Corrective Action Plans

Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the special education grant for 2026, as well as into future periods.

2024-1 Payroll Allocations Contact Person - Shannon MacKenzie, Director of Finance Description of Corrective Action - The School’s new Director of Finance will continue to work closely with the Deputy Head of School to ensure that payroll and other expenses are being charged correctly to our grant funding. We will ensure that the expenses for the grants are reviewed monthly and will make the correct adjustments on a timely basis to ensure that the grants are charged for the correct amounts based on the grant documents. The Director of Finance will also make sure that the time and efforts match the payrolls and that the changes in the payroll are updated on a timely basis. Completion Date - June 30, 2025 Root Cause - Turnover in the Director of Finance position

Finding 2024-002 Contact Person responsible for corrective action: Kevin Couey The corrective action planned: Strengthen our processes to ensure all grant expenditures are made within the authorized period of performance. The anticipated completion date (or starting date if ongoing): We immediately put new processes into action effective October 1, 2025 and will be validated at next audit in May 2026.

CVCA will verify that for cost reimbursement grants that only the 10% de minimis rate is charged to those grants.

Significant Deficiency in Internal Control over Compliance and Compliance – Procurement, Suspension and Debarment Federal Program: 93.939- HIV Prevention Activities: Non-Governmental Organization Based Federal Agency: U.S. Department of Health and Human Services. Award Number: NU65PS923746. Fiscal Year: July 1, 2023 – June 30, 2024 Recommendation: We recommend that management reinforce procedures to ensure that verification of procurement, suspension and debarment practices are performed and documented prior to entering into any covered transaction or subaward. This may include retaining screenshots from SAM.gov, signed certifications, contract clauses confirming compliance, and documentation of competitive pricing retained for records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The policies and procedures associated with this process will be improved per the audit recommendations and then training for all staff involved will be completed. Name of the contact person responsible for corrective action: Simon Trowell, Chief Executive Officer. Planned completion date for corrective action plan: December 31, 2025 If the third-party reviewer has questions regarding this plan, please call Simon Trowell, Chief Executive Officer at 215-563-0652

Material Weakness in Internal Control over Compliance and Compliance - Reporting Federal Program: 93.939- HIV Prevention Activities: Non-Governmental Organization Based Federal Agency: U.S. Department of Health and Human Services. Award Number: NU65PS923746 Fiscal Year: July 1, 2023 – June 30, 2024 Recommendation: We recommend that management implement procedures to ensure that expenditures reported on the Federal Financial Report reflect actual costs incurred during the reporting period and are supported by appropriate documentation. Staff responsible for preparing the Federal Financial Report should be trained in federal reporting requirements to ensure compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: There is not currently a clear internal procedure on how to complete the Federal Financial Reports. This will be added to the finance department procedures and will be trained to all staff who will be responsible for this reporting. Name of the contact person responsible for corrective action: Simon Trowell, Chief Executive Officer. Planned completion date for corrective action plan: December 31, 2025

Material Weakness in Internal Control over Compliance and Compliance - Cash Management Federal Program: Major Program- 93.939- HIV Prevention Activities: Non-Governmental Organization Based. Other Program- 16.889- Grants for Outreach and Services to Underserved Populations Federal Agency: Major Program- U.S. Department of Health and Human Services. Other Program- U.S. Department of Justice Award Number: Major Program- NU65PS923746. Other Program- 15JOVW-22-GG-00404-UNDE Fiscal Year: July 1, 2023 – June 30, 2024 Recommendation: We recommend that management ensure drawdowns are strictly aligned with incurred and allowable expenses. This should include: • Pre-drawdown verification of expense documentation. • Monthly reconciliations of drawdown activity to actual expenditures. • Training for staff involved in federal fund management on Uniform Guidance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Procedures related to federal drawdowns were not followed in this case. The finance department will review all procedures and ensure that staff are trained on proper drawdown procedures going forward. Name of the contact person responsible for corrective action: Simon Trowell, Chief Executive Officer. Planned completion date for corrective action plan: December 31, 2025

Views of Responsible Officials: We agree with the auditor’s findings and recommendations. Intacct allows for the automatic allocation of salaries to grants directly which provides us with much better records. ADP Workforce now will put all the appropriate approvals in place, both employee and supervisor. We are discussing the right method for project-specific timesheets, but think that biweekly forms for staff to fill out are the best route. Staff would check off grant-allowable activities that they engaged in and then note the hours allocated to those activities.

Condition: During our audit of the financial management system and cash management practices for the Ryan White Federal Program, we identified the following deficiencies: Transposed Drawdown Amount: A drawdown request submitted to the PMS system for the Ryan White Program had the requested amount transposed with the amount of another federal program. This resulted in an over-request of a material amount on the Ryan White Program. Duplicate Invoice Reimbursement: An invoice was requested and received for reimbursement on a prior drawdown and was subsequently included again in a draw after year-end, resulting in a duplicate reimbursement. Incomplete Expenditure Tracking: The entity did not have a complete system for tracking all expenditures eligible for reimbursement. The drawdown process was limited to cash disbursement and payroll transactions and excluded expenditures incurred and recorded by journal entries. This resulted in the entity having unreimbursed expenditures that could have offset the over-requests noted above. Corrective Action Plan: To correct the deficiency, we are implementing a plan focused on establishing a review and approval process for all drawdown requests and revising our policies to ensure that all eligible incurred expenditures are properly captured and reconciled, thereby assuring strict compliance with federal cash management regulations and preventing federal funds from exceeding our immediate needs. Responsible Party: Austin Maddox, CFO Anticipated Completion Date: December 31, 2025

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Type of Finding: Significant Deficiency in Internal Control Over Compliance Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Recommendation: During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their monthly processes to ensure that program income was disbursed prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is spent timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials: Management concurs with the finding and has implemented procedures to ensure appropriate and timely application of program income. Corrective Action Planned: Inova Grants Accounting and Inova Juniper Program (IJP) directors will work collaboratively to disburse funds available from program income prior to requesting additional cash payments from RWHAP funds. Inova implemented a Program Income from Sponsored Programs policy in February 2025. Inova will assess this written procedure and revise as necessary to ensure that program income is applied before requesting federal reimbursement. Inova will review federal grant requirements related to program income and identify sources of program income during kickoff meetings for new awards. Mandatory training will be conducted for program and finance staff responsible for the administration of these awards. (2 CFR 200.307 and 200.305) Inova will require a monthly reconciliation of program income earned and expenditures by grant. Program income tracking will also be included in monthly grant variance reports. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.

Management should implement a procedure requiring authorization and approval from Chief Financial Officer, Chief Executive Officer or Chief Operating Officer for all nonrecurring purchases prior to initiation of the purchase.

Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.

Finding No: 2024-001 Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.917 Program: HIV Care Formula Grants Compliance Requirements: Activities allowed or unallowed/allowable costs, cash management and eligibility Award Year: October 1, 2023 through September 30, 2024 (a) Criteria or Requirement 2 CFR 200.303 requires non-federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Effective internal control should include procedures to ensure federal expenditures are accurately and completely reported on the SEFA. (b) Condition Found The System lacked sufficient internal controls to ensure the allowability of expenditures charged to the HIV Care Formula Grants. Our testing of a sample of 40 transactions totaling $6,054 identified three charges, totaling $488, that were incorrectly billed to the federal program. These costs, although related to services provided to patients, were determined unallowable for the following reasons: • The patients had other insurance coverage that was not billed prior to submission to the federal agency. • The patients did not meet all eligibility requirements and should have been excluded from reimbursement requests. Additionally, management did not maintain adequate documentation to support the annual reverification of patient eligibility, which is required prior to receiving services each year to remain eligible for the program. Due to these deficiencies, an expanded sample of 23 additional charges totaling $2,799 was tested. Of these,12 were determined to be unallowable, totaling $1,808. Charges related to certain costs related to July through September 2024 were related to an agreement that was not fully executed, resulting in an additional $97,782 of unallowable costs. Lastly, management did not retain sufficient supporting documentation for certain amendments to the grant agreement. This documentation is necessary to substantiate various elements of patient eligibility criteria under the grant. The grant amendment includes specific language that the grant is for the treatment of females over the age of 13, however both males and females were expensed and reimbursed under the grant. The male population for the remaining nine months of year represents $404,710. Our testing identified 26 out of our expanded sample of 63 total patients were males that were not also identified in the above testing results, totaling $3,835. (c) Cause The System’s review processes for charges recorded against the grant and submitted for federal reimbursement were ineffective in preventing unallowable charges and inaccurate amounts. Additionally, the System could not provide documentation for certain grant agreement amendments that would have supported the eligibility of specific patients. (d) Effect Federal funds were expended for unallowable purposes or for inaccurate amounts and evidence of the effective operation of management review controls was not maintained in accordance with Federal requirements. (e) Questioned Cost Expenditures related to patient charges of $222,016. (f) Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Not a repeat finding (h) Recommendation We recommend that the System strengthen controls over the management review process to prevent unallowable costs and inaccurate amounts from being charged to Federal programs as well as ensure all relevant documentation is maintained in accordance with Federal requirements. (i) View of Responsible Officials Invoices were submitted to Mississippi State Department of Health (MSDH) for the HIV Care Formula Grants (CFDA No. 93.917); however, clinic staff did not conduct a thorough evaluation to verify continued eligibility for the program among patients who had previously qualified. Additionally, the lack of a fully executed agreement was a management oversight which contributed to the uncertainty regarding allowable billing to the program for reimbursement. Supporting documentation, including paperwork and emails, was also not properly maintained by management. (j) Corrective Action Plan We have reinforced our records retention policy to ensure proper documentation in support of eligibility determinations. Due to a variety of issues with this grant, including incomplete and conflicting guidance from the State of Mississippi, North Mississippi Health Services, Inc., has elected to terminate our participation in the program. As the program has concluded, no further actions are required due to expiration of the contract terms. The Fee-for-Service agreement ended June 30, 2024, while the Ryan White Part B Subgrant Agreement ended March 31, 2025. We will reimburse any funds received that were deemed unallowable due to expenditures occurring outside the grant period or patient ineligibility. Anticipated Completion Date: 10/31/2025 Name of Contact Person for Corrective Action: Sharon Nobles, Chief Financial Officer

The Corporation agrees with the finding and the auditor's recommendations have been adopted. As of the report date and subsequent to the statement of financial position date, the $83,761 was repaid back to the Corporation.

Significant Deficiency: Missing one deposit to the replacement reserve. $11,422 Recommendation: The Project should establish and follow a consistent monthly review process to ensure all deposits to the replacement reserve are made on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management continues to review and establish processes related to review and approval to ensure monthly replacement reserve deposits are made.

Material Weakness: Unauthorized Loan Recommendation: Management should implement a monthly review process to ensure that management fees are billed in accordance with the terms of the management agreement. Additionally, payroll allocations should be reviewed monthly to confirm that only the appropriate share of expenses is charged to the Project. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management continues to review and establish month end and year end procedures to properly record management fees accordance with HUD approved rate. The payroll allocation issue arose due to a salary allocation being missed during the property management transition. Management continues to review and establish procedures related to payroll allocations to ensure correct expenses are allocated to the Project.

VIEWS OF RESPONSIBLE OFFICIALS Management agrees with the audit finding and has implemented a comprehensive corrective action plan to address payroll processing errors, strengthen internal controls, and ensure accurate and timely payments. As part of PRDE’s Fiscal Plan of 2020–2021, the Department launched the official integration project between the Time, Attendance, and Leave (TAL) system and the Payroll (RHUM) system. This integration ensures that payroll disbursements are made only after the employee’s attendance has been validated through the TAL system. Employees are required to record their attendance using biometric verification or have an authorized leave properly documented and approved by their supervisor before receiving payment. If attendance is not validated, the system automatically issues a notification and applies the necessary adjustment. This project, initiated in November 2020 with the collaboration of the Puerto Rico Fiscal Oversight and Management Board (FOMB), MS Consulting, the Department of the Treasury (Hacienda), the Financial Advisory Authority (AAFAF), and the Puerto Rico Innovation and Technology Service (PRITS), was fully integrated by February 2021. As a result, PRDE has significantly reduced overpayments, duplicate payments, and other payroll inconsistencies. To reinforce this effort, PRDE issued a new Time and Attendance Policy on December 7, 2021, later updated on April 11, 2022, which clearly defines employee responsibilities, authorized leaves, disciplinary procedures, and supervisor accountability. Under this policy, employees and supervisors are required to follow strict timekeeping procedures, and noncompliance triggers automatic system notifications and salary adjustments. The PRDE’s Time and Attendance staff continues to monitor and maintain compliance through: i. Ongoing training sessions for PRDE personnel; ii. System dashboards tracking attendance behaviors; iii. Issuance of notifications and payroll adjustments as required; and iv. Regular follow-up and evaluation activities. Additionally, PRDE’s Finance Office implemented a reconciliation process that integrates data from TAL, RHUM, and SIFDE, ensuring that payroll expenditures align with validated attendance records. The system now performs cross-checks before submission to the Treasury Department, preventing disbursements for unverified time. These combined measures—technological integration, policy enforcement, staff training, and reconciliation controls—have strengthened payroll accuracy, reduced the risk of overpayments, and improved financial accountability across the Department. IMPLEMENTATION DATE Done RESPONSIBLE PERSON Evelyn Rodríguez Cardé Finance Office Director Jullymar Octtaviani Vega Sub-Secretary of Administration

VIEWS OF RESPONSIBLE OFFICIALS The PRDE does not agree with the Recommendation to establish an allocation method for TPFA invoices because TPFA services are overhead costs paid from administrative funds and are not tied to any specific federal grant. In addition, the PRDE does not agree that contract terms should be revised before the contract expiration to require a reconciliation of total hours and rates because again, payments to the TPFA are overhead costs not directly tied to any specific program. Finally, the PRDE does not agree with the recommendation that the TPFA submit supporting evidence for the reimbursement of expenses because (i) the TPFA contract is a fixed fee that is inclusive of all professional service fees and expenses and (ii) the TPFA provides an explanation of major expenses incurred within each monthly invoice. Auditor Comment on Management Response for Finding No. 2024-004 As stated in CONDITION 2., “…on invoice 830311-2023-32 the amount of $1,978,791 (85% of total invoice amount) was charged to several programs of ALN 84.425, although the services described in the invoice were not related only to these programs; therefore, the cost objective is not chargeable in accordance with the relative benefit received.” Further, the 2 CFR 200.1, establishes that: “Indirect [facilities & administrative (F&A)] costs mean those costs incurred for a common or joint purpose benefitting more than one cost objective, and not readily assignable to the cost objectives specifically benefitted, without effort disproportionate to the results achieved. To facilitate equitable distribution of indirect expenses to the cost objectives served, it may be necessary to establish a number of pools of indirect (F&A) costs. Indirect (F&A) cost pools must be distributed to benefitted cost objectives on bases that will produce an equitable result in consideration of relative benefits derived.” This information was not provided for our evaluation. Also, we made reference to the Program Determination Email for ALNs. 84.938 and 84.425 dated September 18, 2024 (Audit Control Number 02-21-39634), received from Ms. Catherine Miers of the Office of Elementary and Secondary Education of the US Department of Education (USDE), in which they required that the PRDE provide documentation for the following corrective actions: “revised the contract terms to include a reconciliation of total hours and rates to adjust the payments made to the vendor before the contract expiration; requested that adequate supporting evidence from the vendors be presented for any expenses to be reimbursed by the PRDE; and develop an adequate review of the vendors invoice to properly identify the actual hours of services that benefited the Federal programs so a correct allocation of the costs incurred can be made within Federal programs and state funds”. IMPLEMENTATION DATE None RESPONSIBLE PERSON Jullymar Octtaviani Vega Sub-Secretary of Administration María de los Angeles Lizardi Valdés Office of Federal Affairs Director

For ALN 16.575 Crime Victim Assistance There was a staffing change for the program after FY23-24. Since the new Program Manager joined in December 2023, she worked with her team to put together the following procedures and protocols: For direct program expenses, all copies of rent payment requests, check stubs and client signed half sheets are retained. Client support purchases have original receipts. For proof of client eligibility, the previous management team kept the files in paper format. The new management team saved all the copies of client IDs, birth certificates or passports in AWARDS to verify age of participants. Client agreements are saved electronically in AWARDS. Paper copies are stored in locked cabinets as well. All time entries are reviewed, approved, submitted, processed and saved in Paycom.

For ALN 21.027 Coronavirus State and Local Fiscal Recovery, There was a staffing change for the program between June to September 2024. The new program team met with the OSH’s fiscal team to review billing requirements and spending guidelines in the beginning of FY24-25. Starting October 2024, the new program team followed the guideline to restrict allowable expenses for clients only to the following: ● Tenant rent portion only on an emergency or as needed basis ● Move in deposit ● Housing application fees In FY24-25, clients came from referrals from OSH as agreed upon. Client eligibility is verified by data in HMIS by the program team. Client files are stored in locked cabinets in the program team’s office. All time entries are reviewed, approved, submitted, processed and saved in Paycom.

Given the complexities of the compliance requirements of the State and Federal governments, this issue will remain a finding, but GWAAR Fiscal Staff will work towards ensuring that all opportunities to follow GAAP standards will be met and all costs will be properly posted.

Management is not in agreement with this finding. We have a policy in place to ensure that all purchases above the micro purchase threshold needs to be supported with competitive bids. Senior management was not informed in time to produce the necessary documentation to the auditors. To ensure compliance in the future, management has revised its formal policy manual to include a formal checklist before signing any commitments that competitive bids have been obtained.

Management believes that in order to ensure that the amount being drawn down are timely and more accurate to the amounts being drawn upon, management is in the process of developing a more formal policy whereby the general ledger will be formally closed on a monthly basis and all amount will be reconciled to the ledger. Once all amounts are proven, then the drawdown amounts will be initiated with the proper documentation attached.

Finding 2024-004 Compliance Requirement: Reporting Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: The report for the year ending December 31, 2024, was not filed within the required report submission period. Action Planned in Response to the Finding: The new management team has established transparency with the Finance Committee and the Governing Board to increase accountability and have established a regiment which includes timely audit engagement and monthly and annual checklists that ensure deadlines are met. Official Responsible for Ensuring the CAP: Bruce Craven Planned Completion Date: December 2025

Finding 2024-003: Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: A walkthrough of fourteen individuals was performed to review personnel files and payroll related to salary for the Organization. Of the fourteen files reviewed, eight had no approved current pay rate documented, one was paid at a rate different from the current rate in the file, two files did not contain an I-9 Form, and one was missing Form W-4. Also, there was no time sheet provided to support the time charged to the federal grant for three of the fourteen individuals tested. Action Planned in Response to the Finding: All payroll activities are managed through ADP. The Human Resources team has assigned grant codes to each staff member which identifies the source of funding that supports their salary. During the timecard approval process for each payroll, the hours worked for a particular grant source will be included. Additionally, the Finance team has taken the following steps to strengthen compliance and accuracy in grant reporting: 1. Assigned personnel whose responsibilities are 100% fully dedicated to specific grant activities. 2. Maintained a detailed allocation table tracking employee time and effort by individual grant. Official Responsible for Ensuring the CAP: Marilyn Powers-Campbell Planned Completion Date: December 2025