Corrective Action Plans

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

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

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

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

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

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

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

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

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

We concur with the auditor's recommendation to enhance internal controls, ensuring compliance with timely reporting as required by the grant agreements. Calendar reminders will be added to staff's calendars, and multiple levels will be notified of the reporting submissions.

2024-011 Oregon Health Authority Strengthen existing controls to ensure only those costs incurred during the period of performance are charged to the grant Management Response: The agency agrees with the finding. While the appropriate internal controls are in place to review the period of performance, a mistake was made while following the procedures. Secondary reviews will be performed going forward to ensure all expenditures are appropriately captured. The expenditures in question were moved to the correct phase 22 on Jan. 23, 2025 with document BTCG3186. Anticipated Completion Date: January 23, 2025 Contact Person: Travis Labrum, Accounting Manager

2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case management system is well-documented and current. This issue was initially identified during the statewide single audit for the period ended June 30, 2023. In response to the prior year’s finding, the agency created a new case-note category for documenting client employment start date and wages at exit. Compliance with this new control is then verified as part of our pre-closure case file review process. The agency will continue to provide training to staff on the use of this case note category to ensure we are consistently documenting the start date of employment in the primary occupation and the hourly wage at exit. Anticipated Completion Date: July 1, 2025 Contact person: Angel Hale, Director of Vocational Rehabilitation Services

2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We will update internal controls related to this matter. Anticipated Completion Date: September 30, 2024 Contact Person: Bryan Campbell, Vocational Rehabilitation Operations Manager

2024-035 Oregon Business Development Department Ensure CDBG expenditures are recorded in SFMA under the appropriate grant year Management Response: We agree with this recommendation. In February of 2025, the agency’s accountant assigned to this program began a full reconciliation of the CDBG program from FY 2020 to FY 2024. We have identified the differences between our accounting records in SFMA and what has been recorded through IDIS, our portal to request funds from the federal government. As of March 2025, we are beginning to finalize our reconciliation of administrative funds and our own agency’s matching contributions. Once incorporating this first step, our accounting staff will continue with a full project reconciliation for the current fiscal year, 2025. Any errors or adjustments identified will be corrected in this current fiscal year. This reconciliation between accounting records in SFMA and IDIS is expected to be complete in May of 2025. Anticipated Completion Date: May 31, 2025 Contact person: Imee Anderson, Chief Financial Officer, Mia Seo, Deputy-Chief Financial Officer, Rory Spencer, Accounting Manager, Jon Unger, CDBG Program Manager

2024-042 Oregon Military Department Ensure payroll expenditures are coded to the correct period and errors are corrected timely Management Response: We agree with this recommendation. OMD acknowledges the finding regarding payroll expenditures coded outside the period of performance. We are committed to strengthening controls to ensure payroll expenses are properly recorded and errors are promptly corrected. OMD will implement following corrective actions to address the recommendation made in the Audit Report. • All Payroll Coding Review Procedures: Establish a mandatory review process before finalizing payroll reimbursement requests to verify the correct coding of federal fiscal year allocations. • Timely Error Correction Process: Develop a formal procedure to ensure errors are identified and corrected within 60-90 days of discovery. • Training and Oversight: Conduct mandatory training for finance and payroll personnel on proper coding procedures and compliance with federal performance periods. • Review and Correction of Prior Year Coding Errors (FFY 2019, 2022, and 2023): Conduct a comprehensive review of payroll expenditures from FFY 2019, 2022, and 2023 to identify and correct any remaining errors. This process will involve reconciling payroll records with federal grant periods, adjusting accounting records, and ensuring proper documentation for any necessary retroactive corrections. Anticipated completion date: January 31, 2026. Contact person: Adam Giblin, Chief Financial Officer.

2024-041 Oregon Military Department Ensure undisbursed obligation extension support is retained Management Response: We agree with this recommendation. The Oregon Military Department (OMD) acknowledges the finding related to the retention of support for undisbursed obligation extensions. We recognize the importance of maintaining documentation to support the extensions of General Terms and Conditions (GTC) Cooperative Agreement (CA) Awards to ensure compliance with federal regulations and avoid potential funding risks. OMD will implement following corrective actions to address the recommendation made in the Audit Report. • Standardized Documentation Process: We will develop and implement a standardized process for tracking and retaining all submitted GTA CA Award extensions, including detailed listings of un-cleared obligations and projected liquidation timelines. • Internal Review and Monitoring: A designated team within the finance division will conduct quarterly reviews of undisbursed obligations to ensure compliance with extension requirements. • Training and Accountability: Training will be provided to relevant personnel on the importance of documentation retention, compliance requirements, and the consequences of noncompliance. Management will also assign accountability measures to track adherence to the new procedures. Anticipated completion date: June 30, 2025. Contact person: Adam Giblin, Chief Financial Officer.

Harris County Public Health management acknowledges the requirements that each grant has a specified period of performance per the grant agreements of Federal awards. We also agree that failure to ensure expenses are properly reviewed and coded to the correct period or grant could result in noncompliance with the award contract, which may result in the early termination of the grant award, non-reimbursement of grant funding, or cessation of future funding. HCPH management will ensure that a detailed review of the period of performance is performed by grant staff by instituting staff training and reemphasizing the grant closeout process and procedures by September 2025

2024-011 Oregon Health Authority Strengthen existing controls to ensure only those costs incurred during the period of performance are charged to the grant Management Response: The agency agrees with the finding. While the appropriate internal controls are in place to review the period of performance, a mistake was made while following the procedures. Secondary reviews will be performed going forward to ensure all expenditures are appropriately captured. The expenditures in question were moved to the correct phase 22 on Jan. 23, 2025 with document BTCG3186. Anticipated Completion Date: January 23, 2025 Contact Person: Travis Labrum, Accounting Manager

2024-029 Oregon Commission for the Blind Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with the recommendation. The agency is committed to ensuring the RSA-911 client case information report is accurate, and to ensuring the agency’s case management system is well-documented and current. This issue was initially identified during the statewide single audit for the period ended June 30, 2023. In response to the prior year’s finding, the agency created a new case-note category for documenting client employment start date and wages at exit. Compliance with this new control is then verified as part of our pre-closure case file review process. The agency will continue to provide training to staff on the use of this case note category to ensure we are consistently documenting the start date of employment in the primary occupation and the hourly wage at exit. Anticipated Completion Date: July 1, 2025 Contact person: Angel Hale, Director of Vocational Rehabilitation Services

2024-028 Oregon Department of Human Services Strengthen internal controls to ensure performance data reports are accurate Management Response: We agree with this recommendation. We agree with the recommendation and will ensure adequate supporting documentation is maintained and readily available to support information reported in the RSA-911. We will update internal controls related to this matter. Anticipated Completion Date: September 30, 2024 Contact Person: Bryan Campbell, Vocational Rehabilitation Operations Manager

2024-035 Oregon Business Development Department Ensure CDBG expenditures are recorded in SFMA under the appropriate grant year Management Response: We agree with this recommendation. In February of 2025, the agency’s accountant assigned to this program began a full reconciliation of the CDBG program from FY 2020 to FY 2024. We have identified the differences between our accounting records in SFMA and what has been recorded through IDIS, our portal to request funds from the federal government. As of March 2025, we are beginning to finalize our reconciliation of administrative funds and our own agency’s matching contributions. Once incorporating this first step, our accounting staff will continue with a full project reconciliation for the current fiscal year, 2025. Any errors or adjustments identified will be corrected in this current fiscal year. This reconciliation between accounting records in SFMA and IDIS is expected to be complete in May of 2025. Anticipated Completion Date: May 31, 2025 Contact person: Imee Anderson, Chief Financial Officer, Mia Seo, Deputy-Chief Financial Officer, Rory Spencer, Accounting Manager, Jon Unger, CDBG Program Manager

2024-042 Oregon Military Department Ensure payroll expenditures are coded to the correct period and errors are corrected timely Management Response: We agree with this recommendation. OMD acknowledges the finding regarding payroll expenditures coded outside the period of performance. We are committed to strengthening controls to ensure payroll expenses are properly recorded and errors are promptly corrected. OMD will implement following corrective actions to address the recommendation made in the Audit Report. • All Payroll Coding Review Procedures: Establish a mandatory review process before finalizing payroll reimbursement requests to verify the correct coding of federal fiscal year allocations. • Timely Error Correction Process: Develop a formal procedure to ensure errors are identified and corrected within 60-90 days of discovery. • Training and Oversight: Conduct mandatory training for finance and payroll personnel on proper coding procedures and compliance with federal performance periods. • Review and Correction of Prior Year Coding Errors (FFY 2019, 2022, and 2023): Conduct a comprehensive review of payroll expenditures from FFY 2019, 2022, and 2023 to identify and correct any remaining errors. This process will involve reconciling payroll records with federal grant periods, adjusting accounting records, and ensuring proper documentation for any necessary retroactive corrections. Anticipated completion date: January 31, 2026. Contact person: Adam Giblin, Chief Financial Officer.

2024-041 Oregon Military Department Ensure undisbursed obligation extension support is retained Management Response: We agree with this recommendation. The Oregon Military Department (OMD) acknowledges the finding related to the retention of support for undisbursed obligation extensions. We recognize the importance of maintaining documentation to support the extensions of General Terms and Conditions (GTC) Cooperative Agreement (CA) Awards to ensure compliance with federal regulations and avoid potential funding risks. OMD will implement following corrective actions to address the recommendation made in the Audit Report. • Standardized Documentation Process: We will develop and implement a standardized process for tracking and retaining all submitted GTA CA Award extensions, including detailed listings of un-cleared obligations and projected liquidation timelines. • Internal Review and Monitoring: A designated team within the finance division will conduct quarterly reviews of undisbursed obligations to ensure compliance with extension requirements. • Training and Accountability: Training will be provided to relevant personnel on the importance of documentation retention, compliance requirements, and the consequences of noncompliance. Management will also assign accountability measures to track adherence to the new procedures. Anticipated completion date: June 30, 2025. Contact person: Adam Giblin, Chief Financial Officer.

2024-003 – PERIOD OF PERFORMANCE Significant Deficiency Auditee’s Response and Planned Corrective Action This finding relates to Operations funding and FHA fundamentally disagrees with the finding. The obligations for Operations were obligated in a timely manner. eLOCCS demonstrates that FHA was FHA is creating a master Capital Fund tracking calendar reviewed monthly by the Finance Department. FHA is also consulting with HUD field office staff on upcoming CFP grant timelines to avoid future errors. Planned Implementation Date of Corrective Action: Immediate Person Responsible for Corrective Action: Bobbi Richards, Executive Director

Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on invoice date to ensure the incurred date is within the proper period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review grant requirements and make sure that allowable costs are incurred and allocated to the grant within the grant period.