Corrective Action Plans

Corrective Action Plan: ALN 93.568: The LIHEAP program reports were submitted late and the obligations were reported on the Federal Financial Reports and Carryover/Allotment Report. The LIHEAP carryover/allotment report was late due to staff turnover. Person(s) Responsible: Deanne Bear Catches, LIHEAP Director Estimated Completion Date: December 31, 2025

Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging additional stakeholders to expedite the completion of future financial reports. Completion Date: September 30, 2025

Consistent with Management’s Response to Audit Finding SA 2023-002, the City’s grant processes have been updated to ensure that grants administration and reporting are compliant with individual grant requirements and that there is interdepartmental coordination to ensure appropriate monitoring, reviews, and reporting. Training will also be provided to all departmental managers and Finance staff involved in grants administration, accounting, and reporting. Responsible Personnel Name and Position: Jill Taura, Interim Finance Director Expected Implementation Date of Corrective Action Plan: Fiscal year 2026

DSCEJ will enforce its existing month-end and year-end close procedures with accounting staff to ensure all expenses are consistently recorded in the correct accounting period.

Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll and finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors' approval to time recorded by employees. Corrective Action Planned: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employee's time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. The entire process is fully documented, with approvals recorded within the ADP by employees and supervisors and the shared file drive where HR and Finance intimal off on the reviewed payroll times, ensuring a traceable record of the entire payroll approval process. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.

Finding Number: 2023-002 Planned Corrective Action: City Auditor has confirmed the ARPA 3/31/24 and 3/31/25 Project and Expenditure Reports submitted agree to City Accounting records. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess

The organization agrees with the finding. The organization will implement a method to ensure accrued vacation is appropriately adjusted and vacation costs are accurately recorded and allocated to grants. Completed in FY2023-2024

The Organization acknowledges this repeat finding and will take steps to address the deficiencies noted. Since the prior year's audit, management will implement updated procedures to strengthen internal controls around documentation of allowable costs charged to federal awards. These measures include the development of a formal time and effort reporting system, which requires all grant-funded employees to submit periodic certifications that reflect actual hours worked and funding source allocation. Supervisors are now required to review and approve these certifications to ensure alignment with actual program activities. Additionally, the Organization will reinforce its invoice documentation and review process. All expenditures charged to the Block Grant and Opioid STR programs must now be supported by detailed invoices and documentation that clearly demonstrate allocability, allowability, and consistency with the approved grant budget and period of performance. These requirements are monitored through monthly reviews by the finance department. The Organization has also adopted a document retention policy aligned with 2 CFR §200.334, and relevant staff have received training on documentation and compliance requirements for federal awards. These corrective actions are being actively monitored by the Director of Finance to ensure full implementation and ongoing compliance. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025

Department of Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs Finding 2023-001 – Career and Technical Education - Perkins CFDA No. 84.048 Condition: During our test of controls over compliance it was noted that there are expenditures charged to the Career and Technical Education - Perkins 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 Career and Technical Education Perkins Program – 2023 Skills USA was September 15, 2022 through August 31, 2023 & Career and Technical Education Perkins Program – Equitable Access Grant was August 19, 2022 – August 31, 2023. Context: During our test of expenditures and review of the general ledger against the Career and Technical Education Program Perkins 2023 Skills USA grant as it is related to compliance it was noted that a payroll for the pay period of 8/14/22 – 8/27/22 was charged to the grant for services prior to the grant start date of September 15, 2022 and thus would be outside the period of performance and an unallowable cost. During our test of expenditures and review of the general ledger against the Career and Technical Education Perkins Program Equitable Access grant as it is related to compliance it was noted that an invoice charged to the grant was for services provided on August 8, 2022 & August 9, 2022 and that was charged to the grant for services prior to the grant start date of August 19, 2022 and thus would be outside the period of performance and an unallowable 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 for the payroll charged to the Career and Technical Education Perkins Program 2023 Skills USA grant whose service period was prior to the grant start date of September 15, 2022 in the amount of $5,321.54. Questioned costs for the invoice charged to the Career and Technical Education Perkins Program Equitable Access grant whose service period was prior to the grant start date of August 19, 2022 in the amount of $1,872.00. 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 payroll and expenditures charged to the grants are 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.

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.

2023-003 Period of Performance - Community Development Block Grants/Entitlement Grants Cluster Assistance Listing Number 14.218 Grant Period - Year Ended December 31, 2023 Condition Found The City did not meet program timeliness spending requirements. The City’s unexpended balance at December 31, 2023 of $2,683,379 is more than 1.5 times the $1,374,790 entitlement grant for the current year. We consider this to be an instance of non-compliance relating to the Period of Performance Compliance Requirement. Corrective Action Plan The City of Decatur Economic & Community Development Department is under new leadership with Lacie Elzy as Acting Economic & Community Development Director. Director Elzy will be reviewing all grant programs and duties in the department and ensuring that grant requirements are being met. Responsible Person for Corrective Action Plan Lacie Elzy, Acting Economic & Community Development Director Implementation Date of Corrective Action Plan April 30, 2025

U.S. Department of Health and Human Services U.S. Department of Housing and Urban Development Material Weakness in Internal Control over Compliance Community Service Block Grant – Assistance Listing No. 93.569 Community Development Block Grant – Assistance Listing No. 14.218 Condition: During our testing, we noted there were several salary expenditures charged to the grant based on the payroll period ending date, however the costs were incurred for the period 12/24/22 - 1/6/23, which the first eight days were prior to the start of the period of performance. There was also one transaction selected for testing where no supporting documentation was able to be located and one transaction that was incurred after the period of performance for the program. Recommendation: The Organization should work with the federal agency to provide additional documentation or justification for the expenses, or to adjust the budget or funding limits to ensure that all expenses are within the approved period of performance. It is important to address any period of performance findings as soon as possible to avoid potential penalties or repayment obligations. The Organization should also review its process of entering invoices and payroll related expenses into the accounting software to ensure the correct period is used for federal expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Organization expanded contract compliance to include financial contract compliance. The organization will also implement grant tracking and spend management modules in the accounting software to assist with monitoring expenses applied to contracts. A new process will also be implemented regarding payroll related expenses to ensure the correct period is used for federal expenditures. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2025.

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

Finding Number: 2023-002 Planned Corrective Action: The Chief Financial Administrator will ensure all ARPA expenditures are included on the Project and Expenditure Reports. Anticipated Completion Date: March 31, 2025 Responsible Contact Person: Ben Cowdery, Chief Financial Administrator

Recommendation: We recommend that management ensure that internal controls are in place and operating effectively for period of performance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recurrence of the issue, we began implementing a corrective action plan. Specifically, we are enhancing our internal controls and began developing a comprehensive technical procedure manual that will serve as a detailed guide that provides a clear reference for finance and accounting staff to ensure consistency, compliance and efficiency in financial operations. Additionally, as SHRA is filling vacancies due to significant turnover across the entire Finance Department, specific training is provided to new employees in the following areas: • Building HOME • Capital Fund • CDBG • Continuum of Care • Developing a Cost Allocation Plan • Financial Management Part I and Part II (for CPD programs) • HCV Two Year Tool • IDIS • Mainstream Vouchers • Overview of Asset Management • PHA Financial Management Name(s) of the contact person(s) responsible for corrective action: Irene De Jong, DIRECTOR OF FINANCE Planned completion date for corrective action plan: December 31, 2025

We will implement several key improvements to enhance our compliance and reporting processes. We will utilize new software to automate the preparation and compilation of audit and compliance reports, streamlining workflows and reducing the risk of delays. Additionally, we are establishing a centralized document management system with strong retention and access protocols to ensure all relevant documentation is properly maintained and readily accessible. As part of this process, we will improve our procedures for identifying and aligning expenses with the appropriate grants to ensure accurate reporting and proper use of funds.

Recommendation: We recommend the Center review its contracts against the criteria set forth in the Uniform Guidance to ensure that all sub-awards in the future contain the required information for subrecipients. Action Taken: Tri-County 010 has taken the following corrective steps: Reviewed and Updated the Subrecipient Contract Template to include all required elements as outlined in Pennsylvania Department of Education. Implemented a Pro-Award Contract Review Checklist to ensure each contract is verified for compliance prior to execution. Established a Documentation Process for storing all subrecipient agreements and related compliance materials in a centralized location. Anticipated Completion Date: March 31, 2025 Contact Person Responsible: Christina Johnson, Executive Director

Develop external reporting matrix/schedule and report it to the Board of Directors by March 2025

Develop external reporting matrix/schedule and report it to the Board of Directors by March 2025

The Sheriff’s Department separated from the individual that handled the grant funding as of the first of 2025. We have worked diligently to get these reports correct as of December 31, 2024.

The Sheriff’s Department separated from the individual that handled the grant funding as of the first of 2025. We have worked diligently to get these reports correct as of December 31, 2024. Municipal Court recognizes that Quarter 5 was not submitted timely to the grant authority. We have since implemented a policy for grant reporting that related to the only current open grant administered by Municipal Court Probation Department. Section F states that a similar reporting schedule be implemented for all future grants received by the Probation Department. We want to reiterate that when received for the entire calendar year 2023, expenditures from the Violence Reduction Grant that were reported to BCS matched the expenditures on the Expense Transaction Ledger provided by the Auditor’s Office. The discrepancy was solely related to quarterly reporting to BCS and was corrected in the following quarter after initial understatement. We have controls in place to ensure that all grants will be reported timely and accurately moving forward

Finding 2023-003 The reporting package and data collection form for the 2022 audit was not filed by the September 30, 2023 deadline. This is a repeat of Finding 2022-001 from the 2022 audit. Auditors’ Recommendation NCST should ensure that its records are completed and reconciled in a timely manner, so that the single audit can be performed and completed on time, and the reporting package and data collection form can be submitted before the deadline. Corrective Action Taken To prevent future delays, NCST has streamlined financial reporting and established a timeline for federal and grant audit compliance. A Finance Director with extensive nonprofit experience has been hired, and a third-party accounting firm has been contracted for ongoing oversight, improved audit preparedness, and enhanced reporting accuracy. All financial reports are now being prepared and submitted by the deadlines, with continuous support and oversight by the third-party accounting firm and our internal Finance Director. Audit reconciliation and financial compliance processes have been significantly strengthened to ensure future deadlines are met without delay. Responsible Individual Executive Director, Rey Chavis Anticipated Completion Date March 2025.

The City will update amounts and descriptions within the Department of Treasury’s reporting portal to ensure all amounts expended are properly reported and proper revenue loss amounts are recognized.

Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025