing #93.767, Contract #2Y2CMS331859-02-05, Contract year: 07/01/23 – 06/30/25. U. S. Department of Health and Human Services, Passed through Texas Health and Human Services Commission, Block Grants for Prevention and Treatment of Substance Abuse, Assistance Listing #93.959, Contract #HHS000539700204 YPI, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPS, Contract year: 09/01/23 – 08/31/24, Contract #HHS000539700204 YPU, Contract year: 09/01/23 – 08/31/24. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost compliance – all major programs. In a sample of 59 non-payroll transactions tested for internal controls over compliance: One instance of annual advertising contract charged in full rather than establishing a prepaid expense for the eleven months after Civic Heart’s year-end of August 31, 2024. The applicable grant period is July 1, 2023 through June 30, 2025 and thus, only one month, or approximately $417, was outside the period of performance (AL #93.767 Children’s Health Insurance Program). One instance of $2,700 charged to wrong program. Allowable costs of the Navigator program were charged to Connecting Kids program due to coding to the wrong class code in the general ledger. (AL#93.767 Children’s Health Insurance Program (Connecting Kids). In a sample of 135 payroll transactions tested for internal controls over compliance: Four instances of errors in the amount of costs charged to class code due to a clerical error in the payroll allocation spreadsheet. (AL #93.959 Block Grants for Prevention and Treatment of Substance Abuse and AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based). Other non-compliance: AL #93.767 Children’s Health Insurance Program: In a sample of 40 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($417). AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 42 payroll or vendor charges, one instance of non-compliance with allowable cost compliance ($2,700). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based: In a sample of 40 payroll or vendor charges, two instances of non-compliance with allowable costs due to charge to the wrong program. Controls over period of performance – all major programs. In a sample of 56 vendor transactions and 4 pay periods with grant beginning or ending dates during the audit period, we found: 13 instances of charging vendor costs to the wrong grant period. One instance of charging payroll costs to the wrong grant period. Other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges: In a sample of 14 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $3,120). AL #93.939 HIV Prevention Activities Non-Governmental Organizational Based. In a sample of 27 vendor charges tested, we found 4 exceptions for charging to the wrong grant period (approximately $480). In a sample of four pay periods tested, we found one exception for charging costs to the wrong grant period (approximately $5,350). AL# 93.959 Block Grants for Prevention and Treatment of Substance Abuse. In a sample of 25 vendor charges tested, we found 5 exceptions for charging to the wrong grant period (approximately $660). Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance of payroll spreadsheets and reviews of coding for all transactions. Planned corrective action: Adherence to established policies and procedures will be strengthened by providing additional training when onboarding accounting staff, as well as additional oversight to the disbursement and payroll process. New accounting staff will be more thoroughly trained on established policies and procedures, including accruals, proper financial statement period recognition, grant award period of performance, tracking of grant activities using class codes, and allowable cost requirements. In addition, the CFO will ensure sufficient time is dedicated to reconciling payroll spreadsheets, payroll allocations, period of performance, and payroll accruals. Salaries and wages charged to the grant are now based on actual work performed determined by hours submitted by employee and approved by the applicable supervisor; this new control should assist in mitigating posting errors related to incorrect grants and grant periods. Responsible officer: Angelica Castillo, CFO. Estimated completion date: June 30, 2025.

During fiscal year 2024, the College had two grant awards with Natural Resources Conservation Services (NRCS). The first grant award was from September 1, 2022 through August 31, 2023. The second grant award was from the date of final contract signature which was September 29, 2023 through September 21, 2028. Due to the gap period between contracts, the September 2023 NRCS general ledger was cleared of any expenses. A grant program staff member attended a training in August 2023 and submitted for travel reimbursement in October 2023. Grant program staff members attended a conference in September 2023 and the registration fees were paid in October 2023. The travel reimbursement, conference registration fees and corresponding indirect costs were included in the October 2023 financial report submitted to NRCS for reimbursement. Once the error was discovered, the expenses were removed from the NRCS general ledger and charged to an ·appro pri at e account. An adjustment was made to reduce the expenses on the October 2024 financial report submitted to NRCS. The college recognizes the importance of proper reporting for financial reports and reimbursement requests and that those reports should only include costs that are incurred during the grant period. The grant finance team will work with grant program staff to implement a schedule that will help to ensure that goods, services and travel are completed during the grant term, that invoices are submitted in a timely manner and prior to grant end, and when possible, payment will be made for said items prior to the end of the grant term. The grant finance team will review expenses incurred during the grant term and immediately following the grant term to confirm expenses are being reported in the correct period for financial reporting and reimbursement requests. Person(s) Responsible: Carrie Patton, Jen Evans Timing for Implementation: Immediate

CORRECTIVE ACTION PLAN: Staff transitions in Financial Aid and the Enrollment Center at the onset of the Fall 2023 term contributed to the later-than-usual submission/certification of First of Term enrollment reporting. Financial Aid and the Enrollment Center experienced staff shortages with resignations and leave. The initial fall enrollment (First of Term) was certified by the Institution and submitted to the National Student Clearinghouse (NSC) on October 18, 2024 within 60 days of the start of the term on August 21, 2023, but the National Student Loan Data Systems (NSLDS) did not receive the submission within the 60-day requirement. Although we anticipate this to be a one-time incident, to prevent any recurrence and ensure enrollment changes are reported to NSLDS within 60 days, Financial Aid provided additional staff training in the Enrollment Submission process, and Early Registration enrollment submissions will be submitted within the first week of classes with the First of Term enrollment submission sent during the third week of classes. Financial Aid also updated the Institution’s NSLDS profile to ensure that records submitted for NSLDS Transfer Monitoring and Financial Aid History are added to the Enrollment Roster submitted to NSC. Financial Aid and the Registrar established an updated policy to ensure that Financial Aid is informed of students who graduate after the graduation process runs each term. After that, the Registrar will report late graduations to the National Student Loan Data System (NSLDS) via the National Student Clearinghouse (NSC). Financial Aid updated the student in question’s graduation status in NSLDS. Person(s) Responsible: Angela Weaver Timing for Implementation: Immediate

MW 2024‐001 REPORTING Recommendation: The Chief Operating Officer should obtain in writing any adjustments or clarifications to the grant awards to ensure the requested reports are prepared and reviewed. Management’s Response: EPA has never requested the SF425 (Federal Financial Reporting Form) from year’s prior and we were told verbally that we were only required to submit them at grant closeout. During a current EPA OIG audit, we were informed that the procedural process we were following was incorrect and that yearly reports were required to be submitted. To bring the IRL Council back into compliance with all federal awards, the Chief Operating Officer completed the FY 2024 forms and submitted them to EPA on March 10, 2025. Responsible Party: Daniel Kolodny, Chief Operating Officer Anticipated Completion Date: Remedial action completed on March 10, 2025.

Teenage Pregnancy Prevention Program – Assistance Listing No. 93.297 Recommendation: We recommend the Organization implement stronger internal controls to monitor the period of performance on its federal awards. This includes regular training for staff on compliance requirements and establishing clear communication channels between finance and program departments. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has reviewed and updated processes to ensure the expenses for the grant period are for the period in question and not merely reported in the General Ledger during the grant period. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: May 1, 2025

In order to strengthen internal controls, the School District will train the staff responsible for reimbursement requests, final reports, and amendments as well as those responsible for purchasing for the grant to ensure that there is proper supporting documentation and grant management. The training will include but is not limited to: NJ Finance law, good business practice, as well as a review of the purchasing manual. After this training in completed, the business office will be responsible for the review of reimbursement requests, final reports, amendments and purchases, prior to completion and submission to ensure compliance with the grant requirements and purchasing laws.

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure payments to providers were allowable and properly supported for the Social Services Block Grant. Questioned Costs: Assistance Listing # 93.667 Amount $9,098,747 Status: Corrective action in progress Corrective Action: The Department maintains that funds were not improperly charged or reported for the Social Services Block Grant (SSBG) program. The Department implemented grant-level management of all federal funds, including the SSBG program. This process consists of making grant-level adjustments between allowable grant sources to properly spend grant funds within the allowable period of performance and ensure level of effort and matching requirements are met. The Department allocated the SSBG funds to eligible clients and allowable activities in compliance with 45 CFR 98.67 but did not include the level of data recommended by the State Auditor’s Office (SAO) for some transfers. In response to the auditor’s recommendations, the Department submitted a budget request for the 2024 supplemental budget. The enacted budget included funding to implement the Department’s budget request beginning July 1, 2024. The Department is working with a developer to assist with building out the required databases between the Social Service Payment System and the Agency Financial Reporting System to allow transfers between funding sources to include transaction level data related to the expenditures. The Department is committed to collaborating with SAO to determine an appropriate methodology which identifies a sampling unit that can be used to accurately test compliance. The Department looks forward to working with SAO to resolve the data concerns in the audit of the SSBG program. The conditions noted in this finding were previously reported in finding 2023-070. Completion Date: Estimated December 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Commerce did not have adequate internal controls to ensure payments to subrecipients were allowable, properly supported and met period of performance requirements for the Coronavirus State and Local Fiscal Recovery Funds. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department maintains that there are effective internal controls over programs that are funded by the Coronavirus State and Local Fiscal Recovery Funds. Due to delayed audit planning and scoping, the auditors were unable to perform procedures to ascertain whether the Department established and followed internal controls to ensure compliance with program requirements. The Department plans to ensure sufficient time and resources are available for all future audits by performing the following steps: • Performing outreach to all federal programs to document internal controls for all applicable compliance requirements before the start of the next single audit cycle. • Working with the State Auditor’s Office earlier in the audit cycle to identify the audit scope for selected programs. • Providing support and guidance to programs selected for audit to ensure compliance with all internal controls and compliance requirements. The conditions noted in this finding were previously reported in findings 2023-027, 2023-028, and 2022-019. Completion Date: Estimated August 2025 Agency Contact: Gena Allen, CFE Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov

U.S. Department of Treasury No. 21.027 – Coronavirus State and Local Fiscal Recovery Funds Grant Period Year Ended December 31, 2024 Corrective Action Plan: In order to ensure future submissions are containing segregation of duties, the organization will ensure there are two people a part of the reporting and submission process. One person will fill out the reporting information and another person will sign off and submit the information to ensure two people are part of the process. Responsible for this plan: Ariel Rodriguez, Executive Director Implementation Timeline: Immediately as of April 22nd, 2025

Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have the right to close purchase orders with federal fund sources to expedite this process. Also, the Provider Utilization Report has been updated with Key Performance Indicators (KPIs), Contract End Date Exceeds Period of Performance and Payments Exceed Period of Performance, that specifically address the period of performance as of December 2024.

Georgia State University (GSU) will ensure all team members are appropriately trained related to the return to title IV process. Procedures have been enhanced to ensure that unearned funds required to be returned to the program due to return to title IV calculations are immediately reconciled and returned during the required window. GSU has established an Assistant Director over Electronic Processing to carry out these procedures.

Management agrees that we did end up having a pause in a project that we had previously drawn grant funds on to cover. However, when this was realized, we did have additional allowable expenditures available to reallocate that draw down over to that had incurred within the audit period, it was just after the date of the original drawdown and caused the timing issue. The pause on the project was unknown at the time of the original draw, so this would have been very difficult to know ahead of time.

Recommendation: We recommend the Agency more carefully monitor expenditures incurred near grant end dates to ensure compliance with period of performance compliance requirements. Action taken: Management agrees with this finding and will more carefully monitor grant end dates to comply with period of performance compliance requirements.

CT Energy Assistance Program– Assistance Listing No. 93.568 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are charged to grants in the proper period. Action taken in response to finding: All expenditures will be reviewed and recorded in the proper period of performance. The correction was put into place during the audit and all expenditures have been reviewed during entry and at the point of signature from the Finance Director. Name of the contact person responsible for corrective action: Indi Hayes, Finance Director Planned completion date for corrective action plan: March 21, 2025

1. Implement pre-approval controls; require date validation for all expenses against the award' s period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitations. 3. Perform periodic reviews; monitor compliance quarterly to detect outliers.

1. Implement pre-submission controls; require Date validation for all expenses against the award's period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitations. 3. Perform periodic reviews; monitor compliance quarterly to detect outliers.

Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limted to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.