Corrective Action Plans

Finding 2023-004: Federal Procurement Requirements for Policies and Documentation a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities in response to a formal Request for Proposal are consistent with current federal requirements and specifically with the regard to ensuring that proper documentation and records are maintained in sufficient detail to support the history of each procurement transaction by having three competitive bids and retaining the bids in the procurement file. b. Planned Implementation Date of Corrective Action: Management will implement this change immediately. c. Person Responsible for Corrective Action: Executive Director in conjunction with the Board of Directors.

Finding 2023-003: Federal Procurement Requirements for Suspension and Debarment a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities are consistent with the current federal requirements and specifically with the regard to ensuring contractual parties are not disbarred. This is to ensure compliance with HUD entering into contracts with vendors who are disbarred or suspended from participation in federal programs. Maintain documentation in each vendor file to verify selected vendors are not disbarred or suspended. b. Planned Implementation Date of Corrective Action: Management will implement this change immediately to ensure proper documentation is in place for selected vendors. c. Person Responsible for Corrective Action: Executive Director

Management established formalized internal controls in the second quarter of 2023, approved by the Board of Directors, with all fund requests approved by the Executive Director and the CFO.

Management has implemented and adopted a new procurement policy effective May 2023 regardless of dollar value that will maximize open and free competition and that the Trust shall not engage in procurement practices which may be considered arbitrary or restrictive. Purchases will be reviewed by the Tule Trust Finance Committee to prevent duplication and to ensure that costs are reasonable.

Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Division/Office and Individual: • NWYS Housing leadership staff – Luis Reyna, Andy Johnson, Rebecca Pendergraft, Addison Ausley • Finance leadership staff – Stephanie Wagner, Dianne Ersser Estimated Completion Date: 9/30/2024

The Fulton County District Attorney’s Office (FCDAO) was made aware during the recent Department of Justice audit in July 2024 of the need to strengthen compliance in this process. Effective August 2024, processes were revised to comply with the 2 CFR 200 compliance requirement for documentation. The revised processes have been documented and are now included in the FCDAO standard operating procedure for time and effort management.

Management’s Corrective Action Plan For the Year Ended December 31, 2023 Contact Person(s): Sophia Hernandez, Chief Operations Officer Sophia.Hernandez@youthcare.org Amber Aman, Deputy Operations Office - Finance Amber.Aman@youthcare.org Finding Number: 2023 - 002 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective action taken: • Develop a contract expenditure compliance review process created with final review and approval by Deputy Operations Officers. To be established by September 30th, 2024, and implemented in 2025 annual operating plan Anticipated completion date: In Process

The System returned the remainder of funds required. Firelands Regional Medical Center School of Nursing has implemented the following control to prevent this error in the future. The Financial Coordinator will submit a copy of the Return of Title IV funds report to the business office when returning funds. The business office will use this report to make sure the appropriate amount is posted to the student's account.

Recommendation: We recommend that the Organization implements policies and procedures to properly calculate and allocate payroll benefits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will develop and implement an allocation plan for payroll benefits. We will develop process and procedures where charging of payroll benefits expenses to federal grants includes the written recommendation from compliance team and written approval of the CFO/CEO prior to payroll benefits being charged to federal grants. We will consult with the grantor to discuss whether the questioned costs identified in the audit should be repaid. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO) Planned completion date for corrective action plan: 12/31/2024

Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent versus actual time spent. ● From a list of 244 clients, 21 client intake forms (used to determine eligibility for services) for Business Growth Services clients were unable to be produced. The auditors recommend the following: 1. Management to implement procedures to ensure all expenditures, including personnel costs, are properly reviewed, approved, and supported with documentation in accordance with federal regulations. SDA Response The SDA accepts the above findings and would like to add the following information for context: ● The requirement to collect T&E forms wasn’t initially established until the completion of the 2022 audit and after the departure of some personnel. Management attempted to collect T&E forms from prior contractors, but was not successful in securing the specific forms identified by the auditors. ● The SDA created a payroll classification document during 2023 which outlined T&E for all W-2 employees at a set rate for the year. This document, however, was not accepted by the auditors as evidence of actual hours expended on each grant, resulting in this finding. ● The SDA onboarded a new Director of Business Growth Services (BGS) in 2023, which led to changes in both the operational structure and the nature of the data collected for BGS activities. During this period, a data migration took place to a newer version of Salesforce that was built specifically for the SDA. Unfortunately, some data was either lost or unmapped during the migration process, leading to discrepancies in the completeness of historical records. SDA Corrective Actions Management is committed to continue training for personnel to ensure timely completion and compliance of hiring as well as time and effort documentation going forward. The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits.

Corrective Action: ABHS plans to optimize technology to improve the month-end closing process and allow for reconciliations to be performed on a consistent basis. Person Responsible: Alethea Velasquez, Chief Financial Officer, and CLA Estimated Completion Date: December 31, 2024

Finding 2023-001: The Corporation did not obtain a HUD approved management certification (HUD Form 9839-B) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management certification should be submitted to HUD for retroactive approval for the period beginning September 1, 2023. Action(s) Taken or Planned on the Finding: The Corporation concurs with the recommendation and will submit the management certification to HUD for approval retroactively.

LSNYC will ensure that the proper accounting period is selected for all subsidiary ledger entries, as well as all journal entries, before posting is approved into the general ledger. We will also train relevant staff on the importance of recording transactions in the correct period in order to minimize the likelihood of mistakes.

This expense was reallocated to LSC in accordance with LSNYC's Cost Allocation Plan, which was developed to comply with LSC regulations on cost allocations and situations where funders will not cover certain costs. In this situation, the initial funder did not allow capital expenses, which is why the expense was then allocated to LSC. In the future, we will get advance approval for expenses that we know will get allocated to LSC before they are purchased.

Finding No. 2023-001: Fraudulent Payroll Activities Resulting in Theft (Material Weakness) Person Responsible: Reginal Barner Date of Completion: 12/31/2024 Corrective Action Plan: Our fee accountant and payroll consultant will access the payroll process and implement corrective actions, including adding internal controls and training.

AUDIT FINDINGS 2023-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, there was a system pricing issue that resulted in an incorrect amount of expenses related to inventory that were submitted to FEMA for reimbursement. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: FEMA has been notified and the amount has been updated as part of the project closeout. Anticipated Completion Date: September 2024 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2023-001.

Finding Reference Number: 2023-2 Recommendation The Company must deposit $13,918 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

Finding Reference Number: 2023-2 Recommendation Management should establish internal controls and procedures to ensure that surplus cash is properly monitored and disbursed. Reporting views of responsible officials Auditee concurs with this finding. Auditee agrees with auditor recommendations. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management agrees with the recommendation of the auditor and internal controls are being put in place to ensure that surplus cash is deposited into the residual receipts reserve prior to paying down intercompany balances.

Finding Reference Number: 2023-1 Recommendation The Company must deposit $586,006 into the residual receipts reserve. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for depositing surplus cash into the residual receipts reserve. Completion date or proposed completion date: December 31, 2024 Action(s) taken or planned on the finding Management will make the required deposit to the residual receipts reserve.

Management is dedicated to enhancing the competencies of our federal grant personnel. The College will offer focused and comprehensive re-training on both our internal procurement policies and the procurement requirements outlined in the Uniform Guidance to workforce members responsible for procurement under federal awards. This re-training will ensure that all staff members understand protocols and regulations, thereby promoting compliance and efficiency in our procurement processes. The Privacy and Research Compliance Officer will monitor Program Management staff to ensure that price and rate quotations are obtained from a sufficient number of qualified sources. The Legal Department will not move forward in contract drafting until evidence of compliance with the College’s federal procurement policies is confirmed. This collaborative effort ensures informed purchasing decisions based on competitive pricing. Additionally, the Privacy and Research Compliance Officer will maintain evidence of price and rate quotation consistent with procurement policies. Through these initiatives, management aims to ensure procurement that aligns with both internal standards and federal regulations, ultimately supporting the effective and responsible use of federal funds.

Management is committed to enhancing staff knowledge of Uniform Guidance requirements, particularly concerning allowable costs and cost principles. To achieve this, we will implement additional training sessions for all relevant personnel. These sessions will cover key aspects of compliance, ensuring that staff are well-informed about federal regulations and their implications for our grant management processes. The Controller will ensure the calculation of payroll costs are based solely on the actual hours worked and certified by grant personnel. This practice will help maintain accuracy and accountability in our financial reporting. In addition, the Technical and Internal Controls Accountant will conduct quarterly internal reviews to monitor and verify that payroll costs reported on cost reimbursement invoices are consistent with the actual hours certified by grant personnel. These regular reviews will serve as a critical check to uphold the integrity of our financial processes and ensure compliance with federal guidelines. Through these initiatives, management aims to foster a culture of compliance and accountability, equipping our team with the knowledge and tools necessary to effectively manage grant funds.

Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward or downward—to ensure it accurately reflects our current cost structure. To maintain compliance and integrity in our financial processes, the Technical and Internal Controls Accountant will oversee the review of costs included in the indirect cost pool to ensure they meet the criteria for allowability. Additionally, this role will involve verifying that invoices utilize the most current indirect cost recovery rate. Furthermore, management will prepare and submit the required indirect cost proposal to the appropriate cognizant agency to finalize our provisional billing rates used in fiscal year 2023, that aligns with our operational needs and complies with federal guidelines. This proactive approach will strengthen our financial management practices and support our ongoing commitment to transparency and accountability in the administration of federal grants.

US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization requested drawdowns of grant funds in excess of amounts awarded for the grant years ended 10/31/2023 and 10/31/2022 that were denied by the passthrough agency, Omaha Public Schools, resulting in an overstatement in grant revenue and receivables, and federal awards expended included in the schedule of expenditures of federal awards. Corrective Action Plan: Management is in the process of reviewing its accounting policies and procedures over grant monitoring to ensure amounts are tracked appropriately. Management has hired a new fiscal services director to oversee this process. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024

Corrective Action: Name of Contact Person Wayne Moyer and Brenda Chandler To further prevent the issues regarding employee clearances, CSC HR department will have an in-depth discussion with the grantor at time of grant renewal to ensure that the contract language states that the clearances for hiring will be the responsibility of the grantor. While the grantor placed the instructions for clearances in the scope of work for Safe Passage, it was not clearly outlined in the grant under personnel requirements. Proposed Completion Date August 31, 2024

2023-002 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21.027 Recommendation: Procurements should follow the required methods per Uniform Guidance and document the full procurement history. Procurement procedures should be designed, implemented, and written consistent with Uniform Guidance. Personnel responsible for procurement should be trained on Uniform Guidance requirements and Centro Hispano's written procurement procedures. Action Taken: Centro Hispano drafted and approved an Accounting Policies and Procedures manual in September 2024 which conforms with Uniform Guidance requirements.