Corrective Action Plans

We agree with the finding and provide below the corrective action plan. Corrective action plan: We will provide additional training to staff responsible for tracking federal and state awards and utilize another member of management to review and approve the grant tracking spreadsheets routinely. Additionally, reconciliations will be performed monthly between the grant spreadsheets and the financial reporting software.

Views of Responsible Officials: As of 6/1/2024, NEW's accounting has been outsourced and a new accounting system will be utilized.

Views of Responsible Officials: As of 7/1/204, NEW's accounting has been outsourced and a new accounting system will be utilized. The accounting department has been restructured to ensure accounts are properly reconciled each month.

Action Taken: Management agrees with the finding and adopted the appropriate policies and procedures in December 2023.

Recommendation: We recommend that the Organization should ensure that program managers compare all program reports to the reporting requirements within the grant documents to ensure all quantitative and qualitative information is appropriately included prior to submittal to the oversight Organization. Views of responsible officials: There is no disagreement with the audit finding.

Condition: The District overstated their claim by $302. Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. Anticipated Date of Completion: 6/30/2024. Name of Contact Person: Justin Whitten, Business Manager. Management Response: Management will work together with staff to ensure that grant budgets are periodically reviewed and amended as necessary.

Finance staff will review grant budget simultaneously as costs are invoiced for reimbursement. Additionally, Finance staff will receive training on grant budgeting including federal grant regulations and requirements. Expected completion date: July 2024

The Council will move to the Time & Effort method of reporting to allow employees to sign off on their time allocation for each pay period which will subsequently be approved by the supervisor and Executive Director. Expected completion date: May 2024

Health Center Infrastructure Support Financial Reporting Management’s Views and Corrective Action Plan Management’s View and Opinion Sunset Park agrees that the Federal Financial Reports (FFRs) were filed on a cash basis, however the accrual method was selected in error. Corrective Action Plan Sunset Park is dedicated to upholding full compliance with all federal regulations and guidelines. Sunset Park will contact the funding agency's Project Officer and Grants Management Specialists to verify Sunset Park’s understanding of federal reporting standards and the specific reporting requirements for equipment expenditures on the FFRs. This verification will ensure clarity and adherence to federal guidelines, including distinguishing between cash and accrual basis reporting requirements. Sunset Park will also implement enhance its control procedures to ensure that FFRs submitted are reconciled to the underlying accounting records. Timeline for Action Plan Date of Completion: 08/31/2024 Responsible Individual Leonardo Arias Email: Leonardo.Arias@nyulangone.org

2023-002 Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the County establish internal control procedures to ensure that all amounts charged to grant programs for employee payroll costs be reconciled to the specific employee payroll records and that supporting documentation be maintained throughout the grant award period and beyond. Views of responsible officials: Management concurs with the finding. There were minimal variances in the number of employees tested and the County believes the wage report discrepancies are isolated due to the complexity of the EMS salary structure. The County claimed $26,038,852 of the $37,618,256 total eligible expenses available. Action planned/taken in response to finding: Effective fiscal year 2024, Management will implement the following corrective action: The County will create a process to ensure the payroll wage reports generated by Human Resources agrees to support documentation. Name of the contact person responsible for corrective action plan: Pete Winton Planned completion date for corrective action plan: The above action plan will be implemented in fiscal year 2024.

Recommendation: Internal controls over reporting should be designed, implemented, and documented to ensure compliance with 2 CFR section 200.302(b)(2), including who is responsible, what they are reviewing for, when reviews are to take place, and how documentation of the controls will be maintained. The general ledger should be set up to properly capture and track expenses as well as budgets prepared and approved with the actual costs expected to be incurred. Reports should be reconciled to the general ledger. Budgets should be complete and include all line items and not just include all expenses under supplies. Ac􀆟on Taken: This is a project Finance team is currently working on. The new Compliance Director will manage the grant writing process. During the grant and award process, Compliance, the Program with award, and Finance will establish an appropriate budget which, in turn, will be reflected in general ledger and monitored by the team. The contact persons responsible for this corrective action plan are Alan Branch, Sr VP of Compliance and Workforce Development, the new Compliance Director, Wendi Speed, CFO, and the entire Finance Team. The anticipated completion date is June 30, 2025.

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, 2024

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization properly apply allowed indirect cost rates across its Federal awards, we concur with the recommendation and are in the process of creating a single, succinct schedule and the supporting documentation on indirect cost rates and rationale to allow the auditors to easily verify that the costs have been charged appropriately.

Person Responsible: Chief Operating Officer, Deirdre Bagley, will coordinate with the finance team Implementation Date: By August 30, 2024 Management’s response: In response to the recommendation that the Organization apply salaries on each of its Federal awards, based on actual time spent on each award per employee, as supported by timesheets and other records, we concur with the recommendation and are in the process of creating a single, succinct schedule so that the auditors can easily test and reconcile the salary amounts to the supporting details.

The Treasurer will review both the elementary and the jr high/high school lunch and breakfast counts prior to the claims being submitted to CRRS.

The Hospital recognizes the importance of having a methodology in place for estimating  the allowance for contractual adjustments in accounts receivable and the estimate for third‐party payor settlements.   The  Hospital  will  work  on  strengthening  procedures  for  the  allowance  for  contractual  adjustment  estimate and develop an estimate for the Medicaid lump sum payments. Our goal will be to use our Medicare cost report model to estimate the Medicare cost report settlement on a quarterly basis. In addition, our goal is to have the model tested against the most recently submitted Medicare cost report on an annual basis. An accountant was hired on February 13, 2024, to assist the Chief Financial Officer (CFO)   in the monthly accounting duties. The accountant immediately began reconciling cash accounts and is caught up on  all  prior  month  reconciliations.   The  accountant  is  working  with  CFO  to  post  activity  and  corrections  to  the  general ledger. The accountant will ensure that cash and investment accounts are reconciled monthly in a timely manner going forward. Now that the cash reconciliations are caught up, the accountant will begin reconciling all other balance sheet accounts. Responsible Individuals: Stephani Tipton, Accountant and Ken Fisher, CFO Anticipated Completion Date: Ongoing

The migration to a new general ledger financial reporting system is an isolated incident and given the improved reporting capabilities the change in product provided a positive impact. UWGC experienced turnover for the program manager position that created a learning curve that was addressed but resulted in audit completion delay. UWGC has an experienced manager currently overseeing the program who will follow policies and procedures as prescribed and on a timely basis to allow for prompt reporting submission.

UWGC experienced a staffing turnover during the 2024 fiscal year of the manager responsible for the reporting on the SEFA. The manager tracked financial reports on a cash basis causing a timing difference with not recognizing accounts payable. The finance team accounted for expenses in the appropriate period, therefore the Finance team will crosscheck reports for timing difference prior to submission to governing agency.

Finding 2023‐001—Significant Deficiency in Internal Controls over Compliance: Research and Development Cluster Contact Person: Melissa Quintero, Director, Sponsored Programs Administra􀆟on and Peter D. Friedmann, Chief Research Officer, Baystate Health. Views of Responsible Officials: Management agrees and acknowledges that well‐defined roles, responsibili􀆟es, processes, and monitoring are necessary. Management wishes to highlight that no unallowable charges were incurred as a result of the iden􀆟fied deficiencies. Correc􀆟ve Ac􀆟on Plan and Expected Comple􀆟on Date Roles and Responsibili􀆟es—Management has engaged Huron Consul􀆟ng Group (Huron) to review roles and responsibili􀆟es across Sponsored Programs Administra􀆟on (SPA), Research Accoun􀆟ng and other affected areas to ensure adequate defini􀆟ons and clarity across control owners. Huron’s recommenda􀆟ons should be available by April 11, 2024. Once Huron’s recommenda􀆟ons are received and reviewed by management, posi􀆟on descrip􀆟ons will be revised, new posi􀆟ons created, and training implemented to ensure personnel understand their role and responsibili􀆟es related to internal controls, including controls over compliance and documenta􀆟on requirements. Policies and Procedures—Management maintains policies and procedures that govern the conduct of grantrelated ac􀆟vi􀆟es. Policies and procedures will be updated following Huron’s review of the roles and responsibili􀆟es, and management will con􀆟nue to make addi􀆟onal updates as necessary. Personnel will be trained on relevant updated policies and procedures. Documenta􀆟on and Document Maintenance—Management has ini􀆟ated implementa􀆟on of ServiceNow to improve the consistency and accessibility of documenta􀆟on evidencing review over research and development (R&D) compliance requirements and performance of internal control procedures. ServiceNow is a cloud‐based pla􀆞orm that will allow for the opera􀆟on of 􀆟cket‐based help desk func􀆟onality for SPA. This system will replace the large volume of email communica􀆟ons that currently documents a significant propor􀆟on of internal control ac􀆟vity and solve the problem of such emails lost to incomplete archiving and Baystate’s email reten􀆟on policy. SPA has a Microso􀅌 Teams central repository for all award‐related documents, as well as any legacy email and other documenta􀆟on related to compliance requirements and internal controls over compliance. Salary Cap—Management will re‐emphasize to end‐users via wri􀆩en communica􀆟on that the quarterly Excel summary report of salary cap is a courtesy report only, and that end‐users should rely on Infor Lawson as the system of record and its (1) Labor Cost by Ac􀆟vity report for labor cost and (2) Ac􀆟ve 10.2 report for salary cap distribu􀆟on and valida􀆟on. Prior to the quarterly mee􀆟ngs with the Departments and Service Lines to review award ac􀆟vity and expenditures, SPA and Research Accoun􀆟ng will compare the Excel summary with the two Infor Lawson reports for accuracy, inves􀆟gate and resolve differences in a 􀆟mely manner, and document evidence of review in SPA’s Microso􀅌 Teams site. Indirect Cost and Fringe Benefit Review—Due to the manual nature of entering and maintaining award data in the financial system, complete accuracy in data capture con􀆟nues to be an ongoing goal and objec􀆟ve. Management will develop and implement a checklist to enhance the review of internal controls associated with the SPA form maintained in IRBNet prior to submission to Finance. Documenta􀆟on of this review will be maintained in the Microso􀅌 Teams central repository. SPA has ac􀆟vated in IRBNet a system‐generated email alert that will be sent to Research Accoun􀆟ng on the comple􀆟on of the SPA form to enable the account set up step to be ini􀆟ated or revised, as required. SEFA Review—An enhanced monthly Infor Lawson report and a quarterly schedule of expenditures of federal awards (SEFA) report from Research Accoun􀆟ng has been added to the SPA’s quality assurance process to ensure 􀆟mely review of the SEFA data to improve accuracy. All quality assurance reports are available monthly a􀅌er the month end close. These reports will be reviewed by SPA and Research Accoun􀆟ng for accuracy and retained in SPA’s Microso􀅌 Teams site with evidence of review. Management expects to complete the above ac􀆟ons by December 31, 2024.

March 27, 2024 2023-003: Material weakness in Internal Control / Material Noncompliance – Cash Management (repeat comment) Condition: 1) The Condition requested funds in advance of when the related distributions were made, 2) the basis for the advance (requests) were not supported by appropriate documentation, and 3) authorization for requesting funds in advance was not obtained. Corrective Action: We agree with the finding. The Consortium has carefully reviewed our policies and procedures and have made the necessary changes to ensure that cash draws are based on expenditures already incurred and they are supported by transactions recorded in the books and records of the Consortium. We believe the updated procedures will result in the reduction over time and ultimately the complete elimination of this issue. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: December 2024 Respectfully, Shamar Herron

Additional preventive internal control procedures will be implemented, including an additional level of review of the Schedules and reconciliation. These procedures and internal controls have been implemented as of the date of this report.

The Public Works Department shall consult with the Finance Department to revise the reimbursement process to ensure future requests reconcile the specific amount expended by the grant. The revised process will include preparation of the reimbursement request using the City's financial system of record, and an independent review prior to submission to the grantor.

The Auditor-Controller’s office will provide additional training to applicable departments to educate staff on appropriate records maintenance related to grant files and the importance documented review and approval processes. This training will provide additional education over appropriate supporting documentation to verify internal controls and compliance requirements are being reasonably followed

The County is continuing to draft and establish written procedures for county-wide and department specific use when determining the allowability of personnel costs related to federal awards. A primary function of this policy will be to provide guidance to county staff to ensure personnel costs are recognized in accordance with cost principles, statues, regulations, and terms and conditions of federal awards.

Corrective Action With the organization of the Business Office under the new Business Administrator, the Charter School has implemented a system that utilizing docuware support to ensure that supporting schedules and documents for claims are readily available and ensure proper safekeeping of pertinent documents. In addition, this supports that the Charter School maintains supporting documentation for seven (7) years and making it available to the NJDOE, the U.S. Department of Education, and/or their authorized representatives upon request. Person(s) Responsible Bernadette Pinto, Interim School Business Administrator Planned Completion Date June 30, 2024