Corrective Action Plans

2023-002 Finding: Allowable Costs and Allowable Activities Status: Corrective action in progress Criteria: According to 2 CFR Part 200.303 - The non-Federal entity must (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “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 the Committee of Sponsoring Organizations of the Treadway Commission (COSO). (b) Comply with the U.S. Constitution, Federal statutes, regulations, and the terms and conditions of the Federal awards. (c) Evaluate and monitor the non-Federal entity's compliance with statutes, regulations and the terms and conditions of Federal awards Condition: During testing, we noted that one transaction totaling $1,501,269 related to 2022 activities and was included as an expenditure on the fiscal year 2023 Schedule of Expenditures of Federal Awards. The period of performance for the project began in 2022 and extended through 2023. Corrective Action: To facilitate more accurate and timelier grant reporting the following improvements are proposed: 1. Increased grant training for all departments. The Engineering Department is bringing in CDOT to do this, last year Forvis Mazars provided countywide training and the Finance Department will provide additional training on an ad hoc basis. A full understanding of the requirements of the grants that are being applied for is crucial. 2. Departments receiving grants will provide monthly reconciliations of all grants and provide grant agreements to the Finance Department to ensure accurate reporting on the SEFA (Schedule of Expenditures of Federal Awards). 3. Effective communication is essential to successful reporting and the Finance Department will formalize meetings with departments to address issues that surface and reporting expectations. Person(s) Responsible for Implementation: Jill Janz – Accounting Manager, Christie Guthrie – Assistant Finance Director Implementation Date: 6/1/24 and ongoing

Capital Fund Program – CFDA 14.872 Recommendation: The Commission should review the obligation and expenditure of capital grants on an ongoing basis and implement policies and procedures to ensure all federal compliances are followed pertaining to obligation and expenditures verification. Action Taken: New Management has taken over as of March 2023 and will review and implement stronger policies and procedures pertaining to capital fund grants. Anticipated Completion Date of Action: December 31, 2024.

Finding 2023-001 U.S. Department of Education Condition: Tuition invoices and payroll costs were charged to a 2023 grant that were for services rendered prior to the grant start date. Corrective Action Planned: The School will implement procedures to review all manual journal entries for period of performance compliance before posting to the general ledger. Anticipated Completion Date: Immediately Contact: Gilbert Lefort III, Director of Finance, North Attleborough Public Schools

School District 12 Education Foundation (dba Five Star Education Foundation) agrees with the finding and recommendation.School District 12 Education Foundation (dba Five Star Education Foundation) will document approval, or other internal control, to prove transactions charged to grants are allowable, within the period of performance required by the grant and are meet procurement policies established by Uniform Guidance.

The City is developing a formal grants policy that will be implemented in 2024. As a part of this policy, City Departments will be required to demonstrate a detailed understanding of grant terms and conditions and specify to City Administration and the Finance Department how the grant will be administered and monitored prior to application. In addition, Departments will be required to send copies of all grant documents, including reports, to the Finance Department in a timely manner to allow the Finance Department to monitor grant activities

Views of Responsible Officials: The Organizations concur with the auditor's assessment and are in the process of implementing a pre-award risk assessment procedure.

Research and Development – Assistance Listing No. Various Recommendation: We recommend the University review its current close out procedures and implement additional procedures to monitor the timeliness of federal account close outs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Langston is strengthening the close-out process of federal awards to halt expenditures thus reducing redistributions and cost-transfers. Name(s) of the contact person(s) responsible for corrective action: Mr. Robert Dixon, Director, Grants and Contracts Fiscal Administration at Oklahoma State University and Mr. Chris Kuwitzky, Vice President for Fiscal and Administrative Affairs. Planned completion date for corrective action plan: September 2024

We agree that the allocation being performed once annually does not create the most equitable allocation of costs between our individual programs. We will perform our indirect cost allocations more periodically during the course of the fiscal year to ensure that more appropriate times studies and applicable participant hours are being utilized to limit the potential of allocating unrelated indirect costs from the year to individual programs, including the federally funded programs.

SECTION III – FINDINGS – FEDERAL AWARD FINDINGS Finding 2023-001 – Activities Allowed/Unallowed, Costs Principles, and Period of Performance (Internal Controls Over Compliance) Significant Deficiency Criteria: Uniform Guidance 2 CFR, Part §200.313(a) requires that non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “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 the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our review of the Coalition’s disbursements related to the Title V major program, we examined 40 transactions for internal controls over compliance. 2 of the 40 transactions examined did not contain sufficient evidence that a review and approval process was completed prior to payment being processed. Questioned Costs: None Cause: The Coalition does not have sufficiently established control policies and procedures to ensure proper approvals are obtained prior to the disbursement transactions being processed. Effect: Disbursements are being processed without proper approval, resulting in the possibility of disallowed expenditures. SECTION III – FINDINGS – FEDERAL AWARD FINDINGS Finding 2023-001 – Activities Allowed/Unallowed, Costs Principles, and Period of Performance (Internal Controls Over Compliance), continued Recommendation: We recommend the Coalition becomes familiar with requirements of 2 CFR, Part §200.313(a) and establishes appropriate internal control policies and procedures and that all staff be trained on those policies and procedures, so they are familiar with the requirements. We further recommend the Coalition does not process payment for disbursements that do not contain necessary approvals. Responsible Official: Carlett Gregory, CFO Corrective Action: In response to the finding regarding insufficient internal controls over compliance for disbursements related to the Title V major program, the Coalition will take the following corrective actions: 1. Review and Revise Policies and Procedures: o The Coalition will conduct a thorough review of our current internal control policies and procedures related to disbursements to ensure they align with the requirements of 2 CFR, Part §200.313(a). o We will revise and update our policies and procedures as necessary to ensure they are comprehensive and robust, providing clear guidelines for review and approval processes. 2. Training and Education: o We will provide additional training to all staff involved in the procurement process to ensure they are fully aware of the updated policies and procedures. o The training will cover the importance of obtaining proper approvals prior to processing payments and the specific requirements of 2 CFR, Part §200.313(a). 3. Implementation of Approval Controls: o We have implemented a standardized approval process for all disbursements, ensuring that each transaction is reviewed and approved by the designated authority before payment is processed. o We currently have in place a checklist to document the review and approval process for each transaction, ensuring that evidence of compliance is retained. 4. Monitoring and Compliance Checks: o We will establish regular monitoring and compliance checks to ensure adherence to the updated policies and procedures. o Quarterly internal audits will be conducted to verify that all disbursements are properly reviewed and approved according to the established guidelines. Timeline for Implementation: The corrective actions outlined above have been implemented. Training sessions will be part of the onboarding process and existing programs. It will also be reviewed as needed to address any changes.

CORRECTIVE ACTION PLAN: The Organization will adopt procedures that allow for the timely tracking of refundable advances, to ensure funds are properly expended during the period of performance.

Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifying their payment support to show any payer-initiated adjustments. Responsible Individuals: Keith Rachey, Chief Financial Officer Anticipated Completion Date: Completed and staff trained by September 2024

Finding Summary: Guild’s controls did not operate as designed, which resulted in rent reasonableness tests not being performed timely and/or reviewed before the rent being paid. Corrective Action Plan: Working with all Rental Assistance staff, we will develop a standard for documentation and a checklist for signing off by the responsible official. Responsible Individuals: Keith Rachey, Chief Financial Officer Anticipated Completion Date: Completed and staff trained by September 2024

The County agrees with the recommendation and will work with the Grant Administrator to implement policies and procedures to ensure all pre-award payments occur within the grant timelines.

U. S Department of Health and Human Services North Iowa Community Action Organization respectfully submits the following corrective action plan for the year ended September 30, 2023 Audit period: October 01, 2022 to September 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-001 Special Supplemental Nutrition Program for Women, Infants and Children (WIC) – Assistance Listing No. 10.557 Recommendation: We recommend the organization expense transactions in the month incurred. Although transactions below $50 are individually immaterial, this is not in compliance with the period of performance compliance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will revisit their policy not to backdate expenses less than $50 to their correct period if invoices are received 15 days after the end of the grant period. Name(s) of the contact person(s) responsible for corrective action: Cindy Davis, Executive Director. Planned completion date for corrective action plan: year ended September 30, 2024

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolved in FY2024. We will continue to work with our departments to ensure that all controls for grants are documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023-002 Head Start Cluster- Federal Assistance Listing Number 93.600 - Significant Deficiency in Internal Control over Allowable Costs Recommendation: Internal Controls should be implemented around expense cutoff to ensure all expenses relate to the appropriate period, or in this case, school year. Action taken: We concur with the recommendation. On May 30, 2024, HRCAP drafted Accounting Policy 3.10 to be reviewed for addition to the Finance Policy Manual. This policy would serve to provide internal control procedures for grant-related transactions in accordance with Generally Accepted Accounting Principles (GAAP). Specifically, it outlines precise year end and cut-off procedures tailored to grant revenue and expenses, emphasizing the critical importance of recording these transactions within the appropriate grant period. Sincerely yours, Audrea Lambert, Chief Financial Officer

Action Taken: The Senior Programs have undergone significant improvements in the last 6 months following an audit by the federal funder which resulted in a corrective action plan (CAP) and a repayment of $54,228. Plans were implemented during the spring of 2024 in response to the CAP which resulted in an overhaul of the processes in place to properly develop the volunteer checklists and assure all records for staff and volunteers are now compliant. Our Quality and Compliance and Finance team worked closely with the new Program Manager to assure that we will be fully compliant and remain so.

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated correctly within the period of performance. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards from inception to closeout.

Finding 2023-001: Internal control deficiency and noncompliance over Period of Performance. In response to this finding City of Hope (COH) will complete the following: 1. Research Accounting will present finding and revisit guidelines on period of performance requirements with Research and Post Award Accounting personnel. 2. COH will refund the identified questioned costs. Contact Person: Joe Norton, Vice President, Corporate Accounting and Operations Expected Completion Date: September 30, 2024

EARMARKING – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: It is recommended that the County reviews their policies and federal requirements to ensure all costs are reported under the correct category. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review their policies and federal requirements related to earmarking to ensure compliance requirements are met. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2024

The Department of Health Care Finance (DHCF) agrees with the finding. The drug rebate vendor’s IT staff will test the calculation to see if there would have been interest calculated or if there is a system glitch that requires further attention. If additional interest should be billed for this invoice, the vendor will add the interest that should have been billed. Currently, the drug rebate vendor calculates interest every Tuesday. The system is also calibrated to calculate interest on invoices that were paid in full that had outstanding balances based on the postmark date applied in the system. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - November 30, 2024 See Corrective Action Plan for chart/table

Finding 2023-051 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. Planned Corrective Action The LEO Office of Global Michigan will update established procedures and tracking logs to ensure compliance with SOM Technical Standard 1340.00.020.01. The LEO Internal Controls unit is in the process of establishing a grants compliance team that will perform validation of the ongoing reviews. Anticipated Completion Date December 31, 2024 Responsible Individual(s) Ben Cabinaw, LEO Allen Williams, LEO

Finding 2023-027 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS began performing weekly reconciliations of the Medical Services Administration Manual Payment System (MSAPay) payment details and Home Help beneficiary applications during February 2024, to ensure only approved outstanding applications are paid. In addition, MDHHS implemented additional steps in the MSAPay approval process during May 2024 to prevent duplicate payments, including a review process to verify the beneficiary did not receive previous payments related to the respite grant, prior to creating a new payment voucher. Anticipated Completion Date Completed Responsible Individual(s) Crystal Kline, MDHHS Jessica Bowen, MDHHS Elaina Brown, MDHHS

Finding 2023-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action EGLE’s Water Resources Division’s Administration staff reviewed the existing process with staff conducting the administrative review to ensure the technical review will be completed in advance of making any payment. If Administration staff have received a request for payment without the technical review, Administration staff will forward all documents received to the project manager to obtain the technical review. Once the technical review has been completed, Administration staff will conduct the administrative review and process the payment request. Additionally, EGLE subsequently reviewed the reimbursement request noted in the finding to ensure that the cumulative totals requested have been for projects that are consistent with the grant award. Anticipated Completion Date Completed Responsible Individual(s) Phil Argiroff, EGLE Amy Hicks, EGLE

Cambridge Public Schools' CFO or Grants Coordinator will review and sign-off on all tuition requisitions that will be charged to grants to confirm the grant approval date and compliance with the period of performance.