Corrective Action Plans

The City acknowledges the finding. The City will strengthen procedures to identify, track, reconcile, and report federal award activity throughout the fiscal year so that a complete and accurate SEFA can be prepared in a timely manner for future audit periods. Procedures will include maintaining award documentation sufficient to identify the federal agency/program, Assistance Listing number, award or loan identifiers, expenditures or loan proceeds, outstanding federal loan balances, sub-recipient amounts if any, and required SEFA notes.

Organization Response: Management acknowledges the auditors’ comments, with the clarification below, and has taken the actions listed below. The overstatement noted in this finding was a misstatement. The omission noted in this finding references funds received from state and county agencies. Therefore, the funds were recorded consistent with the information and documentation provided by the pass-through entity (Cascade County) which did not clearly identify the original funding source as the federal entity. To ensure internal controls over funding sources and expense reporting, the grant award and processing policy has been reviewed and updated to include due diligence of original funding sources.

CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Audit Finding Reference: 2024-003 Document Policies and Procedures Over Federal Awards Views of responsible officials: The Town agrees with the recommendation to implement written policies and procedures to be in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action: The Town plans to implement recommendations for the next fiscal year. Official Responsible for Implementing Corrective Action: Kurt Ginthwain Finance Director/Town Accountant

Finding No. 2024-001 Implement System-Based Tracking of Federal Expenditures Finding: During our review of the SEFA, we noted that CAIR-CA utilizes workbooks outside of its accounting software to track federal expenditures. The workbooks do not reconcile directly with the general ledger (GL), so management performs a separate reconciliation to support the SEFA amounts. This approach was similarly observed in the prior year's audit. Views of Responsible Officials and Corrective Action Plan: Management concurs with the finding and has already updated the accounting system to incorporate grant-specific tracking codes to further align with federal reporting standards. Because the organization’s first single audit in FY2023 was conducted concurrently with the FY2024 single audit, there was limited opportunity for these procedural improvements to be reflected in the FY2024 single audit testing cycle. As a result, the impact of these changes will be more fully reflected in the FY2025 single audit, which is scheduled to commence this year. As part of a layered approach to internal controls, excel worksheets will continue to be used as a supplementary monitoring tool, providing an additional cross-check to the system-generated reports. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Implementation date: November 20, 2025

Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with federal cost principles. Actions include: • Enforcing segregation of duties within the AP workflow. • Implementing standardized invoice naming conventions. • Requiring secondary review for all grant-related invoices. • Conducting quarterly post-payment audits to detect and correct errors. • Implementing ERP system enhancements to flag potential duplicates. • Hiring an AP Manager to manage and improve the AP processes. Responsible Staff Chief Financial Officer (CFO) Target Completion Date June 30, 2026

Audit Finding: 2024-001 Non-Material Non-Compliance – Allowable Costs and Activities; 2024-002 Revenue Recognition – Material Weakness Corrective Actions: This plan outlines the steps to address the staffing shortage and implement necessary controls to ensure financial statement accuracy and compliance. Phase 1: Immediate Actions Prioritize Key Hires: The immediate priority is to recruit and hire a Controller with significant non-profit accounting experience. This individual will be crucial in designing and implementing the necessary internal controls. 1. Interim Support (If Needed): While searching for permanent staff, explore options for interim accounting support through a consulting firm or temporary staffing agency specializing in non-profit organizations. This can provide immediate assistance with critical tasks and help bridge the gap until permanent staff are in place and sufficiently trained. 2. Documented Job Descriptions: Develop detailed job descriptions for the Controller, Senior Accountant, and Staff Accountant positions. These descriptions should clearly outline the required qualifications, responsibilities, and reporting lines. Emphasis should be placed on experience with non-profit accounting principles (GAAP), fund accounting, and relevant regulations. 3. Recruitment Strategy: Implement a robust recruitment strategy that includes: ○ Posting job openings on relevant job boards (e.g., Idealist, LinkedIn, specialized non-profit job sites). ○ Networking with professional organizations (e.g., state non-profit associations, accounting professional groups). ○ Partnering with recruitment agencies specializing in non-profit finance. Phase 2: Staffing and Implementation 1. Hire Controller: Complete the recruitment process and hire a qualified Controller with proven non-profit accounting experience. 2. Hire Senior Accountant: Once the Controller is in place, begin the recruitment process for a Senior Accountant to support the Controller and manage day-to-day accounting operations. Experience with fund accounting and grant management is highly desirable. 3. Hire Staff Accountants: Recruit and hire the necessary number of Staff Accountants to handle transaction processing, reconciliations, and other accounting tasks. 4. Control Design and Implementation: The Controller, in collaboration with the Senior Accountant, will be responsible for designing and implementing the necessary internal controls. This includes: ○ Segregation of duties (e.g., authorization, custody, recording). ○ Approval processes for expenditures and journal entries. ○ Regular reconciliations of bank accounts and other key accounts. ○ Documentation of accounting policies and procedures. Phase 3: Review and Monitoring (Ongoing) 1. Training: Provide comprehensive training to all finance staff on non-profit accounting principles, internal controls, and the organization's specific policies and procedures. 2. External Review (Optional): Consider engaging an external accounting firm to review the implemented controls and provide recommendations for improvement. This can provide an independent assessment of the effectiveness of the controls. 3. Regular Monitoring: The Controller will be responsible for regularly monitoring the effectiveness of the internal controls and reporting any deficiencies to the Executive Director and the Board of Directors. 4. Policy Updates: The Controller will ensure that accounting policies and procedures are reviewed and updated regularly to reflect changes in regulations and best practices. Responsible Parties: ● Executive Director (Todd Hixson) : Overall responsibility for implementation of the plan. ● Board of Directors: Oversight and approval of the plan and budget. ● Controller: Responsible for designing, implementing, and monitoring internal controls. Timeline: Phases 1 and 2 were completed as of January 2025. As noted above, phase 3 is an ongoing process. Regular progress updates have been and will continue to be provided to the Executive Director, Finance Steering Committee, and the Board of Directors as appropriate. This Corrective Action Plan demonstrates Safe Harbor Crisis Center’s commitment to addressing the identified control deficiencies and strengthening its financial management practices. By implementing this plan, the agency will be better positioned to ensure financial accountability, transparency, and compliance in service of the mission.

Finding 2024-001 Allowable Cost Principles and Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need for a formalized, written policy governing expenditures charged to federal awards. To address identified material weaknesses, Wabash is committed to implementing a comprehensive written policy by June 30, 2026. This policy will formalize the coding, review, and reporting processes for all federal expenditures. Key improvements will include: • Enhanced Internal Controls: We will establish a clear segregation of duties to ensure oversight and accuracy. • Timely Reporting: We are refining our payroll allocation process. Previously, payroll expenditures were withheld pending budget verification, which occasionally led to reporting delays. New controls will ensure that all expenditures, including payroll, are reported within the required quarterly timeframes. • Monitoring: The Controller will oversee the development of these procedures and remain responsible for ongoing monitoring and compliance. These steps will ensure our financial practices meet federal standards and provide rigorous oversight of project funds. Contact person(s): Cheryl Gaither, Controller Justin Gephart, Chief Operating Officer

The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.

The City will develop written procedures to implement the requirements of 2 CFR § 200.305 Payment.

Finding No.: 2024-052 Reporting Responding Agency: Guam Homeland Security (GHS) Responsible Personnel: Esther Aguigui, Director GHS will work with DOA to make sure reports are submitted on time. GHS will also retain documentation of submitted reports.

Finding No.: 2024-048 Eligibility Special Test and Provisions- Utilization Control Provider Eligibility (Screening and Enrolment) Provider Health and Safety Standards Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director DPHSS agrees with this finding. To address the recommendation for a reconciliation process, DPHSS is in the process of forming a multi-agency technology initiative which will include: • Establishment of an Inter-Agency Data Hub: DPHSS, in collaboration with the Office of Technology (OTECH) and the Department of Administration (DOA), aims to establish a centralized Data Hub. This hub will facilitate real-time or scheduled data synchronization between the DPHSS medical management systems and DOA’s financial accounting records, which are managed in the Guam Financial Management Information System (GFMIS). The data hub is intended to ensure all claims paid are automatically after proper approvals and are then reconciled with the general ledger. • Inter-Agency Agreement and Coordination: DPHSS acknowledges that successful implementation of this Data Hub requires a unified commitment. DPHSS leadership is coordinating with the Director of DOA to discuss the technical requirements and administrative protocols. A formal Memorandum of Agreement (MOA) or a joint standard procedure will be sought, subject to the concurrence and approval by both Agency Directors. • Manual Interim Reconciliation: Until the Data Hub is fully operational, DPHSS will work with DOA to implement a monthly manual reconciliation process. This will involve a "crosswalk" review of claim batch totals against financial system postings to identify and resolve variances (such as voided checks or manual adjustments) in a timely manner. • Engagement with OTECH: Once the two directors agree on the framework, DPHSS will engage OTECH to design the data architecture necessary to ensure data integrity, security, and compliance with federal reporting standards. Estimated implementation timeframe: March 31, 2027

Finding No.: 2024-039 Procurement, Suspension, and Debarment Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) GSA will continue to verify vendor eligibility through SAM.gov prior to contract award. Documentation of the verification will be retained in the procurement file for each transaction. GSA has revised IFB templates to include the required debarment and suspension certification language in accordance with 2 CFR 200.214. Effective immediately, all new contracts will include this clause prior to execution. For local vendors that may not appear in federal systems, GSA will require a debarment and suspension certification as part of the contracting process and maintain this documentation within the procurement record.

Finding No.: 2024-027 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director GSA will continue to verify vendor eligibility through SAM.gov prior to contract award. Documentation of the verification will be retained in the procurement file for each transaction. GSA has revised IFB templates to include the required debarment and suspension certification language in accordance with 2 CFR 200.214. Effective immediately, all new contracts will include this clause prior to execution. For local vendors that may not appear in federal systems, GSA will require a debarment and suspension certification as part of the contracting process and maintain this documentation within the procurement record.

Finding No.: 2024-024 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director The Agency is reviewing its federal grants management to ensure robust handover and succession plans are in place of future programs.

Finding No.: 2024-015 Reporting Responding Agency: Bureau of Budget and Management Research (BBMR) Responsible Personnel: Lester Carlson, Director BBMR will work with DOA to keep soft copies of submitted and approved Federal Financial Reports (FFR) on hand.

Finding No.: 2024-013 Allowable Costs/Cost Principles: Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director Agency disagrees with 2 out of the 3 findings. • Condition 1 regarding the Authorization To Proceed (ATP), as per the Grant and Cooperative Agreement and the Grant Terms and Conditions, it did not state that an ATP is required to begin work on the grant for D20AP00048 and D21AP10145.The Government complies with ATP requirements for grants which mandate such compliance. If the grant is silent, no ATP is required.. • Condition 2 GSA will continue to verify vendor eligibility through SAM.gov prior to contract award. Documentation of the verification will be retained in the procurement file for each transaction. • Condition 3 The necessary controls will be strengthened when the updated Federal Grant module is fully implemented.

Finding No.: 2024-012 Procurement, Suspension, and Debarment Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) GSA will continue to verify vendor eligibility through SAM.gov prior to contract award. Documentation of the verification will be retained in the procurement file for each transaction. GSA has revised IFB templates to include the required debarment and suspension certification language in accordance with 2 CFR 200.214. Effective immediately, all new contracts will include this clause prior to execution. For local vendors that may not appear in federal systems, GSA will require a debarment and suspension certification as part of the contracting process and maintain this documentation within the procurement record.

Corrective Action Plan • Policies and Procedures Reinforcement – Review and reinforce procurement policies to ensure all purchases are supported by approved requisitions and required quotations. • Documentation Retention Controls - Implement controls to ensure all procurement documentation is properly filed and retrievable. • Staff Training and Development – Provide training on procurement requirements under uniform guidance. This training will focus on compliance with policies and procedures and emphasize the importance of require documentation for each process and best practices. • Monitoring and Compliance Review - Establish periodic internal review procedures to ensure adherence to procurement policies. Name of the contact person responsible for corrective action plan Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date June 30, 2025

Finding reference: 2024-004 - 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Cash Management Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Action taken: With the hiring of our grant accountant, the policy is that all drawdowns are to be reconciled to general ledger prior to submitting.

Finding reference: 2024-009 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Cash Management Recommendation: We recommend that the City review policies, procedures and practices in place to ensure drawdowns are reconciled to the general ledger, and reviewed and approved before requests have been submitted. Action taken: With the hiring of our grant accountant, the policy is that all drawdowns are to be reconciled to general ledger prior to submitting.

Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice and Payment Documentation: • All invoices related to the federal program will be promptly reviewed and approved by the appropriate personnel to ensure they reflect allowable costs under the specific terms and conditions of the award. • Management will establish clear procedures for the proper recording and classification of payments, ensuring that they are linked directly to the corresponding federal program expenses. • All supporting documentation (e.g., purchase orders, contracts, receipts) will be retained in electronic formats within the accounting system, in accordance with the Organization’s record retention policy, ensuring availability for future audits or reviews. Retention and Accessibility: • The Organization will maintain a secure, organized filing system for all invoices and payments, ensuring that each record is easily accessible for audit purposes. This system will include electronic records that are stored in a centralized database, with restricted access to authorized personnel. • Retained invoices and payment documentation will be kept for the full duration required by federal regulations, typically for a period of at least seven years after the final expenditure report for the federal award has been submitted, or as otherwise required by the specific federal agency. Periodic Reviews and Monitoring: • To ensure ongoing compliance, Management will perform periodic reviews of federal program expenditures and documentation. This will include random sampling of invoices and payment records to confirm that they are complete, accurate, and in compliance with federal regulations. • In the event of any discrepancies or issues identified during these reviews, Management will take immediate corrective action to address the issue and prevent recurrence. By maintaining thorough records of all invoices and payments, the Organization aims to not only comply with federal audit requirements but also to ensure transparency, accountability, and sound financial management of federal funds.

Retain Supporting Documentation for Journal Entries (Material Weakness, Compliance Finding) Planned Corrective Action Effective March 1, 2026, the District implemented procedures requiring that all journal entries include appropriate supporting documentation prior to posting in the accounting system. Supporting documentation can range from invoices, written explanations describing the purpose of the entry, and calculations. The accounting system has been changed so all entries have supervisory review and approval. The Business Offi ce has established a standardized review process to ensure journal entries affecting federal programs are properly supported and retained within the District’s fi nancial records. Documentation will be maintained electronically to ensure availability for audit and internal review. The Business Offi ce will also provide guidance to staff responsible for fi nancial reporting and grant accounting regarding the requirement to maintain adequate documentation for journal entries in accordance with Uniform Guidance fi nancial management requirements. Periodic internal reviews will be conducted to ensure compliance with these procedures. Name of Contact Person and Completion Date Nancy J. Konisky, Business Manager Completion Date: Implemented March 1, 2026

Establish dual authorization for all disbursements >$500. • Require approval documentation for all payments. • Monthly review of check registers and reconciliations by Board Treasurer or Board President. • Revise Finance Policy Manual to reflect new procedures.

Finding 2024-004 Internal control weakness over activities allowed/allowable costs Name of responsible official: Evan Howard – Business Manager Corrective action: With stabilized staffing in place, management is currently updating the District’s federal funds procurement and compliance policies to address Uniform Guidance requirements related to allowable and unallowable costs. In conjunction with this effort, management will design and implement internal control procedures to ensure that expenditures charged to grants are reviewed for allowability prior to payment. These procedures will include documented review and approval processes, supervisory oversight, and periodic monitoring to ensure ongoing compliance. Anticipated completion date: June 30,2026

Finding 2024-003 Material Weakness in Internal Control over Compliance Name of responsible official: Evan Howard – Business Manager Corrective action: The municipality is in the process of reviewing roles, responsibilities, and job descriptions to ensure appropriate segregation of duties and proper internal controls, in accordance with the Corrective Action Plan. The plan has not yet been formally adopted. Anticipated completion date: June 30,2026