Corrective Action Plans

Views of responsible officials and planned corrective actions: Management agrees with this finding and will put procedures in place for the review and approval of expenditures and maintenance of supporting documentation surrounding federal awards. Action Plan:  See the “Conduct Training Sessions for Expenditures Personnel” and “Audit of all FY25 YTD Expenditures” sections of management’s action plan for finding 2024-001  Review and update the Allowable Funds document o Locate the latest Allowable Funds Guide created by KIPP Delta. o Review and update the guide as necessary. o Store the updated guide in a central cloud location for responsible personnel to access easily. o Process completed as of April 17, 2025.  Develop a Federal Funds Workflow in Avid for POs and invoices: o A designated finance team member must review all federally funded purchases to improve the federal funds purchasing process. Steps include:  Create a separate workflow in Avid for POs and invoices to track federal purchases.  Ensure a purchase order is created before an invoice is submitted and paid.  Attach all required documentation to the PO, as with all other expenditures.  Verify that the expenditure complies with the Allowable Funds guide o Anticipated completion date of May 30, 2025.

Finding 2024-002: Review of Compliance Matrices and Narratives The single audit report included the following recommendation: We recommend that Amtrak establishes a more defined timeline for the events that would trigger the update and review of the compliance matrices and compliance narrative, which could include execution of any new federal awards or amendments to existing federal awards. Additionally, Amtrak should establish a process where the modifications to the provisions are assessed for materiality/applicability and include documentation of the respective conclusions as part of the review process. Management Response/Status of Action Plans: Amtrak acknowledges the need to augment process documentation around the controls over the preparation and updates to the compliance matrices. The company is in the process of updating these controls now and will incorporate the identified findings in developing more robust controls. The company specifically notes the need to add more documentation on considerations for what provisions are updated in the compliance matrices and the evidence of review. The review procedures and controls are being enhanced to include a checklist to improve the review. This checklist will be completed by both the compliance matrix creator (upon creation) and the compliance matrix reviewer/approver (upon review and final approval). The contact for this item is Lucia Butts, AVP Funding and Grants and Meghan Histand, Director of Discretionary Grants. Amtrak anticipates fully remediating this finding by September 2025.

Finding 2024-001: Preparation of Schedule of Expenditures of Federal Awards (SEFA) The single audit report included the following recommendation: We recommend Amtrak to strengthen the SEFA oversight process to ensure appropriate preparation and review of the SEFA to validate its accuracy, including reconciliation with prior year audited SEFA. This should include having one reviewer take overall responsibility for the completeness and accuracy of the final submitted SEFA. This robust review process should include appropriate procedures to confirm accuracy of the SEFA, which may include a protocol where representatives from various groups (both discretionary and non-discretionary federal programs) work collaboratively to review the SEFA and underlying details of expenditures, to ensure all the adjustments have been properly reflected as well as any projects that might have multiple fund sources are identified timely and reviewed for appropriate inclusion within the SEFA. Additionally, Amtrak should establish a process where any modifications of WBS funding assignments and allocations are updated in a timely manner Management Response/Status of Action Plans: Amtrak recognizes the need to improve the preparation and review of the SEFA. The company has documented the steps for preparing and reviewing the SEFA within its process narrative. The company will update the narrative to address the preparation and review issues that led to the multiple versions of the SEFA being provided during the audit. The company is in the process of updating the SEFA preparation documentation for FY2025, which will be used at the end of the year. The review procedures and controls are being enhanced to include a checklist to improve the review. The company will review and update the Grants Management Compliance Narrative and controls to improve timing of updates for modifications of WBS funding assignments. The contact for this item is Lucia Butts, AVP Funding and Grants. Amtrak anticipates fully remediating this finding by September 2025.

Views of responsible officials and planned corrective actions: The Clinic will be seeking professional consultation and guidance on a process to support and enforce monthly reconciliations of the amounts submitted for the grant with the amounts booked within the system, using appropriate grant-tracking schedules. Relevant staff will be retrained, and a monthly review will be completed by an appropriate professional and submitted to the Chief Executive Officer (CEO). Personnel responsible for implementation: Deborah Lerner, CEO and Board of Directors Date of implementation: July 1, 2025

Finding 2024-027 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-023 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

Finding 2024-026 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes; 2023-022 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

Finding 2024-024 U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Material Weakness in Internal Controls and Noncompliance over Cash Management Repeat Finding: Yes; 2023-020 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

Finding 2024-023 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-019 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

Finding 2024-021 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-016 Auditee’s Corrective Action Plan: The Federal Financial Report (FFR) is a cumulative report covering the entire project or award period, which for this grant spans from March 1, 2020, to February 28, 2025. As a result, the cumulative amounts reported on the FFR will not align with the amounts recorded in the general ledger for fiscal year 2024. BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established the Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

Finding 2024-020 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Significant Deficiency in Internal Controls and Noncompliance over Earmarking Repeat Finding: No Auditee’s Corrective Action Plan: BCHD fiscal will revise its internal processes to ensure compliance with 2 CFR 200 and the OMB compliance supplement (Part IV) by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include training on earmarking requirements. B. Established a Contract and Compliance Unit which responsibilities include ensuring program and fiscal staff are informed of all grant compliance requirements. C. Establish a process for periodic review by BCHD Fiscal internal audit team of grant expenditure reports and general ledger details to ensure compliance with the earmarking requirements. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

Finding 2024-019 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Significant Deficiency in Internal Controls and Noncompliance over Cash Management Repeat Finding: No Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

The reconciliation process implemented in Finding 2024-001 includes a formal method of matching drawdowns to allowable expenditures. Each grant will continue to be tracked in a separate cost center and La Casa will document the reconciled expenditures in the general ledger to amounts drawn from each grant. The monthly reconciliation will be reviewed by the CFO to ensure that revenue is recognized in accordance with ASC 958-605 and that federal expenditures reported on the SEFA and financial statements comply with 2 CFR §§200.302, 200.303, and 200.305. The CFO will utilize the reconciliations to prepare the SF-425 filings and confirm that cumulative drawdowns reconcile to allowable costs and recorded revenues. All supporting documentation will be retained electronically and included in monthly close procedures.

U.S Department of Treasury 2024-001 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommended that the organization implement a review and approval process for all quarterly progress report submissions. This should include: •Training staff on the importance of the review and approval process. •Ensuring adequate staffing levels to handle the review process. •Developing clear guidelines and procedures for the review and approvalprocess. •Regularly monitoring and auditing the review process to ensure compliance. Explanation of disagreement with audit finding: Management concurs with the finding. Action taken in response to finding: Additional fiscal staff has been hired to assist with various fiscal tasks including grant compliance and reporting. The guidelines are being updated, the checklist expanded, and documentation of secondary approval of reports is being retained. Grant guidelines, procedures, and checklists will be utilized to ensure compliance is maintained. Name(s) of the contact person(s) responsible for corrective action: Pete Winton Planned completion date for corrective action plan: The above action plan will be implemented in fiscal year 2025.

Finding No. 2024-001 NONCOMPLIANCE WITH US GAAP – VARIABLE INTEREST ENTITIES (VIE) We acknowledge the audit finding and appreciate the auditor’s diligence in identifying the issue. After evaluating the matter, we agree that the effect on the consolidated financial statements is immaterial and does not impact the fair presentation of our financial position, results of operations, or cash flows. Additionally, after assessing the costs and benefits of remediation, we have determined that the corrective action required to fully address this issue is not cost-effective at this time. The resources required would outweigh the potential benefits, particularly given the immaterial nature of the issue and the lack of impact on users of the financial statements. We, will continue to monitor this area as part of our internal controls framework and will reassess if conditions change or if the issue becomes material in future periods.

CONDITION: The District did not properly record its federal program expenditures for the ESSER and ARP ESER federal grant programs using the various funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations and well as Section 2 CFR 200.302(a) of the Uniform Guidance. CRITERIA: The financial management system of the District must provide for 1) identification in it’s accounts, of all Federal awards received and expended and the Federal programs under which they were received, and 2) accurate, current and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements set forth in sections 200.328 and 200.329 of the Uniform Guidance.CORRECTIVE ACTION PLAN: The School District concurs with the above noted finding. The School District has employed a new Business Manager whose responsibilities include the oversight of the financial management system and the posting of all transactions into that system. Procedures will be put into place during the remaining months of the 2024-2025 fiscal year, and all subsequent years, for ensuring federal program expenditures are properly coded within the District’s financial management system so as allow for proper reporting related to those expenditures.

Action Taken: HEA's leadership team, including our Director of Finance, will develop an updated version of our accounting and procedures manual that includes written policies related to all applicable compliance areas under Uniform Guidance. This will be a priority for the leadership team and will be developed by May 30, 2025 and reviewed by HEA board members by June 30, 2025. HEA's leadership team will work with staff to ensure all policies and procedures are implemented in our new fiscal year (beginning in July 2025). Contact Person: Sarah Metzler, HEA President/CEO; Aliah Carolan-Silva, HEA VP of Research; Cindi Dixon, HEA Director of Finance Expected Completion Date: July 2025

FINDING 2024-003 Finding Subject: COVID- 19 – Education Stabilization Fund – Reporting Summary of Finding: The School Corporation submitted one ESSER III report where the expenses per the report did not tie to the ledger or the Schedule of Expenditures of Federal Awards by approximately $300,000. Contact Person Responsible for Corrective Action: Matt Miles Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will ensure ESSER reports are saved and tie to the accounting records and will improve record keeping of supporting documentation. If any edits are made to the reports, the Curriculum and Accounting Departments will document the reason for all changes. Management in each department will review all ESSER reports and sign off on all documentation. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures. Management expects to present the policies to the board for approval at the May 2025 board meeting.

Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025

After the September 2023 quarter, controls were put in place to ensure accurate Federal quarterly reports. These controls included preparing the report based on our accounting records, e.g. the general ledger. Another control is that the Chief Financial Officer or her designee reviews all reports and compares them to the general ledger prior to signature, approval and our submission to the grantor. Furthermore, periodic reviews by program fiscal staff during the performance period take place to closely monitor activity. GDOL will continue to follow the updated procedures and internal controls. As we transition to GA@Work, the system itself will control overspending and provide alerts.

Georgia Tech management agrees that internal audit reports demonstrated departmental deficiencies in knowledge of policies and procedures that needed to be addressed. Upon disclosure of Internal Audit’s recommendations, the departments and central offices immediately responded with additional training, proactive compliance reviews, and re-enforcement of existing policies and procedures via Institute wide communications and enhanced reviews of support. New system controls regarding spend authorizations were put in place, with Georgia Tech’s Internal Audit department continuing to test these controls through the month of February. Central and departmental units within Georgia Tech will continue to work together to further enhance guidance and training to faculty and staff and to identify and test controls in our systems that will mitigate these issues.

Friday, April 11, 2025 Dear Sir(s): CORRECTIVE ACTION PLAN In prior years the accounting of Pyramid Learning Corp. was executed externally by a contracted accounting company. During the year ended June 30, 2024 we acquired a specialized accounting software. After the acquisition of the new software, we recorded the data from the beginning of the year to the present, which required significant staff effort and made it impossible to maintain accounting and financial reports on a month-to-month basis. At the present, the data is already being recorded, and the accounting is up to dates. This allows us to keep our accounting and interim financial reports such as Balance Sheet, Statement of Activities, Bank Reconciliations, and monthly analysis of accounts, up to date and on a current month-to-month basis to be more transparent, and any errors are corrected on a timely manner.

Finding 2024-001—Significant Deficiency in Internal Controls over Compliance: Research and Development Cluster Contact Person: Jennifer Sabbagh Peirce, Senior Director Research Operations, Sponsored Programs Administration and Dr. Andrew Artenstein, Chief Physician Executive and Chief Academic Officer, Baystate Health, Inc. Views of Responsible Officials: Management agrees and acknowledges that controls over compliance and documentation of these controls should be assessed and improved. Management highlights that no unallowable charges were incurred and there was no evidence that sponsors were overcharged as a result of the identified deficiencies. Corrective Action Plan and Expected Completion Date: Policies and Procedures – Baystate has already begun a review and revision of policies and procedures that govern sponsored activity in fiscal year 2025. As policies and procedures are revised and finalized, training is provided to the research community, as necessary. This includes effort reporting, subrecipient monitoring and calculations related to salary cap and indirect cost rates. Documentation and Document Maintenance – Baystate is in the process of implementing a pre-award grants system. This electronic system will be the institutional record of all award documentation and award actions. Built into the system are a number of internal controls including workflow approval, tracking and management of award actions and modifications, and management of subrecipient monitoring activities. Salary Cap – Baystate has implemented a number of immediate solutions for salary cap including additional reports to flag salary cap issues. Guidance has been developed and training is underway for individuals that certify effort. In fiscal year 2025, Baystate will consider implementing system delivered functionality in Lawson to manage salary cap calculations. Indirect Rates and Grant Attributes – Implementation of the pre-award grants system will provide an internal control to ensure accurate setup of indirect cost rates and other grant related attributes. These attributes are maintained in the pre-award system based on the sponsor documentation. With each award action and at least annually, Baystate will reconcile attributes between the pre-award system and Lawson to ensure accuracy and completeness. The Corrective Action Plan is expected to be completed by December 2025.

The City is in agreement with the finding and noted and will consider formally documenting policies and procedures. Heather Shippey, City Clerk will be responsible for the corrective action and anticipated completion of corrective action is undetermined.

Views of Responsible Officials and Planned Corrective Action The County has a written policy regarding Federal Grants that was passed by the Grant County Commissioners in January 2025. Finding resolution timeline: Resolved. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager