Corrective Action Plans

Corrective Action to be Taken for Finding 2023-002 - Report Deadline Tracking o Catholic Charities will create a shared calendar for use by the Caseworkers, Program Director, Operations Director, and Fiscal Manager to document all deadlines of required reports and staff responsible for completing the reports. o This calendar will be monitored and updated by all staff with new arrival dates, quarterly report deadlines, close of case report dates, billing dates, Match Grant enrollment dates, 180-day budget deadlines, and 240-day budget deadlines. - Trainings o The Program Director will contact the staff of United States Council of Catholic Bishops, here after referred to as USCCB, when an individual begins employment and request a login and password into the USCCB resource website, MRS Connect, which has all USCCB trainings recorded and saved for staff to review. o Within 30 days of an employee’s start date the individual will participate in all approved USCCB training on reporting requirements. - Case File Review o Within the first week of arrival, the Program Director will review a case file. o Thereafter, a weekly case file review to monitor that case files have required documentation in accordance with the federal guidelines will be completed.

Management’s Corrective Action Plan Management takes its responsibility to maintain effective internal control over the federal award that provides reasonable assurance that the agency is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the award seriously and gave significant consideration to what additional controls would be effective to ensure the proper amount of indirect costs are charged to all federal grants. To prevent another occurrence, the organization will: On October 17, 2023, the agency refunded the indirect costs that were overbilled in error. By December 31, 2023 and annually thereafter, the Director of Grants Management will provide training and technical assistance to all Grant Specialists and Grant Accountants on allowable costs, including detailed training on proper determination of indirect costs for each grant. This training will also be incorporated into the onboarding process for any new grant staff. Continue its current policy that the Director of Grants Management complete a detailed review of each grant reconciliation monthly, to ensure all costs charged to the grant are reasonable and necessary for the performance of the award. This review will include appropriate tests of indirect costs including ensuring the appropriate indirect cost base is used, all items required to be excluded from the indirect cost base are excluded, and the appropriate indirect cost rate is applied to the indirect cost base. Continue its monthly analytical review to test the reasonableness of grant revenue relative to grant-funded expenditures. At least twice annually, the Controller will complete a second detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. At the end of each award cycle, the CFO will complete a third detailed, documented review of each grant reconciliation to ensure all costs charged to the grant are reasonable and necessary for the performance of the award, which will also include appropriate tests of indirect costs. Going forward, should indirect rates or methodologies change for any award, the CFO will review the grant reconciliation the first month following the effective date of the change to ensure the change has been properly implemented.

Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System’s expense tracking spreadsheet, which identified the expenses claimed under the federal program as allowable costs included three expenses which were subsequent to December 31, 2022, and therefore, outside the period of performance. Although invoices were approved for payment, only one invoice included documentation relating to specific approval as allowable costs related to the grant. Likewise, the Health System’s expense tracking spreadsheet did not include a documented secondary review and approval by someone other than the preparer. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a control process which includes an independent review and approval of the expense tracking spreadsheet which identifies the expenses claimed under the federal program as allowable costs and retain documentation of the review process. The expenses referenced as being outside of the period of performance were costs to a vendor whom was contracted/engaged prior to the period of performance. Due to supply chain/vendor demand issues, the work was completed subsequent to the period of performance. It was our understanding that these are eligible expenses under the program, as the work and payment was delayed due to supply chain/vendor demand issues. However, if necessary, we have identified other qualifying expenditures incurred within the period of performance we can submit which will satisfy allowable costs claimed for the period of performance. Anticipated Completion Date: 01/31/2024

Finding 2023-001 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. The expenditures were reported on the schedule of expenditures for federal awards subsequent to the period of performance end date. These funds were not charged to the agency and are considered cost share for the grant as the work on the grant continued past the grant end date. We will review our grant close-out procedures to ensure that grants are closed out in a timely manner based on the grant end date preventing subsequent charges to the grant award. Anticipated Completion Date: March 1, 2024

Management’s response - In response to the finding indicated in the governance letter, management recognizes that the physical work performed for this expense occurred in FY23, but this is also an ongoing project and the period of performance for the ARP ESSER grant ends on 9/30/2024 not 6/30/23. Therefore, Management believes their interpretation is also correct. All federal and state grants with a period of performance ending 6/30/23 were accrued back to FY23 ensuring payments and receipts activities were in the correct time frame. Final reimbursement was requested, and the grants were closed out. The implementation of our new financial system also added an extra layer of complexity to our end of year accounting. Work in 2 different systems that do not work cohesively with each other was very challenging. We respect and appreciate the work of our auditors and understand that at times we will disagree and interpret things differently, which is what happened in regard to the expense for the HVAC project surrounding the "period of performance" language.

Name of Auditee: Poughkeepsie Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: March 31, 2023 CAP Prepared by: Thomas Shanley, Accountant Phone: (845) 485-8931 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2023-002 (a) Comments on the Findings and Recommendations - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action Taken - The Authority also agrees with the recommendation and will review all compliance requirements and HUD notifications for all new funding sources. (c) Planned Implementation Date - The Authority expects to complete the corrective action by March 31, 2024.

State Agency: Office of Children and Family Services Single Audit Contact: Bonnie Hahn Title: External Audit Liaison Telephone: 518-486-1034 E-mail Address: Bonnie.Hahn@ocfs.ny.gov Federal Program(s) (ALN # [s]): Rehabilitation Services-Vocational Rehabilitation Grants to States (84.126) Audit Report Reference: 2023-010 Anticipated Completion Date: January 15, 2024 Corrective Action Planned: New York State Commission for the Blind (NYSCB) is updating the Internal Controls and Data Validation policy for the RSA 911 report to implement an additional control to ensure the accuracy of the key elements including ‘Start date of Employment in Primary Occupation’ #350. The Senior Vocational Rehabilitation Counselor (VRC) will review the start date for employment during their review of cases when the Individualized Plan for Employment (IPE) is approved and at the time of successful closure. The Senior VRC will also verify that the employment start date is entered and accurate on the employment information form in the case management system. Training on this additional internal control will be provided to the Senior Vocational Rehabilitation Counselor’s and District Managers virtually on December 11, 2023. State Agency: State Education Department Single Audit Contact: Jeanne Day Title: Auditor 3 Telephone: 518-474-5919 E-mail Address: Jeanne.Day@nysed.gov Federal Program(s) (ALN # [s]): Rehabilitation Services - Vocational Rehabilitation Grants to States (84.126) Audit Report Reference: 2023-010 Anticipated Completion Date: December 2023 Corrective Action Planned: Adult Career and Continuing Education – Vocational Rehabilitation (ACCES-VR) will continue to implement and document review processes and methods. The implementation of the Aware electronic case management system is complete and will enhance the agency’s review process. A review process memo is currently in development related to Testing and will clearly document the scope and requirements associated with the review process.

Planned Action: The organization will review and revise all internal processes to ensure that there is proper accounting regarding this program and others. A review of policies and systems will be an important part of this process to ensure that only expenses incurred during the period of performance are billed to the grants.

2023-001 Cash Disbursement Review and Approval. BPC established its policies and procedures that included processes for proper approval of all transactions in September of 2023 during the audit for the previous year. The transactions without approval were all prior to the new policy and procedure. The organization continues to follow written policies and procedures for proper approval of all transactions posted in the general ledger.

Finding number: 2023-002; Finding: During our testing, we noted that internal controls were not properly designed over activities allowed or unallowed, allowable costs/cost principles and period of performance to identify program expenditures from other expenditures in the cost center. Additionally, we noted controls were not operating as designed to ensure payroll expenses charged to the program were properly approved. In our sample of 20 payroll expenditures, two had no evidence of timesheet approval. Correction actions taken or planned: Additional review and approval of allowable expenditures will be done by another individual outside of the preparer. Any payroll related dollars charged to the grant will require sign off by the manager prior to charging the expense to the grant. Anticipated completion Date: February 2024; UW Health employees responsible for Corrective Action Plan: Heather Brahm, Director of Finance & Controller, and Jamie Soyk, Program Director of Financial Reporting

Finding Number 2023-005 — Significant Deficiency in Internal Control/Non-Compliance — Appropriate Expense Period of Covid 19-ESSER II 23b — Credit Recovery Condition: During expense testing of ESSER funds, a journal entry that reclassed the cost of Edmentum, program licenses for Plato courses, had expensed the entire annual license fee. The period for eligible expenditures did not begin until October 1, 2022. This journal entry expensed the full cost of the invoice, $11,914.50, and the district did not prorate the costs to include only those expenses from October 1, 2022 through June 30, 2023. The District did not adhere to the proper period for expenditures. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop a summary of all federal grants. This summary will detail the fiscal year it is associated with but more importantly, it will provide the proper period of eligible expenditures for each federal funding source. This summary may be used and readily available at the time approvals are granted for expenditures. If an expense does not fall within the eligible time period, the expense can be rejected by the approver. This summary will be shared with all administrators and staff. In addition, the process for reclass journal entries will also include a pause to check that each invoice associated with a federal grant, is falling within the proper period of expenditures. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools

United States Department of Treasury Indiana Finance Authority, a Component Unit of the State of Indiana (IFA) submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Katz, Sapper & Miller, LLP 800 East 96th Street, Suite 500 Indianapolis, IN 46240 Audit period: Year ended June 30, 2023 The findings from the schedule of findings and questioned costs for the year ended June 30, 2023, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINANCIAL STATEMENT FINDINGS None FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-001 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Significant Deficiency in Internal Control over Compliance and Noncompliance – H. Period of Performance Recommendation: The Auditor recommended the IFA implement procedures to ensure the disbursement review process is operating effectively. Planned Corrective Actions: The Indiana Finance Authority (IFA) has procedures in place to assure the appropriate use of the federal funds the IFA manages. IFA oversight includes the robust review process of all disbursements which includes IFA engineers and finance staff. With respect to the matter your letter references, the IFA reviewed our existing Standard Operating Procedures and have edited them to reflect the date of the period of performance as part of the checklist for the program. The new IFA Program Manager has been updated on the procedures and the importance of being in compliant with the federal guidelines. The funds were corrected subsequent to year end and paid with operating revenues during fiscal year 2024. If the United States Department of Treasury has questions regarding this plan, please call Dan Huge, Public Finance Director of the State of Indiana at 317.233.4332.

See corrective action plan in audit report

Corrective Action Plan 2023-002: The University concurs with the finding and has provided corrective action through correcting the identified errors and adding additional review of the R2T4 calculations. Anticipated Completion Date: June 2023 Contact Person: Reta George, Director of Student Financial Services

Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi, Vice President and CFO Completion Date: March 31, 2022

Finding Reference Number 2022: Approval and Support for Costs Description of Finding: For the Emergency Rental Assistance Program, adequate supporting documentation could not be provided for 8 of 60 transactions tested, and 16 of 60 transactions did not contain evidence of appropriate approval. The audit reports questioned costs of less than $25,000. Statement of Concurrence or Nonconcurrence: Threshold CoC concurs with the finding. Corrective Action: Management will continue to follow and reinforce established internal controls for processing and approving costs charged to federal programs. Personnel responsible for processing and approving federal expenditures will receive additional training. Management will require adequate supporting documentation to be retained with each charge and evidence of appropriate review and approval before costs are charged to a federal program. This is similar to prior-year finding 2021. The corrective action above strengthens documentation retention, approval evidence, and staff training in response to the repeated issue. Name of Contact Person: Jason Feldhaus, Executive Director, jason@thresholdcoc.org Projected Completion Date: December 31, 2026 Questioned Costs: Less than $25,000, as reported by the auditors.

We will estalish a procedure by which review of invoices for grant-funded expenses will include compliance with allowable expenses and period of performance and note it on the invoice.

We will establish a procedure by which review of invoices for grant-funded expenses will include compliance with allowable expenses and period of performance and note it on the invoice.

Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. CFDA numbers for new federal awards will be identified, along with the applicable compliance requirements in accordance with the OMB Compliance Supplement (Matrix of Federal Compliance Requirements). Policies and procedures will be established for each applicable compliance requirement and will be communicated to employees responsible for monitoring and ensuring compliance.

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCA has worked diligently to strengthen its accounting standards when it comes to Federal awards, including the centralization of reporting through its YESS shared services accounting systems and procedures. Operations personnel review the tenants of the grants up front in the process of executing each Federal grant. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: Complete

The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.

Management agrees with the finding presented by the audit. Management has taken corrective actions to meet this standard. The Organization has taken corrective actions to meet this standard for FY23. These actions include the Organization implementing a grant reimbursement approval system with three levels of review. The controls include segregation of duties between the employee who process the data and the employees who review in order to ensure any errors are identified and remediated prior to submission to the grantor. The Staff Accountant and Shared Services team process data for reimbursement and provides the data to the Finance Manager to review and create the grant filing. Once the grant filing is prepared, the Grant Administrator reviews the grant filing and provides the completed filing to the Operations Director to review and approve prior to submission to the grantor.

Finding No.: 2022-042 AL Program: 97.036 - Disaster Grants - Public Assistance (Presidentially Declared Disasters) Area: Period of Performance Questioned Costs: $423,234 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: 1. Regarding the finding related to DR4235MP, PW 95, the Public Assistance Office agrees that the liquidation was processed after the liquidation deadline. 2. Regarding the finding related to DR4396MP, PW 4, the Public Assistance Office disagrees with this finding. Liquidation was done prior to the closeout deadline of December 31, 2022. 3. Regarding the finding related to DR4511MP, PW 27, the Public Assistance Office disagrees with this finding. Liquidation was done prior to the closeout deadline of June 30, 2025. 4. Regarding the finding related to DR4511MP, PW 8, the Public Assistance Office disagrees with this finding. Liquidation was done prior to the closeout deadline of June 30, 2025. As of Fiscal Year 2024, the Public Assistance Office initiates drawdown requests, allowing for more timely processing. The office will implement better financial monitoring procedures to ensure obligations are liquidated within the required liquidation period. Staff will also be refreshed on liquidation requirements to ensure compliance. When delays are anticipated, the office will coordinate with subrecipients and promptly request necessary time extension approvals from Grantor to maintain compliance. Proposed Completion Date: Ongoing Condition 2: The Public Assistance Office respectfully disagrees with this finding. • Regarding the finding related to DR4235MP, PW 49, the Public Assistance Office disagrees with this finding. The invoice was dated and recorded after the period of performance (June 30, 2022), but date of actual work completed as shown on the Megger Test was May 20, 2022. The Public Assistance Office acknowledges that the record of the Megger Test had not been submitted to the auditors when submitting documentation. The Public Assistance Office will continue to exercise diligence in reviewing project documentation to ensure that all work is verified and completed prior to payment/reimbursement. The office will continue to monitor performance timelines to confirm that work is completed on or before the established period of performance deadlines. This process will include periodic internal reviews and coordination with subrecipients to ensure compliance. When delays are anticipated, the office will coordinate with subrecipients and promptly request necessary time extension approvals from Grantor to maintain compliance. Proposed Completion Date: Ongoing