Corrective Action Plans

We have provided additional training to the accounting team, underscored the importance of verifying vendor invoices are related to the Organization, and have implemented an additional control to detect misappropriation of Project funds prior to release of payments.

Finding 2023-001 – Equipment and Real Property Management The single audit report included the following recommendation: We recommend that Amtrak continue to work toward a full integration or reconciliation between Amtrak’s fixed asset system of record and the different equipment-tracking systems. We recommend that management consider redesigning one of its key controls to help ensure that the monitoring of the observations is occurring on a preventive basis to help identify any exposure to non-compliance before it occurs. For example, Amtrak should consider an automated system report that would flag an asset proactively when a 2-year inventory deadline is approaching. During the observation process, management should ensure there is a review control within the process to validate that the asset is accurately tagged and such identifying information matches the equipment-tracking system. Additionally, this review control should also be performed when the asset is first logged into the equipment-tracking system. In the interim, until such processes are fully implemented, Amtrak should enhance the current control procedures surrounding the asset documentation and ensure that field personnel are aware of and are consistently and carefully updating the asset records such that clerical/human errors are minimized and that the asset records contain the necessary asset details in order to properly track equipment by federal requirements. This would include enhancing the asset chain of custody recordkeeping so that such changes are identified and reported timely. Additionally, management should consider requiring the serial number and model number to be documented in the system of record at set up in addition to the asset tag number. This will help ensure that the equipment has a unique ID number that can help it be identified and matched to the system record should an asset number not get added timely. Finally, as it relates to condition #4 above, management should investigate the root cause of the asset that could not be located and determine if additional control changes or modifications need to be made in order to prevent reoccurrence. Identification as a repeat finding: This finding was identified as a repeat finding in the immediate prior year as Finding 2022-001. This finding was reported in prior years as well, beginning in at least FY2012. Management Response/Status of Action Plans: Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. Amtrak continues to progress on a multi-year effort to remediate this finding. Amtrak created the EAMDT which has been tasked to improve equipment record keeping which will resolve this finding. 1. In April 2024, Amtrak completed an engagement with an outside consulting firm that delivered three items: an updated Equipment Control Policy (ECP), standard operating procedures (SOPs) for equipment management based on the accountable property system of record, and a one-hour eLearning course that reinforces the importance of good equipment management practices and the need to follow the equipment tracking requirements of 2 CFR Part 200. These deliverables will improve policies and corporate governance over assets by providing training to the employees and improving the processes needed for oversight of equipment management, as well as to help ensure that assets are not capitalized without a complete record, which would include a unique asset identifier and the condition and location of the asset. The ECP was approved and published in the Amtrak Policy and Instruction Manual in May 2024. Amtrak will communicate the updated policy to all relevant personnel by the end of June 2024. The EAMDT is working with the Learning and Development team to identify the employees who will need to take the eLearning course, and these employees will be required to take the eLearning material beginning in the first quarter of FY25. 2. The EAMDT is implementing controls throughout the equipment lifecycle as it identifies improvement opportunities. For example, EAMDT has been added as an approver to the purchase requisition workflow for equipment purchases, and EAMDT is working with Capital Accounting to ensure that assets are recorded completely before being capitalized, which would include a unique asset identifier, condition, and location of the asset. EAMDT is reviewing assets currently in the system that do not have assigned asset IDs. EAMDT’s goal is to resolve and update existing records that are missing IDs and other information by the end of April 2025. Additionally, in August 2023, the Asset Disposition group began reporting into EAMDT which enables centralization of a more complete oversight of Amtrak’s assets. EAMDT is working to improve the record keeping for asset dispositions. 3. EAMDT is working with Amtrak’s Digital Technology (DT) Department to find ways to track equipment electronically. This includes installing location tracking technology on yard and Engineering Maintenance of Way equipment to better track and locate Amtrak assets. As of the end of April 2024, location tracking technology has been installed on over 1,500 pieces of equipment with the goal of having location tracking technology installed on approximately 2,400 assets by the end of June 2024. EAMDT is also coordinating with DT on an application accessible via a mobile device (e.g., cell phone, tablet) used by field personnel to perform audits and update equipment records. 4. EAMDT has developed trend reporting and operational reporting to help EAMDT and the departments track their compliance progress and identify assets that are out of compliance or soon-to-be out of compliance to both bring assets back into compliance, as well as to ensure an inventory is done and recorded within the two-year period. As of September 2023, two primary dashboards have been developed and can be used by all departments to help identify assets that are out of compliance and/or need to be audited. 5. EAMDT performs site visits to assist the equipment managers in performing equipment and vehicle audits. During these visits, equipment managers are educated on their responsibilities and tools available for performing audits. The contacts for this item are Ian Hinke, AVP Supply Chain Management and Robert Hoban, Director Asset Management. Amtrak anticipates the implementation of the above procedures, along with continual process monitoring and refinement, will fully remediate this finding by June 2026.

Response/Views: We agree with the finding. Corrective Action Planned: All future construction contracts that are being funded with federal funds will have the appropriate Davis Bacon and Related Acts Provisions and Procedures outlined within the contract. The Colbert County Board of Education will verify employees working on the project are paid prevailing wage rates. The contractor or subcontractor will be required to submit to the Colbert County Board of Education weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). Anticipated Completion Date: This corrective action plan will be implemented immediately. Contact Person(s): Shauna James, Taylor Leathers

2023-008. Rent Deposits Corrective action planned: We implemented our new practices in January of 2024. Contact person: Matt Brady, Executive Director. Anticipated completion date: January 2024

Prairie-Hills Elementary School District 144 07-016-1440-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-002 Condition: During the audit we noted that the District claimed expenditures in excess of amounts that could be supported by the accounting records by $102,438. Plan: The District will implement a policy that requires the utilization of grant specific expenditure accounts within the accounting software to be used exclusively for managing each individual award. These expenditure accounts will be used to support expenditure claims. Reports from the accounting software system that are utilized to prepare expenditure claims will be reviewed, reconciled and approved by an appropriate member of management prior to final submission. Supporting documentation for each grant expenditure claim submission will be maintained electronically for future reference. Anticipated Date of Completion: June 30, 2024 Name of Contact Person: Ms. Sheryl Coleman; Chief School Business Official

Prairie-Hills Elementary School District 144 07-016-1440-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2023 Corrective Action Plan Finding No.: 2023-003 Condition: During the audit we noted that the District claimed expenditures in excess of amounts that could be supported by the accounting records by $52,112. Plan: The District will implement a policy that requires the utilization of grant specific expenditure accounts within the accounting software to be used exclusively for managing each individual award. These expenditure accounts will be used to support expenditure claims. Reports from the accounting software system that are utilized to prepare expenditure claims will be reviewed, reconciled and approved by an appropriate member of management prior to final submission. Supporting documentation for each grant expenditure claim submission will be maintained electronically for future reference. Anticipated Date of Completion: June 30, 2024 Name of Contact Person: Ms. Sheryl Coleman; Chief School Business Official

In accordance with HUD regulations, entities should not make unauthorized distributions of Project. The Project paid expenses for an adjacent project. The Corporation paid non-project expenses from Project funds. The Project is noncompliant with HUD regulatory agreement. Management is in agreement with the finding, amounts were paid for non-project expenses.

The district will contact the Arkansas Division of Elementaiy and Secondary Education for guidance on returning the funds and the district will take care to make sure all unallowable expenditures are not included in the calcu lation for indirect cost taken in the future on all federal funds.

Finding 2023-008: Compliance with Federal Wage Requirements Finding: The District did not include federal wage rate requirements in construction contracts which were partially funded with federal grant funds. Additionally, the District did not require the contractors in those agreements to submit weekly certified payrolls. Corrective Actions Planned: The District will update the language used for construction contracts and develop an internal process for the collection and retention of the required weekly certified payrolls. Expected Implementation Date: June 30, 2024 Contact Person: Dr. Frank Williams

Finding #2023-001: Type of Finding: Questioned Cost and Other Noncompliance Responsible Person Hector P. Luevano – Controller Richard Davidson – Chief Operating Officer Implementation Date January 1, 2024 Views of responsible officials and planned corrective actions Management agrees and will more closely monitor obligated and incurred expenditures near the end of reporting periods to ensure they are completed within 120 days after the close of the grant year. Future planned expenditures are to be tracked separately and not reported as expenditures until an expense is obligated or incurred by the program. Family Service will be elevating the responsibility of monitoring the execution of projects with their scheduled expenses to the Chief Operations Officer and Controller, to avoid future gaps between obligated and/or future planned expenditures, project completion and payments.

2023-007 ALLOWABLE COSTS/COST PRINCIPLES - TIME AND EFFORT REPORTING (50000) • Time Certification Schedules: Implement semi-annual time certifications for employees funded by a single federal source and monthly certifications for employees funded by multiple sources.

Finding 2023-002, Significant Deficiency – Allowable Costs Corrective Action Plan: Goal: To ensure that duplicative expenses are not drawn down in state funding. Plan: The County identified the duplicate transaction of $20,740 reported for drawdown for Project AA 362 was due to an issue with the reporting mechanism. Specifically, the report used to extract project costing details included a commitment number column, which inadvertently resulted in the creation of duplicate records for each commitment associated with a single invoice. Performance Improvement Strategies: To address this issue and prevent its recurrence in the future, immediate steps have already been taken. County Finance has amended the report to exclude the commitment number parameter, thereby eliminating the possibility of duplicate records being generated. Responsible Parties: Nursing Supervisor Brooke Hamby and Assistant Health Directors Nicole Priddy & Marie Stephens Timeframes: Brooke Hamby will reach out to the Division of Public Health, Women & Children’s Health/Children & Youth section, no later than June 15, 2024, to inform them of the Audit finding of this duplicate expense and request what the process is for returning the funds.

Comments on the Finding and Each Recommendation: As of June 30, 2023, deposits to the reserve for replacements totaling $768 had not been made. Pursuant to Section 10 of the Regulatory Agreement, the Company shall deposit a monthly amount into the reserve for replacements account. The amount of the monthly deposit may be increased or decreased from time to time at the written direction of HUD. Effective April 1, 2023, HUD increased the monthly deposit from $8,012 to $8,396. Management inadvertently did not increase the monthly deposit until June 2023. As a result, the Company was not in compliance with the terms of the Regulatory Agreement. The reserve for replacements was underfunded by $768 as of June 30, 2023. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation and transferred $768 to the reserve for replacements on August 11, 2023. No further action is required.

Incorrect Pell Calculations Planned Corrective Action: Per our policies we will work in conjunction with Academics to ensure timely response in updating Pell based enrollment changes. Tasks will be generated to ensure both groups are reviewing in a timely manner. Person Responsible for Corrective Action Plan: Ingrid Ortiz, Director of Financial Aid Anticipated Date of Completion: Implemented as of Fall 2023.

Disbursements to Ineligible Students Planned Corrective Action: With the new automation process we have exceptions that will prevent the funding from posting if there is no LDA listed. We have also updated the Disbursement Criteria Approval to help prevent inaccurate disbursements from posting. Person Responsible for Corrective Action Plan: Ingrid Ortiz, Director of Financial Aid Anticipated Date of Completion: Implemented as of Fall 2023.

2023-003 – Period of Performance Recommendation: We recommend that PPS enhance its procedures and internal controls to ensure that expenditures are not charged to federal awards during the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Special Education and Related services and the Portsmouth Finance department will monitor expenditures on an ongoing basis to ensure the funds are spent in accordance with the period of performance of the grant. The Finance department will review all purchases and notify the Office of Special Education if purchases are unallowable and do not follow the period of performance and have alternate suggestions on how the purchase can be made. Name(s) of the contact person(s) responsible for corrective action: Pamela Battle-Hardy, Director of Special Education and Related Services Planned completion date for corrective action plan: January 1, 2025

2023-002 – Allowable Costs/Cost Principles Recommendation: We recommend that PPS enhance its procedures and internal controls to ensure that it retains documentation supporting time and effort on federal grants and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Special Education and related services, in collaboration with Portsmouth Schools Finance department will monitor that the certification of pay certifications are completed on a semi-annual basis. Finance will communicate via email, the list of personnel required to have the certification and also review once they are completed by the Office of Special Education. Finance will review all dates and signatures. Name(s) of the contact person(s) responsible for corrective action: Pamela Battle-Hardy, Director of Special Education and Related Services Planned completion date for corrective action plan: January 1, 2025

Fairview SD 72 agrees with the finding and has taken steps to obtain the adequate expenditure documentatioon. In fact, the adequate expenditure documentation has been obtained and the proper expenditure has been made. Fairview SD 72 has taken steps to help ensure this condition does not occur again.

Low-Income Home Energy Assistance– Assistance Listing No. 93.568 Recommendation: We recommend that the organization implement additional review process over the Fuelware System information when changes are made to family size to ensure the system is updated timely and correctly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: If a household member is removed from the energy application, the Energy Staff will be required to double check the income guidelines and the household composition to make sure that wrong benefits are not given to clients. With the updates to the energy software system, the awards will be based on the new household composition. In addition, when staff encounter this situation, they will have the ability to manually cancel the award and recertify the application in order to approve the correct award amount. Name(s) of the contact person(s) responsible for corrective action: Michelle James Planned completion date for corrective action plan: May 21, 2024 If the Department of Health & Human Services has questions regarding this plan, please call Michelle James at (203) 744-4700.

Finding Number 2023-001 Federal Agency: Department of Health and Human Services Federal Program Name: Transmitted Diseases Prevention and Control Grants Assistance Listing Number: 93.977 Federal Award Identification Number and Year: HHS000031000001 - 2023 Award Period: April 1, 2018 – December 31, 2023 Type of Finding Significant Deficiency in Internal Control over Compliance – Procurement, Suspension and Debarment Corrective Action to be Taken Management updated its policies and procedures to include the required suspension and debarment check in June 2024 and will implement these procedures immediately. Completion of Action Correttive Action was completed June 2024. Controls in place. Agency Response There is no disagreement with the finding. Agency Contact Responsible for Corrective Action Tony Peterson at tpeterson@cardeaservices.org

Corrective Action Plan for Audit Findings 2023-001: Procurement Requirements Criteria: The Organization is required to establish a procurement policy in accordance with Uniform Guidance requirements, as specified in the compliance supplement. Condition: one of the 40 items tested, we noted one food purchase expense have the documentation as required by the procurement policy. Based on inquiry with management, the procurement policy not consistently followed for purchases surrounding food. Questioned costs: $51,200 Cause and Effect: By not maintaining documentation as required by the procurement policy, Organization could expense funds that are not in accordance with the procurement policies established by Uniform Guidance Corrective Plan: Midwest Food Bank will provide additional communication and training to staff on the requirements of the procurement policy with an immediate effective date, led by Lisa Martin, CFO.

2024-05-17 00:00:00

FAVOR, Inc.

State Single Audit Corrective Action Plan

For the Fiscal Year Ended June 30, 2023