Corrective Action Plans

FINDING 2024-004 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Christy Smiley Contact Phone Number and Email Address: 812-663-2570, auditor@decaturcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 27 At least 2 people will look over the report and check all receipts and expenditures when the next P&E report is submitted to prevent and detect any errors. Prior P&E report had already been submitted before the prior audit was complete and we were made aware of the issue and then the Auditor changed in 2025. Control will not be in place until the 2026 P&E report is submitted. Anticipated Completion Date: Submission of next ARPA report, April 2026.

Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding and will adopt a formal Federal procurement policy which includes all elements identified in 2CFR Sections 200.303 and 200.318 through 200.626.

Views of Responsible Officials and Planned Corrective Action: Management agrees with this finding and will adopt a formal Federal procurement policy which includes all elements identified in 2CFR Sections 200.303 and 200.318 through 200.626.

FINDING 2024-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Darrin Boas Contact Phone Number and Email Address: 812-522-4020; dboas@seymourin.org Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: Management developed, adopted and implemented a procurement policy for federal purchases that aligns with the requirement of the 2 CFR 200 Uniform Guidance. This process includes steps within the interview and application process to ensure contractors and subrecipients are eligible (not suspended, debarred, or otherwise excluded) to enter into an agreement, contract, or subaward with the City. The contract in question was agreed to during last year’s audit and part of an overall project/grant overseen by Schneck Hospital entered into in 2021. Going forward, the Clerk Treasurer will review the agreements with the vendors who are being paid from federal grant monies to ensure that the procurement policy is being followed and proper documentation is being obtained based on the procurement method. Anticipated Completion Date: Completed. The City adopted Ordinance 35 on November 25, 2024. This was the effective date of correction.

Recommendation We recommend the Organization update their method of allocating expenditures to federal awards based on the incurred date, rather than paid date.

The City has taken several steps to strengthen its FFATA compliance. In response to this audit finding, the City has implemented the following corrective actions: 1. Standardized Data Collection: An updated subrecipient data collection form has been developed to ensure consistent and complete capture of all required FFATA elements prior to contract execution. 2. Formal Tracking System: The City created a FFATA Tracking Spreadsheet to systematically document and monitor all required reporting elements, including the correct obligation date, which is now tied to the legal execution date of the subaward. 3. Policy and Procedure Development: FFATA reporting policy and procedures have been developed to codify roles, timelines, and compliance responsibilities. This includes guidance on identifying the proper obligation date, data verification steps, and the timeline for submission to SAM.gov (within 30 days of obligation). 4. Staff Training and Oversight: Relevant staff will be trained on FFATA compliance requirements, and the Grants Management Division will conduct quarterly spot checks to ensure accuracy and timeliness of reporting.

The City has taken several steps to strengthen its FFATA compliance. In response to this audit finding, the City has implemented the following corrective actions: 1. Standardized Data Collection: An updated subrecipient data collection form has been developed to ensureconsistent and complete capture of all required FFATA elements prior to contract execution. 2. Formal Tracking System: The City created a FFATA Tracking Spreadsheet to systematically document and monitor all required reporting elements, including the correct obligation date, which is now tied to the legal execution date of the subaward. 3. Policy and Procedure Development: FFATA reporting policy and procedures have been developed to codify roles, timelines, and compliance responsibilities. This includes guidance on identifying the proper obligation date, data verification steps, and the timeline for submission to SAM.gov (within 30 days of obligation). 4. Staff Training and Oversight: Relevant staff will be trained on FFATA compliance requirements, and the Grants Management Division will conduct quarterly spot checks to ensure accuracy and timeliness of reporting.

Following the Auditor's recommendations and as corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds.

The Municipality will designate the appropriate personnel to systematically identify, compile, and securely retain all required reports as stipulated in the grant agreement, ensuring reconciliation with the official accounting records and subsidiary ledgers. Furthermore, the Municipality will develop and implement a comprehensive training program, accompanied by detailed written guidelines and procedures, to equip all staff involved in managing federal funds with the necessary knowledge and tools to maintain compliance and enhance accountability.

Finding: 2024-038 - DMVA management did not issue a management decision for a finding relating to one subrecipient’s single audit. Questioned Costs: None Assistance Listing Number: 97.036 Assistance Listing Title: Disaster Grants — Public Assistance (Presidentially Declared Disasters) Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DMVA concurs with the finding. Corrective Action (corrective action planned): DMVA acknowledges the importance of issuing timely and adequate management decisions to ensure subrecipients take corrective action. The Finance Officer will review internal procedures to identify areas of improvement that may eliminate a single-point of failure in this requirement. Completion Date (list anticipated completion date): 06/30/2025 Agency Contact (name of person responsible for corrective action): Pamela Wiederspohn

2024-001 Research and Development Cluster – Education Innovation and Research (formerly Investing in Innovation (i3) Fund – Validation Grants) Assistance Listing No. 84.411A Condition: For both subawards selected for testing, the identification of the contact information for the awarding agency was incorrect. The contact information was Education Analytics, Inc., the Organization’s grantor, but should have been Future Forward, Inc. Further, one of the two subawards selected for testing had information missing from the subaward including all requirements for the award to be used in accordance with Federal statutes, regulations and terms and conditions of the Federal award. We consider this condition to be an instance of noncompliance relating to the Subrecipient Monitoring compliance requirement. Statistical sampling was not used in making sample selections. Corrective Action Plan: Future Forward will re-issue contracts/MOUs for its two subawards with the correct awarding agency listed (Future Forward instead of Education Analytics). In addition, Future Forward will include requirements for the award to be used in accordance with Federal statutes, regulations and terms and conditions of the Federal award in the revised contracts/MOUs. Responsible Person for Corrective Action Plan: Kate Bauer-Jones, Executive Director Implementation Date for Corrective Action Plan: May 15, 2025

Finding 2024-004 Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town of Lincoln’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.303, and 200.318 through 200.326 within Uniform Guidance. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Management is working with our current auditors to update the Town’s procurement policies to be in compliance with Uniform Guidance. Name of Contact Person John Cimino, Finance Director Projected Completion Date 6/30/2026

Finding 2024-003: Unsubstantiated Expense The single audit report included the following recommendation: We recommend that management strengthen the process to identify and review funding sources of underlying expenditures, that support the amounts of the reclassification journal entries. This could include reviewing approved budgets for the federal award in scope at a necessary level of detail to determine appropriateness of allocations in a timely manner. Management Response/Status of Action Plans: Amtrak believes education and reinforcing the existing upfront controls to ensure the correct initial coding of the expenditures is correct is the best way to address this issue. When this issue was identified during the audit, the company coordinated a meeting with the department where these costs originated to reinforce the need to properly code the expenditures in the purchase order process. Leadership in that department acknowledged the miscoding and committed to proper coding going forward. The company understands that the issue of training on this control to properly code purchase orders may exist in other departments and will develop communication to reinforce education in the proper processes and controls in this area. The contact for this item is Carol Hanna, VP Controller. Amtrak anticipates that changes described above will remediate this finding in the fiscal year ending September 30, 2025

As a corrective measure, BGCPR will take the following actions and will anticipate completing on June 30, 2025: a. Implement and maintain an automated accounting and financial records system to enable real-time oversight of the asset capitalization policy. b. Establish a robust internal control framework including pre-approvals for equipment purchases and cross-validations of financial data. c. Periodic internal monitoring’s to ensure compliance and documentation.d. Update BGCPR’s fiscal management guidance to include a formal provision requiring the capitalization policy to be reviewed every three (3) years in compliance with the ensure compliance with federal regulation 2 CFR §200 regarding asset capitalization criteria. e. Conduct a training program for accounting and financial personnel.

Condition: Obligations and expenditures were overstated by $93,955 on the March 31, 2024 Project and Expenditure report. Corrective Action Planned: Town Administrator will work with CSS Capital Strategic Solutions LLC to potentially amend the filing with the Treasury. Anticipated Completion Date: End of 2025 Contact: Town Administrator Nelson Mui, nmui@townsendma.gov, 978-597-1700 x1703

Finding: The Office of Superintendent of Public Instruction improperly charged $5,139 to the Special Education program. Questioned Costs: Assistance Listing # 84.027 84.027 COVID-19 84.173 84.173 COVID-19 Amount $5,139 Status: Corrective action complete Corrective Action: The Office of Superintendent of Public Instruction concurs with this finding. The Office has strengthened internal controls to address accounting adjustments made during liquidation periods to ensure that expenditures occurring outside of a grant’s period of performance are not shifted to the grant. Procedures are updated to: • Monitor expenditures through reconciliation of monthly reports to ensure the spending level stays within the allowable threshold and grant maximum. • Require all journal vouchers correcting expenditures during the grant liquidation period be verified by budget staff to ensure they are charged to the appropriate grant period of performance. • Complete expenditure corrections within the grant liquidation period. • Liquidate obligations on the last business day of January (or 120 days after the budget period ends). The Office will communicate the corrective action plan with internal stakeholders to ensure compliance with updated procedures. The Office will consult with the federal grantor to discuss whether the questioned costs identified in the audit should be repaid. Completion Date: November 2024 Agency Contact: Tania May Assistant Superintendent, Special Education PO Box 47200 Olympia, WA 98504-7200 (360) 725-6075 Tania.may@k12.wa.us

Finding: The Department of Commerce did not have adequate internal controls over and did not comply with period of performance requirements for the Low-Income Home Energy Assistance program. Questioned Costs: Assistance Listing # 93.568 93.568 COVID-19 Amount $4,409,760 Status: Corrective action in progress Corrective Action: The Department will review and strengthen its policies and internal controls to ensure compliance with the Low-Income Home Energy Assistance Program (LIHEAP) period of performance requirements. This includes: • Implementing additional checks to verify that all expenditures are incurred within the award’s period of performance. • Providing additional training to staff on the period of performance requirements to prevent future misinterpretations. As part of the corrective action, the program has implemented the following changes: • For the 2024 and 2025 program years for LIHEAP awards, all subrecipient contracts were issued with a two-year period of performance to avoid new expenses being added to the closeout year. • Ensured that all new subrecipient contracts align with the Department’s updated internal approach. Based on the recommendation in the audit finding, the Department will consult with the grantor regarding the questioned costs identified in the audit. Completion Date: Estimated October 2025 Agency Contact: Gena Allen, CFE Internal Control Officer PO Box 42525 Olympia, WA 98504-2525 (360) 480-5149 Gena.Allen@Commerce.wa.gov

Finding: The Office of Superintendent of Public Instruction did not have adequate internal controls over and did not comply with federal activities allowed and subrecipient monitoring requirements for the Education Stabilization Fund program. Questioned Costs: Assistance Listing # 84.425R 84.425V Amount $47,322,280 Status: Corrective action complete Corrective Action: The Office distributed the remaining unobligated funds from the program to Local Education Agencies (LEAs) through the apportionment process to meet the legislative intent. Due to the nature of how the payments were calculated, the Office’s grants system could not be used for the distribution. When a grant is awarded through our grants system, an email notification is sent to the organization that contains the federal elements required in 2 CFR 200.332. Although the Office concurs that we did not provide a formal subaward document that included all of the elements since the funds were not distributed through our grants system, the LEA’s received other formal communication through a Gov Delivery email and the School District Accounting Manual that included most of these federal elements. Going forward, if the Office uses the apportionment process to distribute funds to LEAs, all the required federal elements in 2 CFR 200.332 will be included in a separate subaward. The Office’s communication to LEAs also included the allowable use of these funds. Therefore, the Office does not concur that the funds should be questioned as not being allowable or properly supported. Completion Date: February 2025 Agency Contact: TJ Kelly Chief Financial Officer P.O. Box 47200 Olympia, WA 98504-7200 (360) 725-6301 Thomas.Kelly@k12.wa.us

Identifying Number: 2024-005 Finding: Material Weakness: Cash Management Context: Drawdown on reimbursement requests were submitted to the grantor prior to the System incurring qualifying expenditures. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdwn requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.

2024-015 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Management Response: We agree with this recommendation. Interest related to past due amounts will be charged to general funds only. Expenditures will be reviewed both by staff and approving parties to ensure only allowable expenditures are charged to the federal grants. The questioned costs of $68 will be refunded and reported to CMS on the CMS 64. The agency will ensure that future contracts that include any incentive funds for surveys will be structured such that incentives are billed under separate coding that will be charged to general funds only. The questioned costs of $28,801 will be refunded and reported to CMS on the CMS 64 Anticipated Completion Date: April 30, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

Harris County Public Health management acknowledges the requirements that each grant has a specified period of performance per the grant agreements of Federal awards. We also agree that failure to ensure expenses are properly reviewed and coded to the correct period or grant could result in noncompliance with the award contract, which may result in the early termination of the grant award, non-reimbursement of grant funding, or cessation of future funding. HCPH management will ensure that a detailed review of the period of performance is performed by grant staff by instituting staff training and reemphasizing the grant closeout process and procedures by September 2025

2024-015 Oregon Department of Human Services/Oregon Health Authority Strengthen review over direct costs charged to the program Management Response: We agree with this recommendation. Interest related to past due amounts will be charged to general funds only. Expenditures will be reviewed both by staff and approving parties to ensure only allowable expenditures are charged to the federal grants. The questioned costs of $68 will be refunded and reported to CMS on the CMS 64. The agency will ensure that future contracts that include any incentive funds for surveys will be structured such that incentives are billed under separate coding that will be charged to general funds only. The questioned costs of $28,801 will be refunded and reported to CMS on the CMS 64 Anticipated Completion Date: April 30, 2025 Contact person: Jennifer Stallsworth, Chief of Staff, ODHS APD, April Gillette, OHA Medicaid Division, Strategic Operations & Improvement Director

Recommendation: Our auditors recommended the Organization update their method of allocating expenditures to federal awards based on invoice date to ensure the incurred date is within the proper period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review grant requirements and make sure that allowable costs are incurred and allocated to the grant within the grant period.

Finding 2024-02: Indirect Costs (IDC) Views of Responsible Officials Management agrees with the finding and recommendations. Through the merger with Old Dominion University, additional controls have adopted around the processes and controls around the accuracy of the review over indirect costs calculation requirements. Corrective Action Plan Effective July 1, 2024, EVMS merged with ODU and the ODU Research Foundation became the fiscal and administrative agent for EVMS’s transferring sponsored programs on behalf of ODU. As per ODU’s Memorandum of Understanding (MOU) with the ODU Research Foundation, the ODU Research Foundation has policies and processes in place to manage how the indirect costs are calculated. The ODU Research Foundation uses its own system of internal controls for IDC calculation with no reliance on ODU systems for those processes and are audited separately. As a corrective action moving forward, ODU management will notify the ODU Research Foundation management of the audit findings, so they are aware of the internal control deficiencies. ODU will request the Research Foundation to provide a copy of their single audit report to monitor continued compliance with Uniform Guidance. The corrective action plan will be completed by March 31, 2025 and the contact person for this finding is Victoria Dean.

FINDING 2024-004 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Kelli Keith Contact Phone Number and Email Address: 812-438-2655, kkeith@risingsun.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We had never been instructed to do price quotes for items purchased from the HPS Purchasing Co-Op before. In the future, we will obtain price quotes when purchasing from HPS when purchases are above the micro-purchasing threshold. Or we will find a different purchasing avenue and will not use HPS. The cafeteria director is currently discussing this with each of the cafeteria supervisors to decide which avenue they will use to avoid the finding in the future. Going forward, for any vendor expected to equal or exceed $25,000 that is paid from school lunch funds (or any federal funds for that matter), someone at the school corporation will verify those vendors aren’t suspended or debarred. Anticipated Completion Date: 08/01/2025: The next school year.