Corrective Action Plans

State Agency: Office of Children and Family Services Program Name: Rehabilitation Services – Vocational Rehabilitation Grants to States ALN #: 84.126 Single Audit Contact: Bonnie Hahn Title: Audit Liaison Telephone: (518) 486-1034 E-mail Address: Bonnie.hahn@ocfs.ny.gov Audit Report Reference: 2025-001 Anticipated Completion Date: 3/31/2026 Corrective Action Planned: The New York State Commission for the Blind (NYSCB) opens and maintains cases of blind and visually impaired individuals who apply for vocational rehabilitation and low vision services. Participants can apply and receive services multiple times, which can result in reporting more than one cycle on the RSA-911. In some cycles, the cases were open for more than 10 years, so the original application date is reflected on the RSA-911. These instances resulted in missing signatures on applications or Individualized Plans for Employment (IPE). The NYSCB has implemented a process that requires each Senior Vocational Rehabilitation Counselor (SVRC) to select 5 cases per month to complete an internal case review. There are two Internal case review forms used- one is for the case to be reviewed at IPE development or re-development and the other form is for the case to be reviewed at placement/case closure. If the SVRC finds documentation or signatures missing, they will notify the Vocational Rehabilitation Counselor (VRC) of the missing information by providing the completed form with their comments and follow up required. This process will continue. NYSCB will be providing further training to VRCs who complete applications and develop IPEs to emphasize the importance of having the participants sign the required forms. In addition, NYSCB will be providing training to the supervisors (including SVRCs and District Managers) in each district office when applications are taken by telephone to provide reasonable accommodations to our blind participants. Senior management will develop a written protocol which each district will be required to follow for how to manage accepting applications and signatures when cases are assigned to VRCs.

2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurred before the Federal award was made that were authorized by the Federal awarding agency or pass-through entity. All financial obligations incurred under the Federal award must be liquidated within the required time period. Costs incurred outside the approved period of performance are unallowable and constitute questioned costs. Client’s Response: During the grant cycle, the Organization submitted for an extension but did not receive confirmation of said extension. During the current fiscal year, the Organization has implemented additional controls to ensure that all grant funding is expended within the timeframe allotted. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444

2025 – 001: Period of Performance Federal Program CFDA # 14.872 Capital Fund Program Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: Recommendation: It is recommended the Authority review all of the policies in place relating to the obligation of capital programs to ensure that funding is properly obligated and expended within the required time frame. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in response to finding: The PHA will proactively seek clarification from HUD when guidance is unclear or when operational challenges arise. The PHA remains committed to full compliance with HUD requirements and values its collaborative relationship with HUD. The Authority appreciates the guidance and technical assistance provided and will continue to work proactively to ensure clarity, transparency, and accountability moving forward. Name of the contact person responsible for corrective action: Jacque Sikes, Executive Director Planned completion date for corrective action plan: January 2026

Western Wyoming Community College experienced a transition in leadership within the Financial Aid Office, resulting in a change in the Director of Financial Aid position. This transition caused disruptions in communication and process continuity between the Financial Aid, Registrar, and Institutional Effectiveness offices. As a result, inconsistencies were identified in the timing and accuracy of enrollment reporting to the National Student Clearinghouse (NSC) and the National Student Loan Data System (NSLDS). Corrective Action Plan 1. Leadership and Process Realignment a. A new Director of Financial Aid has been appointed and is collaborating with the Institutional Effectiveness Office and the Registrar to define clear processes and timelines for Records & Registration and Financial Aid operations. b. The Director of Financial Aid and Registrar will maintain continuous communication to ensure timely and accurate enrollment reporting and prompt correction of any identified discrepancies. c. The Director of Financial Aid and Registrar will work together to develop a Standard Operating Process (SOP) to ensure if any future attrition occurs in either department that anyone else in those departments will be able to step in and continue processing without interruption ensuring timely and accurate enrollment reporting continues. 2. Implementation of Controls for Third-Party Reporting a. Recognizing the benefits and responsibilities of using the National Student Clearinghouse (NSC) for enrollment reporting, the institution has implemented controls to verify the accuracy of data transmitted through this third-party servicer. b. The Assistant Director (or the Director of Financial Aid in the Assistant Director’s absence) will generate the Summary Return of Funds Report (ROFS) from Colleague each term and provide a copy to the Registrar for enrollment verification and reconciliation. 3. Quarterly Reconciliation and Internal Review a. The Financial Aid Office will conduct a quarterly comparison between Colleague and NSLDS records to ensure consistency of enrollment and status dates. b. Any discrepancies identified will be communicated to the Registrar for prompt resolution. c. Results of the quarterly reviews will be documented and used for internal compliance monitoring and training. 4. Updated End-of-Term Procedure To ensure ongoing accuracy and compliance, the following revised steps will be followed each term: a. The Director or Assistant Director of Financial Aid will run an All F Report after final grades are posted. b. The Director and Assistant Director of Financial Aid will jointly calculate Return to Title IV (R2T4) funds. c. The Return of Funds Report (ROFS) will be provided to the Registrar monthly to verify last date of attendance and withdrawal dates against Colleague records. d. The Registrar will verify subsequent semester enrollments and continuously monitor student enrollment, reporting any changes to Financial Aid leadership. e. The Registrar will submit end-of-term enrollment data to the National Student Clearinghouse as usual, and one week before the next term begins, will submit the end-of-term R2T4 list to prevent overwriting by subsequent semester reporting. 5. Training and Internal Audit Enhancement a. The Financial Aid and Registrar’s Offices will use findings from this audit to develop staff training on identifying and correcting data discrepancies during the quarterly reconciliation process. b. The Director of Financial Aid will review 80% of R2T4 files during each semester for accuracy in reporting and documentation. 6. Graduation Data Accuracy a. The Registrar’s Office utilizes the Update Academic Credentials File (UACF) in Colleague to batch post student degrees and certificates three times per year (end of spring, summer, and fall terms). b. It was determined that the automatic graduation date populates correctly only when students have a single program with no changes. For students with multiple programs or program changes, the graduation date must be entered manually to ensure accuracy. c. The Registrar will oversee the upload of graduates and verification of accurate credential dates, ensuring these dates are correctly reflected in NSC and the Director or Assistant Director of Financial Aid will make sure the dates are correctly reflected in the NSLDS system. d. The Registrar and Director of Financial Aid will conduct joint reviews to verify that all graduation and enrollment data are reported correctly. Anticipated Completion Date: June 30, 2026 Contact Persons: DeeAnna Archuleta, Director of Financial Aid, and Kayla Miller, Registrar

SIGNIFICANT DEFICIENCY 2025-001 Federal Program Student Financial Assistance Cluster Compliance requirements Special Tests and Provisions – Return to Title IV Condition Of the 37 students tested for Return to Title IV procedures, 2 were determined to have had errors in their calculation. Recommendation We recommend that the College review and update its policies to ensure that accurate Return to Title IV calculations are completed. Comments on the Finding For the issue with an institutional charge incorrectly considered in the R2T4 calculation, this was due to a Federal Direct Parent PLUS Loan that was processed and a refund to the parent. Only seven of these loans were processed in the aid year of 2024-25, and there were no other R2T4 situations that involved a Federal Direct Parent PLUS Loan. The refund to the parent was shown at the top of the Banner form while student refunds show at the bottom of the Banner form. Due to the rarity of these loans being included in the calculation and the variation of where this charge is shown in Banner, this was missed. Barton personnel are now aware of where to look for this in these very rare cases. For the situation where the incorrect starting date was identified, there was human error when that was entered. Barton does have a quality assurance process to double check all dates on the Banner withdrawal form, and the R2T4 calculation spreadsheet, however, this review will now extend to checking the enrollment dates in a second Banner form. Action Taken Since the 2024-25 aid year was still open, both instances were corrected. Barton’s Director of Financial Aid has made all personnel aware of the issues and has revised the quality assurance review to watch for these issues.

Funds were drawn outside of the approved grant period because construction began before the grant start date. A reimbursement request was submitted and approved erroneously by the Environmental Protection Agency (EPA) for work completed prior to the eligible period. To correct this, the City is working with the EPA and has submitted a corrective request for reimbursement that will apply the funds already received to eligible work performed within the grant period. No additional funds will be transferred, as the total eligible amount in the corrective request will equal the amount previously received, ensuring all reimbursements align with allowable costs. To prevent recurrence, the City will avoid beginning construction before the official grant period begins and will ensure future grant budget periods include adequate contingencies for early project start dates. Additionally, all future reimbursement requests will undergo a thorough internal review to verify that costs were incurred within the approved grant period, rather than relying solely on federal approval.

Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. The College experienced some turnover during the year. The new director was unaware that the Cost of Attendance was not being updated when a change in the award was submitted COD due to a change in the student’s schedule. The director is now aware that these changes must be updated manually in COD and has implemented procedures to ensure that the COA is reviewed whenever a revision to the student award is submitted to COD. The college will also confer with the software vendor to determine if any settings in the student information need to be corrected for this update to be automated. The new director of financial aid has been through substantial training in the last six months to better understand how the college’s software communicates with COD and has implemented procedures to ensure the timely submission of disbursements to COD after the disbursements have been made in the student information system. Anticipated Completion Date: Prior records with issues were corrected on September 1, 2025 and ongoing monitoring is taking place

Finding 2025.004 – Period of Performance Federal Program Name: Continuum of Care Federal Assisted Listing Number:: 14.267 Recommendation We recommend that management implement additional controls and policies over period of performance. Staff who purchase items with grant funds should have additional training on period of performance requirements. Planned Corrective Action: TVCCA is strengthening its period of performance controls through the following actions: 1. Training – All employees with purchasing power will be trained on the deadlines of the grants they are responsible for. This training includes what the definition of obligation truly is, as well as allowable spend down period of their grants. Finance staff will also be trained on the timing and definitions of obligations. 2. Revised internal controls and workflow – Cutoff testing will be performed and added to the month close checklist on a quarterly basis to align with grant closing schedules. 3. Monitoring – Cutoff testing will be monitored on a quarterly basis in association with quarter ending checklist. Name of Contact Person: Max Logan, CFO, 860-425-6506, mlogan@tvcca.org Anticipated Completion Date: March 31, 2026

The Administrative Services Office and the Student Affairs Office, or the Grant Manager/Principal Investigator responsible for any specific grants going forward, will work closely with the granting agency to ensure that any unanticipated changes/reductions in funding periods are communicated in time to allow the College to effectively close out the grant, or to obtain permission for funding of expenditures that will not be incurred/and or liquidated timely. Anticipated Completion Date: N/A Contact Person(s): Willie Noseep, Vice President for Administrative Services Coralina Daly, Vice President for Student Affairs

Management agrees with the auditor’s finding and their recommendation. The School returned $37 of Pell Grant Funds on November 25, 2025. Communication will be improved between the financial aid office and the registrar. Procedures will be improved to ensure that R2T4s are calculated correctly. Anticipated Completion Date: The corrective action was completed on November 25, 2025. Contact Person Valorie Quesenberry, Financial Aid Coordinator 513-763-6659

Finding 2025-002 - Accounting Controls - capital Fund Grant Management (Cash Management)-ALN 14.872 Public Housing capital Fund - Noncompliance and Significant Deficiency Corrective Action Plan: AHC has assigned two Senior Managers with eloccs secure system) access. Person Responsible: Shlrley Henderson, Deputy Director, Arnesha Nuniss and Abe Singh, Ex. Dir. Who is waiting for his eloccs access Anticipated Completion Date: September 10, 2025.

Research and Development Cluster— Assistance Listing Nos. Various Recommendation: We recommend that the University review its procedures around review and approval of R&D expenditures to ensure that only valid expenditures are reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University does have existing internal control processes over its federal grants. The principal investigators code, approve, and submit expenditures for payment. In addition, principal investigators receive periodic grant reports which include the detail of all transactions charged to their grants for review. The University will add an additional control step to review coding of research and development payment requests in the ERP system prior to payment. Names of the contact persons responsible for corrective action: Gerri Stepanek and Carole Kampf Planned completion date for corrective action plan: September 1, 2025

Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025

Management agrees with the finding and will establish the internal control recommendations outlined in the Schedule of Findings and Questioned Costs. Internal control procedures will be developed and implemented by September 2025.

Juel Fairbanks Chemical Dependency Services has implemented a change in how we do our day-to-day process of approvals of payments, authorized signature for payments prior to being issued.

Once payroll is processed by the Department of Finance (DOF), a Flex Earnings Report is generated by the Analyst on each payday. A reconciliation is then performed to ensure that all employees, along with their respective fringe benefits, are accurately captured and drawn. Following this process, DOF posts the payroll to the accounting system. However, staffing has identified that deficiencies can occur in DOF’s postings, sometimes arising in periods subsequent to the actual payday. To address this, the Department of Human Services (DHS) has incorporated an internal control requiring retrospective reconciliation of accounts against the Flex Earnings Report to verify accuracy. Additionally, DHS plans to engage with DOF to better understand the underlying factors and nuances that result in discrepancies between DOF postings and the account coding reflected in the Flex Earnings Report. The Federal Grants Financial Analyst also plays a key role in ensuring that transactions are recorded in the appropriate accounting period and that costs are properly allocated. In this particular instance, no federal funds were drawn.

VIDE is strengthening its internal controls and record retention procedures to ensure strict adherence to federal period of performance and liquidation provisions. To address the missing payment support, the department is enforcing a strict back-end system control. All required supporting documentation evidencing payment must be attached directly to the transaction entry within the ERP system prior to final disbursement. To address the specific instance regarding the missing indirect cost reimbursement report, VIDE will leverage its newly finalized Indirect Cost Standard Operating Procedure (SOP). VIDE will coordinate with the Third-Party Fiduciary Agent (TPFA) to ensure that all detailed reimbursement reports are actively verified and securely stored in a centralized repository before indirect costs are drawn down and liquidated. Furthermore, the Office of Fiscal and Administrative Services will implement a mandatory final review step during the grant closeout and liquidation phase. This review will systematically verify the presence and accuracy of all payment and indirect cost documentation within the ERP and SharePoint repositories, ensuring that all expenditures are properly supported, allowable, and completely liquidated within the mandated period of performance timeframe.

The Government’s Audit Committee is leading the development of a structured, three-tier policy and procedures framework under the Public Finance Management project. This framework includes Tier 1, which establishes the overarching Financial and Compliance Policy; Tier 2, which defines Standard Operating Procedures (SOPs) to promote cross-agency consistency; and Tier 3, which outlines detailed, step-by-step procedures that clearly define roles and responsibilities and accountability measures to ensure compliance with all federal regulations including period of performance. Regular training sessions will be provided to staff involved in grant management to ensure they understand and adhere to compliance requirements with monitoring and evaluation occurring by the OMB Compliance Unit supported by the Government’s Audit Committee, to assess and improve the effectiveness of controls.

The Government’s Audit Committee is leading the development of a structured, three-tier policy and procedures framework under the Public Finance Management project. This framework includes Tier 1, which establishes the overarching Financial and Compliance Policy; Tier 2, which defines Standard Operating Procedures (SOPs) to promote cross-agency consistency; and Tier 3, which outlines detailed, step-by-step procedures that clearly define roles and responsibilities and accountability measures to ensure compliance with all federal regulations including fiscal and administrative requirements for expending and accounting for payroll expenditures. Regular training sessions will be provided to staff involved in grant management to ensure they understand and adhere to compliance requirements with monitoring and evaluation occurring by the OMB Compliance Unit supported by the Government’s Audit Committee, to assess and improve the effectiveness of controls.

OTAG recognizes the need to strengthen internal controls related to cash management reporting, matching requirement monitoring, and grant period-of-performance compliance. A comprehensive review of existing Master Cooperative Agreement Appendices management processes has been initiated to identify control weaknesses and implement corrective measures. OTAG will implement tracking tools to monitor award periods, liquidation deadlines, and expenditure charging. Personnel will verify Master Cooperative Agreement Appendices periods prior to processing transactions. Expenditures charged to awards will undergo review to confirm alignment with the applicable award and performance period with cross reconciliation of the Government of the Virgin Islands procurement methods, and the Government of the Virgin Islands fiscal enterprise system. Policy and Procedure Enhancements: OTAG will update SOPPs to address cash management, reporting requirements, matching calculations, expenditure monitoring, and period-of-performance reviews. Training will be provided to personnel upon implementation of the revised procedures. Preventive Measures: •Monthly grant reconciliation reviews. •Quarterly compliance monitoring. •Management review of reimbursement requests and matching calculations. •Annual internal compliance assessment. •Centralized documentation repository for grant records. Monitoring & Accountability: The Adjutant General and Executive Director will monitor implementation and effectiveness. Quarterly compliance reports will be provided to agency leadership, and corrective actions will be tracked through completion.

OTAG has reviewed the payroll transactions identified during the audit and has initiated corrective measures to strengthen controls over payroll documentation, appendix charging, and period-of-performance compliance. Payroll expenditures charged to Master Cooperative Agreement Appendices will be subject to quarterly review to verify that timesheets, payroll registers, and supporting documentation are complete, accurate, and retained in accordance with the SF-270 submission requirements. Payroll charges will also be reviewed against periods of performance before posting to ensure costs are assigned to the correct award. OTAG will revise its SOPPs to establish formal procedures for payroll certification, documentation retention, reconciliation of payroll records to timesheets, and review of Master Cooperative Agreement funded personnel costs. Training will be conducted for personnel on documentation standards and allowable cost requirements. To prevent recurrence, monthly reconciliations between payroll records and supporting timesheets will be performed and documented. Quarterly compliance reviews will evaluate payroll charges and supporting documentation for accuracy and completeness. Monitoring & Accountability: The Adjutant General and Executive Director will jointly oversee implementation. Results of monthly reconciliations and quarterly reviews will be reported to executive management.

As part of the close-out process, all open purchase orders are now submitted to the Department of Finance for closure. The grant close-out process has been shifted to the OMB to ensure the grant is no longer available for transaction entries or liquidations. Additionally, a dedicated Federal Grants Financial Analyst is being integrated into the workflow to ensure compliance. Additionally, a Director of Federal Grants has been onboarded to add an additional level of oversight.

VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a rigorous compliance framework to ensure all grant funds are timely obligated and expended in accordance with 45 CFR §96.14. We will achieve this by integrating strict monitoring protocols into our operations, ensuring that the risk of Non-Compliance is identified and escalated to the federal agency in writing as required. Action Steps: 1. Protocol Development & Review – Develop new "Period of Performance Management Protocols" and conduct a comprehensive review of all existing financial reporting procedures to ensure alignment with 45 CFR §96.14. 2. Implement a Warning System – that alerts management 90 days before the end of the obligation period if funds remain unobligated, triggering an immediate internal review. 3. Automated ERP Obligation Tracking – Configure the new Government ERP system to track obligation deadlines at the grant and activity level, providing real-time visibility into the availability of funds and pending commitments. 4. Communication & Escalation SOP – Establish a formal SOP requiring that any anticipated non-compliance be communicated to the federal awarding agency in writing at least 60 days prior to the expiration of the obligation period, with all approvals archived centrally. 5. Segregation of Duties 6. Staff Training – Conduct mandatory training for all staff responsible for grant management on the Period of Performance requirements, including the legal consequences of unauthorized report amendments. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Eddie J. Burgos Auxiliary Administrator for Finance and Budget Carlos Martinez Colón Finance Director Vanessa Ayala Gerena Director of Budget Nesvia Fontanez Marín Principal Accountant Federal Reports Rodolfo Ayala Muñoz Cash Management

FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Burzynski Thaddeus Contact Phone Number and Email Address: 219-755-3200, burzytx@lakecountyin.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The County will develop and implement a proper system of internal controls and segregation of duties. This will ensure accuracy and correctness of all quarterly P & E Reports in the future. Anticipated Completion Date: December 2026

Mansfield Foundation Corrective Action Plan Summary Reviewed and Approved: Frank Jannuzi, Sara Harriger, Lisa Hosegood May 28, 2026 Action 1: Relevant to single audit finding 2024-001: Use external controller services support to ensure timely submission of Required Federal Financial Reports. Planned Implementation An external accounting/controller firm has been engaged to provide oversight and ensure that all bookkeeping and reporting tasks are completed on time. They report to the Vice President and President and work directly with the Director of Finance. They will provide weekly and monthly monitoring of financial procedures, regular financial reporting to management, and track grant reporting deadlines. This arrangement will continue for the foreseeable future. Responsible Party Outsourced CFO; Director of Finance Target Completion Ongoing Action 2: Relevant to single audit finding 2024-001: Apply an internal tracking system to ensure timely submission of Required Federal Financial Reports. Planned Implementation A reporting calendar will be established and maintained by the Director of Programs, with deadlines flagged 30 days in advance. Automated reminders will be circulated to responsible staff one month, two weeks, and one week prior to each filing deadline Responsible Party Outsourced CFO; Director of Finance, Director of Programs Target Completion Implement within three months Action 3: Relevant to single audit finding 2024-001: Implement a management review system to ensure timely submission of Required Federal Financial Reports. Planned Implementation The Vice President will verify completion of each report prior to submission. The President will receive confirmation that the report was submitted on or before the required deadline. Responsible Party President, Vice President, Director of Finance Target Completion Implement within three months Action 4: Relevant to single audit finding 2024-001: Implement a regular briefing to leadership to ensure compliance and monitor timely submission of Required Federal Financial Reports. Planned Implementation Twice annually, the Director of Finance will brief leadership on the status of required reports and confirm compliance. Responsible Party Outsourced CFO, Director of Finance Target Completion Implement within three months Action 5: Relevant to single audit finding 2024-001: Assign clear lines of responsibility to ensure timely submission of Required Federal Financial Reports. Planned Implementation The President and Vice President are ultimately accountable for submission of timely reports and will provide adequate resources and support, monitor regular bookkeeping and grant deadlines, and hold staff accountable for preparation of the reports. The Directors of Programs and of Finance will be the primary lead for monitoring deadlines, gathering information, and effectuating the timely preparation and submission of all financial reports. Responsible Party President, Vice President, Director of Programs, Director of Finance Target Completion Ongoing Action 6: Develop and formally document a standardized month‑end and year‑end close checklist, including required reconciliations, review sign‑offs, and reporting deadlines. Planned Implementation Management will implement a formal month‑end and year‑end close checklist that outlines key close activities, required account reconciliations, documentation standards, review and approval sign‑offs, and established reporting timelines. The checklist will clearly assign responsibility for each task to designated finance personnel to ensure accountability and consistency in execution. Responsible Party Outsourced CFO; Director of Finance Target Completion Implement for the next fiscal quarter close Action 7: Establish documented review procedures for key balance sheet accounts, including independent review of reconciliations and journal entries. Planned Implementation Management will implement formal, documented review procedures requiring monthly balance sheet reconciliations for all accounts, prepared on a timely basis and reviewed by appropriate Finance lead. In addition, management will require review and approval of journal entries associated with period‑end close activities to strengthen oversight and reduce the risk of error or misclassification. These review procedures will be integrated into the month‑end and year‑end close process and retained as part of the Foundation’s accounting records. Responsible Party Outsourced CFO; Director of Finance Target Completion Ongoing Action 8: Implement a formal budget‑to‑actual review process with documented explanations and periodic reporting to the Board of Directors Planned Implementation Management will establish a standardized budget‑to‑actual review process to be performed on a recurring Quarterly basis. This process will include preparation of variance analyses with documented explanations for significant differences between actual results and the approved budget. These reviews will be completed timely and used as a monitoring control to identify unexpected trends or potential misstatements requiring further review. Responsible Party Outsourced CFO; Director of Finance, Director of Programs Target Completion Implement within three months Action 9: Implement a structured system for tracking grants and contributions, including documentation of donor intent, restriction classification, and release schedules Planned Implementation Management will implement formal grant and contribution tracking procedures designed to document donor and grantor restrictions at the time of receipt and to monitor those restrictions throughout the life of the award. These procedures will support appropriate classification of net assets with and without donor restrictions and timely recognition of releases from restriction in accordance with donor intent and applicable GAAP rules. Responsible Party Outsourced CFO; Director of Finance Target Completion Implement within three months Action 10: Establish procedures for timely identification and release of donor‑restricted funds in accordance with donor and grantor requirements Planned Implementation Management will implement documented procedures to ensure that donor‑imposed restrictions and grantor requirements are identified at the time of receipt and tracked throughout the life of the contribution or grant. These procedures will include quarterly review of restricted net asset balances to ensure that restrictions are released in a timely manner when the applicable purpose or time requirements are satisfied. Responsible Party Outsourced CFO; Director of Finance Target Completion Ongoing Action 11: Strengthen technical accounting review through training, cross‑training, and use of qualified external resources as needed. Planned Implementation To address this recommendation, management has engaged an outsourced accounting team to provide technical accounting support and to assist with the development and documentation of formal finance policies and standard operating procedures (SOPs). These SOPs and policies will establish consistent accounting practices, clarify review and approval responsibilities, and provide appropriate documentation to support accounting judgments and GAAP‑compliant financial reporting. In addition, management will implement targeted training and cross‑training within the finance function to strengthen internal technical accounting knowledge and reduce reliance on single individuals for critical accounting functions. Periodic technical review by qualified internal and external personnel will be incorporated into the close and review process to support accurate application of accounting standards. Responsible Party Outsourced CFO; Director of Finance Target Completion Ongoing Action 12: Improve segregation of duties and compensating controls where full segregation is not feasible Planned Implementation To strengthen segregation of duties within the finance function, management has hired a full‑time Finance Associate, which will allow for clearer separation of transaction processing, review, and reconciliation responsibilities. In addition, management has engaged a part‑time, outsourced accounting firm to provide supplemental support, oversight, and review of selected accounting activities. Responsible Party Vice President, Outsourced CFO; Director of Finance, Finance Assistant Target Completion Within six months Action 13: Continued segregation of duties Planned Implementation Where limited staffing continues to constrain full segregation, management will implement and document compensating controls, including review of reconciliations, journal entries, and financial reports by qualified personnel. Management believes these actions will enhance the design and operating effectiveness of internal controls, reduce reliance on single‑person processes, and support more accurate and reliable financial reporting in accordance with GAAP. Responsible Party Vice President, Outsourced CFO; Director of Finance, Finance Assistant Target Completion Within six months