Corrective Action Plans

COVID-19 State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City reviews its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the procurement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will work with their departments utilizing federal dollars to ensure the proper procurement method is utilized for all procurements and that documentation of that process is retained so it’s clear what considerations were made in the procurement decision. Name of the contact person responsible for corrective action: Pa Thao Planned completion date for corrective action plan: December 31, 2024.

Student Financial Aid Cluster: Federal Supplemental Educational Opportunity Grant – Assistance Listing No. 84.007 Federal Work Study Program – Assistance Listing No. 84.033 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend that the University review policies and procedures related to R2T4 calculations to ensure calculations are performed correctly and timely. We also recommend the University implement formal review procedures to document the Return of Title IV calculations are being performed to minimize the likelihood that errors may go undetected and not be corrected in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This is a repeat finding that was first presented to the university in November 2023, in conjunction with the release of the 2022 audit report. Procedures for review and return of Title IV funds are being updated to ensure refunds are returned in a timely manner. Return of Title IV calculations are being documented and reviewed by a party independent of the preparer to minimize the likelihood that errors go undetected and/or not be corrected in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Mr. Heath Burge, Assistant Vice President for Strategic Enrollment and Advising Services. Planned completion date for corrective action plan: September 2024

Research and Development – Assistance Listing No. Various Recommendation: We recommend the University review its current procedures to ensure non-federal costs are not being allocated to federal fund codes. Also, the University should process retro-active cost transfers or payroll adjustments to ensure that no teaching salaries are coded to USDA grant funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Langston is strengthening budgeting and payroll assignments to properly use appropriate cost codes to categorize types of payroll classification. Redistribution of expenditures between the payroll cost code categories within the appropriate project fund are in process. Name(s) of the contact person(s) responsible for corrective action: Mr. Robert Dixon, Director, Grants and Contracts Fiscal Administration, Oklahoma State University. Planned completion date for corrective action plan: June 2024

Management will seek ways to return or credit the funds back to the DOL or DOL programs in FY23-24.

Management has discussed with DOL and requested relief from paying back the funds in question. The Association has also trained additional staff members to monitor more closely to ensure the percentage requirements are met on a monthly basis.

We agree that the allocation being performed once annually does not create the most equitable allocation of costs between our individual programs. We will perform our indirect cost allocations more periodically during the course of the fiscal year to ensure that more appropriate times studies and applicable participant hours are being utilized to limit the potential of allocating unrelated indirect costs from the year to individual programs, including the federally funded programs.

Mathematical and Physical Sciences – Assistance Listing No. 49.049 Recommendation: We recommend management review the process in place to identify any gaps and inconsistencies with procurement files in comparison to WIYN’s policies and UG requirements and ensure relevant controls are properly designed and operating effectively. In addition, management should ensure all active procurement files are in compliance with WIYN’s policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: WIYN utilizes Marsh as an insurance brokerage service to evaluate, recommend best value, and negotiate policies with the insurance carriers. WIYN stated a preference to renew with Hartford during renewal strategy sessions with Marsh because of the requirements for continuity of service, quality of service, and the understanding of WIYN’s operations. The price/quote was assessed against market trends, but evidence of this comparison was not maintained by Marsh or WIYN. In response to the finding, WIYN will require Marsh to provide evidence that policies are marketed to multiple carriers at least once every 3-years, including an explanation of market conditions when carrier availability is limited. Name(s) of the contact person(s) responsible for corrective action: John Salzer Planned completion date for corrective action plan: 10/01/2024

Additional preventive internal control procedures will be implemented, including an additional level of review of the reimbursement requests prior to submission. These procedures and internal controls have been implemented as of the date of this report.

Contact person: Jeanne Garrett Management’s Response – Trainings for all programs , along with the LW-010-CONS program are held bi-monthly during CSBG staff meetings. These meetings were implemented in June 2023. FACSPRO, the software used by the county coordinators to input applications auto calculates awards. During the trainings Coordinators are trained to know the requirements and eligibilities of the programs well enough to recalculate the awards. During this audit period seven out of a sample of 60 LI-010-CONS applications were still incorrect. Although the overall effect was small, this will be a repeat finding for errors in client awards. The Service Manager will contact ADECA to provide comprehensive training to the service staff. The Service Manager will have a contractor assist with recalculating awards and working with the staff individually with corrections that are made. The Fiscal Officer will re-check a sample of the awards each month. Although the LI-010-CONS program has ended, the training will be applicable to all programs.

Re: Corrective Action Plan (CAP) for Primrose Apartments, Inc. Name of Auditee: Primrose Apartments, Inc HUD Project No.: 033-EE147 Period Covered by Audit: Year Ended September 30, 2023 CAP Prepared by: Kristiann Keller Property Controlller NDC Asset Management LLC 412-578-7833 Current Finding on Schedule of Findings and Questioned Costs Views of Responsible Officials and Planned Corrective Action: Finding 2023-001 There is no disagreement with this audit finding. Management is in the process of communicating with the proper HUD representatives regarding the procedures required to catch­ up the funding of the replacement for reserve erroneously omitted during the year ended September 30, 2023. NDC Asset Management LLC will implement procedures to be followed any time a new property comes under management to ensure that any reserve for replacement required deposits are funded in a timely manner.

Going forward, our internal policies and procedures will be updated to comply with the requirements in place for entities receiving federal awards. Additionally, we believe our new general ledger and payroll integrated software will provide better control and clarity to our recording and reporting operations. We will consult with other agencies of similar size and construct, as well as the Michigan Association of Local Public Health in areas where guidance is needed to return to strict compliance.

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (the program) was not reviewed and approved by a separate individual outside of the preparer. Additionally, the Hospital claimed mortgage reimbursements as expenditures under the program. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. Anticipated Completion Date: June 30, 2024

he County agrees with the recommendation and will continue to work with the Procurement Services Department to ensure acceptable documentation has been retained. We will also discuss additional review procedures with the responsible departments for all contract awards with federal funding.

The County agrees with the recommendation and will work with the Grant Administrator to implement policies and procedures to ensure all pre-award payments occur within the grant timelines.

COVID-19 – Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: We recommend that management review their policies and make revisions where necessary to ensure that documentation is maintained to support amounts reported by the County in their quarterly grant reporting. We also recommend that management review their policies and procedures and make changes necessary to ensure reports are filed timely. Explanation of disagreement with audit finding: The one instance when the County submitted its quarterly report after the due date occurred due to a technical problem with submission. The Treasury data system would not accept the County’s report on the due date. The County sent Treasury an email alerting them to the problem as soon as it was determined that the County was unable to submit. Once the issue was resolved, the County submitted a few days later with no adverse impact to the County or its use of federal ERA funding. As per the concern that audit staff could not verify key line items in the submitted quarterly report, the County completed all required line items in the reports, however, the Treasury report downloads with multiple blank items in report cells. The County cannot control this deficiency in the Treasury downloads. If any submitted report were incomplete, Treasury would have returned the incomplete report to a local jurisdiction for missing elements. No referenced reports were returned to the County for completion, thereby demonstrating that all reports were complete at the time of submission. The problem relates solely to the downloaded report from the Treasury website. Neither the County nor the audit staff were able to determine a workaround for the incomplete Treasury report downloads. Action taken in response to finding: No additional action is needed because the one late quarterly reporting problem was resolved and the report was uploaded as soon as the technical glitch was resolved. Name(s) of the contact person(s) responsible for corrective action: Colleen Mahoney Planned completion date for corrective action plan: Already Completed

CDBG Entitlement Grant Cluster – Assistance Listing No. 14.218 Recommendation: The County should reevaluate its current process, implement proper controls, and perform additional training over time and effort reporting. The County should not seek federal reimbursement unless it can substantiate that the time and effort was dedicated to the federal program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHCD follows Baltimore County’s general payroll policies and procedures. DHCD allocates time and attendance based on a preset budgeted formula and monitors the staff’s time and attendance through biweekly timesheet prepared by the staff members and approved by unit managers and the review of payroll register. Baltimore County migrated to Workday system which has more robust features and capabilities to capture time and attendance. . Name(s) of the contact person(s) responsible for corrective action: Amir Assadi Planned completion date for corrective action plan: 7/1/2024

An excel workbook will be created to include all reports that need submitted. The workbook will have the program dates, how often it needs submitted and when, as well as the person responsible for completing and submitting the reports. This will be a part of the aforementioned accounting calendar and will also be outlined in the Finance Policies due in September as an appendix.

Views of Responsible Officials and Planned Conect Actions: Management of the Agency concurs with the audit finding. The individual preparing the reports this year did not realize that the account was included in the group of accounts used for billings. Additional training will be provided, and management will perform a quality control review over future grant billings to ensure that costs meet the criteria defined by the regulations and included in contracts and grant agreements. AAA WM's CFO, will implement a process to reconcile match amounts, on a monthly basis, to ensure compliance.

Item 2023-001 Special Tests and Provisions – Wage Rate Requirements Recommendation: We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. Action Taken: The Board will strengthen the controls in place to provide assurance that proper prevailing wage rate clauses are added to construction contracts and certified payrolls are received from each week in which construction work is performed. Tricia Norman, CSFO, will be responsible for the corrective action plan and anticipates completion of corrective action will be taken before September 30, 2024.

CORRECTIVE ACTION PLAN Name and Number of the Project: St. George's Senior Housing, Inc. No. 115-EH057 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2023 Compliance Review A. COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING 1: Section 202 Supportive Housing for the Elderly, Assistance Listing 14.157 and Section 8 Housing Assistance Payments Program, Assistance Listing 14.195 CORRECTIVE ACTION COMPLETED: On December 19, 2023, the Company deposited $2,941 into the replacement reserve account. Finding CLEARED. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 US. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Connie Quillen, Vice President, Asset Living.

Finding Number: 2023-001 Internal Control over Compliance and Compliance with Procurement, Suspension and Debarment Summary of Finding: The Federal Acquisition Regulation (FAR) 52.244-5 outlines the following regarding competition: (a) The Contractor shall select subcontractors (including suppliers) on a competitive basis to the maximum practical extent consistent with the objectives and requirements of the contract. (b) If the Contractor is an approved mentor under the Department of Defense Pilot Mentor-Protégé Program (Pub.L.101-510, section 831 as amended), the Contractor may award subcontracts under this contract on a noncompetitive basis to its protégés. The FAR subpart 6.3 outlines policies and procedures, and identifies authorities, for contracting without providing for full and open competition: Per FAR 6.302 the following are circumstances permitting other than full and open competition 6.302-1 Only one responsible source and no other supplies or services will satisfy agency requirements. 6.302-2 Unusual and compelling urgency. 6.302-3 Industrial mobilization; engineering, developmental, or research capability; or expert services. 6.302-4 International agreement. 6.302-5 Authorized or required by statute. 6.302-6 National security. 6.302-7 Public interest. In accordance with FAR 9.405 (e)(1) After the opening of bids or receipt of proposals or quotes, the contracting officer shall review the exclusion records in SAM. During our testing of compliance and controls, we identified the following matters: •For four procurement samples of a total of 15 items sampled management utilized a single source justification. However, the rationale did not conform to the requirements of FAR 6.302 Circumstances Permitted Other than Full and Open Competition. •For three procurement samples of a total of 15 items sampled management was not able to provide evidence that they reviewed the exclusion records in sam.gov in accordance with FAR 9.405 (e)(1). Response to finding: •BlueForge Alliance (BFA) agrees with the comments provided and will take Corrective Action as identified below. Once Corrective Action is undertaken BFA will update policies and procedures to include the use of tools which will lead to full compliance with the requirements of FAR 6.302. BFA will also consolidate this information into BFA’s procurement user manual which will be available to all staff members via BFA’s SharePoint site. BFA agrees with the comments provided and will take Corrective Action as identified below. Once Corrective Action is undertaken BFA will update policies and procedures to include instruction which will lead to full compliance with the requirements of FAR 9.405 (e)(1). BFA will also consolidate this information into BFA’s procurement user manual which will be available to all staff members via BFA’s SharePoint site. Corrective Action: •BFA is currently in the implementation stages of the CPSR Pro Docs tool. BFA is expected to go live with this system no later than August 31, 2024. CPSR Pro Docs will allow BFA to process compliant procurement transactions efficiently and effectively from Micro-Purchases through the issuance of major Subcontracts. The software leverages expert knowledge and streamlines the Procurement process with automated workflow software. CPSR ProDocs is a logic and rule-based system that uses pre-existing text and meta-data to assemble compliant Procurement documentation. It is driven by regulatory compliant logic resulting in output documentation formulating customized results. CPSR ProDocs will allow BFA to check 30 CPSR Audit Points, analyze source elements (prime contracts, thresholds, customized procedures), guide BFA buyers through process of compliant file documentation, and create checklists at the end that show missing items necessary for completion. These CPSR Pro Doc capabilities will result in BFA’s full compliance with FAR 6.302. •BFA is currently in the implementation stages of the Deltek Costpoint tool. BFA is expected to go live with this system no later than October 31, 2024. The Supplier Module tool within Deltek Costpoint will allow BFA to do automatic visual compliance checks when suppliers are onboarded to the portal. Additionally, BFA will consolidate instruction on completing Sam.gov checks on all vendors within the BFA procurement user manual. Additionally, CPSR Pro Docs includes a checklist with assigned peer review that requires buyers to confirm their review of exclusion records in Sam.gov for each vendor being onboarded. The additional visual compliance check through Deltek Costpoint in conjunction with the CPSR ProDocs checklist with assigned peer review will allow BFA to fully comply with the requirements of FAR 9.405(e)(1). Individual(s) Responsible for Corrective Action Plan: Lindy Beasley Principal, Contracts and Compliance 979-229-6465 Anticipated Completion Date: The anticipated completion date for implementation of the CPSR Pro Docs tool is August 31, 2024. The anticipated completion date for implementation of the Deltek Costpoint tool is October 31, 2024. BFA will update their policies, procedures, and procurement user manual at the conclusion of the tool implementations but no later than December 1, 2024.

Finding number: 2023-012 Federal agency: U.S. Department of Treasury Programs: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance listing #: 21.027 Award year: 2023 Compliance requirement: Allowable Costs Corrective Action Plan: College Unbound has increased its administrative capacity and has implemented internal controls to properly track, account for and report on grant expenditures. CU hired the Vice President for Student and Institutional Sustainability in 2023 and subsequently a Controller and Bursar were hired in October 2023 to support the growing needs of the college. The Chief Development Officer, Program Staff and the Financial Team including the VP, Bursar, Financial Aid, and Controller have developed routines and procedures to ensure we are using grant funds as intended and have proper documentation. We are in the process of developing procurement protocols to align with federal grant expectations. Timeline for Implementation of Corrective Action Plan: Currently updating procedures to ensure compliance for FY25. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

Finding number: 2023-011 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 & 84.268 Award year: 2023 Corrective Action Plan: College Unbound has implemented a process to review eligibility for all new students. The Financial Aid Office works closely with Admissions/Recruiting to ensure proper documentation of all new students before the first disbursement. Timeline for Implementation of Corrective Action Plan: Ongoing. Started 8/22/24, fully implemented by the end of FY24. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

Finding number: 2023-009 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 Award year: 2023 Corrective Action Plan: The College has policies and procedures to ensure compliance for calculating the Title IV funds to be returned. This finding was the result of a rounding variance. The College will enact a checks and balances process in which a second party reviews R2T4 calculations. As this was not a repeat finding, and the sample size was 1, we are confident that this finding will not be repeated in the future. Timeline for Implementation of Corrective Action Plan: Corrected. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

Finding number: 2023-007 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 & 84.268 Award year: 2023 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the role was previously filled by a single temporary employee). Part of the Controller’s scope of work is a monthly review of all uncashed checks. Beginning March 2024, the controller initiated a new process for outstanding checks issued to students. After monthly bank reconciliation, the list of outstanding checks will be forwarded to our Director of Employee Success and Student Accounts to follow up with the students and rectify the issues. In addition, College Unbound is undertaking a project to encourage students to receive credit balance refunds through ACH, as opposed to paper check, whenever possible. The ACH process will increase accuracy, security, and speed of delivery. Additionally, for students still opting to receive paper checks, College Unbound has initiated Positive Pay through the bank. Timeline for Implementation of Corrective Action Plan: Ongoing. Fully implemented by the end of FY24. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO