Corrective Action Plans

During fiscal year 2024, the College had two grant awards with Natural Resources Conservation Services (NRCS). The first grant award was from September 1, 2022 through August 31, 2023. The second grant award was from the date of final contract signature which was September 29, 2023 through September 21, 2028. Due to the gap period between contracts, the September 2023 NRCS general ledger was cleared of any expenses. A grant program staff member attended a training in August 2023 and submitted for travel reimbursement in October 2023. Grant program staff members attended a conference in September 2023 and the registration fees were paid in October 2023. The travel reimbursement, conference registration fees and corresponding indirect costs were included in the October 2023 financial report submitted to NRCS for reimbursement. Once the error was discovered, the expenses were removed from the NRCS general ledger and charged to an ·appro pri at e account. An adjustment was made to reduce the expenses on the October 2024 financial report submitted to NRCS. The college recognizes the importance of proper reporting for financial reports and reimbursement requests and that those reports should only include costs that are incurred during the grant period. The grant finance team will work with grant program staff to implement a schedule that will help to ensure that goods, services and travel are completed during the grant term, that invoices are submitted in a timely manner and prior to grant end, and when possible, payment will be made for said items prior to the end of the grant term. The grant finance team will review expenses incurred during the grant term and immediately following the grant term to confirm expenses are being reported in the correct period for financial reporting and reimbursement requests. Person(s) Responsible: Carrie Patton, Jen Evans Timing for Implementation: Immediate

CORRECTIVE ACTION PLAN: Staff transitions in Financial Aid and the Enrollment Center at the onset of the Fall 2023 term contributed to the later-than-usual submission/certification of First of Term enrollment reporting. Financial Aid and the Enrollment Center experienced staff shortages with resignations and leave. The initial fall enrollment (First of Term) was certified by the Institution and submitted to the National Student Clearinghouse (NSC) on October 18, 2024 within 60 days of the start of the term on August 21, 2023, but the National Student Loan Data Systems (NSLDS) did not receive the submission within the 60-day requirement. Although we anticipate this to be a one-time incident, to prevent any recurrence and ensure enrollment changes are reported to NSLDS within 60 days, Financial Aid provided additional staff training in the Enrollment Submission process, and Early Registration enrollment submissions will be submitted within the first week of classes with the First of Term enrollment submission sent during the third week of classes. Financial Aid also updated the Institution’s NSLDS profile to ensure that records submitted for NSLDS Transfer Monitoring and Financial Aid History are added to the Enrollment Roster submitted to NSC. Financial Aid and the Registrar established an updated policy to ensure that Financial Aid is informed of students who graduate after the graduation process runs each term. After that, the Registrar will report late graduations to the National Student Loan Data System (NSLDS) via the National Student Clearinghouse (NSC). Financial Aid updated the student in question’s graduation status in NSLDS. Person(s) Responsible: Angela Weaver Timing for Implementation: Immediate

MW 2024‐001 REPORTING Recommendation: The Chief Operating Officer should obtain in writing any adjustments or clarifications to the grant awards to ensure the requested reports are prepared and reviewed. Management’s Response: EPA has never requested the SF425 (Federal Financial Reporting Form) from year’s prior and we were told verbally that we were only required to submit them at grant closeout. During a current EPA OIG audit, we were informed that the procedural process we were following was incorrect and that yearly reports were required to be submitted. To bring the IRL Council back into compliance with all federal awards, the Chief Operating Officer completed the FY 2024 forms and submitted them to EPA on March 10, 2025. Responsible Party: Daniel Kolodny, Chief Operating Officer Anticipated Completion Date: Remedial action completed on March 10, 2025.

Teenage Pregnancy Prevention Program – Assistance Listing No. 93.297 Recommendation: We recommend the Organization implement stronger internal controls to monitor the period of performance on its federal awards. This includes regular training for staff on compliance requirements and establishing clear communication channels between finance and program departments. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PPNCS has reviewed and updated processes to ensure the expenses for the grant period are for the period in question and not merely reported in the General Ledger during the grant period. Name of the contact person responsible for corrective action: Randy Drager, CFO Planned completion date for corrective action plan: May 1, 2025

In order to strengthen internal controls, the School District will train the staff responsible for reimbursement requests, final reports, and amendments as well as those responsible for purchasing for the grant to ensure that there is proper supporting documentation and grant management. The training will include but is not limited to: NJ Finance law, good business practice, as well as a review of the purchasing manual. After this training in completed, the business office will be responsible for the review of reimbursement requests, final reports, amendments and purchases, prior to completion and submission to ensure compliance with the grant requirements and purchasing laws.

Finding: The Department of Children, Youth, and Families did not have adequate internal controls over and did not comply with requirements to ensure payments to providers were allowable and properly supported for the Social Services Block Grant. Questioned Costs: Assistance Listing # 93.667 Amount $9,098,747 Status: Corrective action in progress Corrective Action: The Department maintains that funds were not improperly charged or reported for the Social Services Block Grant (SSBG) program. The Department implemented grant-level management of all federal funds, including the SSBG program. This process consists of making grant-level adjustments between allowable grant sources to properly spend grant funds within the allowable period of performance and ensure level of effort and matching requirements are met. The Department allocated the SSBG funds to eligible clients and allowable activities in compliance with 45 CFR 98.67 but did not include the level of data recommended by the State Auditor’s Office (SAO) for some transfers. In response to the auditor’s recommendations, the Department submitted a budget request for the 2024 supplemental budget. The enacted budget included funding to implement the Department’s budget request beginning July 1, 2024. The Department is working with a developer to assist with building out the required databases between the Social Service Payment System and the Agency Financial Reporting System to allow transfers between funding sources to include transaction level data related to the expenditures. The Department is committed to collaborating with SAO to determine an appropriate methodology which identifies a sampling unit that can be used to accurately test compliance. The Department looks forward to working with SAO to resolve the data concerns in the audit of the SSBG program. The conditions noted in this finding were previously reported in finding 2023-070. Completion Date: Estimated December 2025 Agency Contact: Stefanie Niemela Audit Liaison PO Box 40970 Olympia, WA 98504-0970 (360) 725-4402 stefanie.niemela@dcyf.wa.gov

Finding: The Department of Commerce did not have adequate internal controls to ensure payments to subrecipients were allowable, properly supported and met period of performance requirements for the Coronavirus State and Local Fiscal Recovery Funds. Questioned Costs: Assistance Listing # 21.027 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Department maintains that there are effective internal controls over programs that are funded by the Coronavirus State and Local Fiscal Recovery Funds. Due to delayed audit planning and scoping, the auditors were unable to perform procedures to ascertain whether the Department established and followed internal controls to ensure compliance with program requirements. The Department plans to ensure sufficient time and resources are available for all future audits by performing the following steps: • Performing outreach to all federal programs to document internal controls for all applicable compliance requirements before the start of the next single audit cycle. • Working with the State Auditor’s Office earlier in the audit cycle to identify the audit scope for selected programs. • Providing support and guidance to programs selected for audit to ensure compliance with all internal controls and compliance requirements. The conditions noted in this finding were previously reported in findings 2023-027, 2023-028, and 2022-019. Completion Date: Estimated August 2025 Agency Contact: Gena Allen, CFE Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov

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