Corrective Action Plans

VIEWS OF RESPONSIBLE OFFICIALS ADSEF acknowledges the findings regarding weaknesses in the Random Moment Sampling (RMS) methodology used for allocating administrative costs. We conclude that the absence of formal written procedures, combined with insufficient communication between the Human Resources Appointments Office and the Finance Division, has contributed to inaccuracies in the distribution of administrative expenses across federal programs. ADSEF reaffirms its commitment to strengthening its cost allocation plan to ensure that only allowable costs, directly associated with the administration of federal awards, are charged to the TANF program, in strict compliance with 2 CFR §200.302. Action Steps: 1. Policy Formalization Develop, approve, and implement a comprehensive Standard Operating Procedure (SOP) that formalizes the RMS methodology, including clear and standardized definitions for all survey response categories. 2. HR–Finance Liaison Establish a structured monthly reporting protocol between the Human Resources Appointments Office and the Finance Division to ensure the RMS participant list remains accurate, complete, and current. 3. RMS Questionnaire Update Revise the RMS questionnaire to remove non-federal program selections and ensure that all response options align directly with federally allowable functions. 4. Quarterly Oversight Institute a mandatory quarterly review of RMS results by senior management to validate alignment between RMS survey data and accounting system allocations IMPLEMENTATION DATE March 31, 2027 RESPONSIBLE PERSON Eddie J. Burgos Auxiliary Administrator for Finance and Budget Coral M. Caceres Alvarez Auxiliary Administrator Human Resources Carlos Martinez Colón Finance Director Vanessa Ayala Gerena Director of Budget Gerhil Medina Baez Auxiliary Administrator Operational Services Rafael Acosta Sepulveda Program Director

VIEWS OF RESPONSIBLE OFFICIALS The data will be evaluated by the IT department to verify the controls in place at the time the files identified as duplicates were issued. Regarding the issuance, the IT department acknowledges an error in the file transmission, which resulted in the information not being matched against the issuance. The data will be available as reference for evaluation. For reconciliation purposes, work will be performed efficiently and within the established timeframes to ensure that all transactions are recorded promptly in the system. This will enable the accurate completion of the reconciliation process, as well as the recording of issuances and any other related transactions, in accordance with established procedures. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Blanca M. Medina Díaz Administrator Eddie J. Burgos Auxiliary Administrator for Finance and Budget Carlos Martinez Colón Finance Director Vanessa Ayala Gerena Director of Budget Carmen Ramírez IT Director

Incorrect Grant Drawdown - Allowable Costs/Reporting - Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding: Material Weakness in Internal Control Over Compliance Cause: Controls designed to ensure grant expenditures were properly aligned with the correct federal award prior to drawdown were not operating effectively, and procedures for identifying, reporting, and correcting drawdown errors were not consistently applied. Corrective Actions: 1. Strengthen internal controls over grant drawdowns by implementing procedures to ensure expenditures are reviewed and reconciled to the appropriate federal award prior to requesting funds. Management should also establish formal procedures for timely identification, documentation, and communication of drawdown errors to the awarding agency when identified.

Recommendations: Management should establish formal procedures requiring documented authorization for all disbursements and ensure that such approvals are retained in an organized and accessible manner. Additionally, the Organization should implement procedures requiring formal documentation of employee compensation arrangements, including established pay rates, and ensure that this documentation is consistently maintained and readily available for audit and compliance purposes. Views of responsible officials and planned corrective actions: Management agrees with the finding and indicates that it will implement formal approval procedures requiring documented authorization for all disbursements and will retain such documentation within its accounting records. Management also plans to implement standardized employment agreements and compensation authorization documentation for all employees and strengthen document retention practices to ensure compliance with federal requirements. Anticipated Completion Date: September 30, 2026

All federal programs requiring engineering assistance will be also be tracked internally for compliance.

The District concurs with the finding and acknowledges the importance of maintaining complete and accessible documentation to support federal expenditures, compliance activities, reimbursement requests, and financial reporting in accordance with Uniform Guidance requirements. The condition identified in the audit resulted from grant management, documentation retention, and accounting practices that existed prior to the current administration. During fiscal year 2025-2026, the District implemented significant corrective measures to strengthen federal grants management, financial oversight, documentation retention, and compliance monitoring. The District established enhanced grant administration procedures designed to improve the organization, retention, and accessibility of grant records. Grant expenditures, reimbursement requests, budget monitoring documents, approval records, and supporting documentation are now maintained in centralized electronic files to improve audit readiness and support compliance monitoring activities. In addition, the District strengthened coordination among program administrators, the Business Office, and District administration to improve oversight of federal grant activity. Grant budgets, expenditures, reimbursements, and compliance requirements are reviewed on an ongoing basis to ensure expenditures are properly supported, allowable, and consistent with grant requirements. The District has also implemented procedures to improve grant-level tracking and monitoring of revenues and expenditures and has worked to ensure that grant activity is supported by documentation sufficient to demonstrate compliance with applicable federal requirements. Efforts have been made to strengthen record retention practices, improve financial reporting by grant award, and maintain documentation necessary to support future audit and monitoring activities. The District will continue to formalize written procedures governing federal grant administration, accounting, reconciliation, reimbursement processing, documentation retention, and compliance monitoring. Staff responsible for grant administration will continue to receive guidance and training regarding documentation and record retention requirements. The District believes that the corrective actions implemented during FY26 have substantially strengthened internal controls over federal grants management, documentation retention, and financial reporting and have significantly improved the District's ability to demonstrate compliance with federal program requirements.

Finding 2024-002 – Untimely and Inaccurate Preparation of the Schedule of Federal Awards (SEFA) (Sig-nificant Deficiency) Financial Reporting / Internal Control Over Compliance CFDA Title and Number: 97.036 Public Assistance Program – Disaster Grants Name of Federal Agency: Federal Emergency Management Agency (FEMA Internal Control over Compliance: Skills Knowledge and Education (SK&E) CFDA Title and Number: 66.202 Wastewater Treatment Plant Name of Federal Agency: U. S. Environmental Protection Agency Internal Control over Compliance: Skills Knowledge and Education (SK&E) Criteria: The Uniform Guidance (2 CFR §200.510(b)), requires the auditee to prepare a Schedule of Federal Ex-penditures of Federal Awards (SEFA) that accurately reports federal expenditures for each federal award, including the Assistance Listing number, federal agency, pass-through entity (if any), and amount expended for the fiscal year. In addition, (2 CFR §200.302(b)), requires financial management systems that provide for accurate, current, and complete disclosure of federal award expenditures and support reliable financial reporting and reconciled to the general ledger. Condition: The auditee did not timely or accurately prepare the Schedule of Expenditures of Federal Awards. Specifically: • The initial SEFA provided to auditors was significantly later than the requested date, and required signifi-cant auditor inquiry and assistance to complete. • Management did not demonstrate an understanding of the dates and amounts of federal expenditures to be reported on the SEFA. • The SEFA provided to auditors did not include all federal awards. • Required Assistance Listing numbers were not included for federal programs. • The format of the SEFA was not easily reconcilable to the general ledger, and required auditor-identified corrections and adjustments in order to fairly present federal expenditures in accordance with federal re-quirements. Cause: The condition resulted from: • An insufficient understanding of SEFA preparation requirements, including which expenditures to report and how federal awards should be presented; and • Inadequate internal controls over the preparation, review, and reconciliation of the SEFA to the account-ing records. Effect or Potential Effect: As a result of these conditions: • There was an increased risk that federal expenditures were incomplete, inaccurate, or improperly re-ported. • Management’s ability to determine total federal expenditures, for the fiscal year, including evaluation of Single Audit applicability, was impaired. • The entity relied on auditor assistance to identify omitted awards, reconcile amounts and bring the SEFA into compliance with federal reporting requirements, indicating a lack of effective internal controls over federal financial reporting. Questioned Cost: None noted here. Repeat of a Prior-Year Finding: No Recommendation: We recommend the entity strengthen its internal controls over federal financial reporting by: • Developing and documenting procedures for the timely preparation of the SEFA, including identification of all federal awards, correct Assistance Listing numbers, and determination of reportable expenditures. • Establish a process to reconcile the SEFA to the general ledger and to supporting records to ensure com-pleteness and accuracy. • Providing training to appropriate personnel regarding Uniform Guidance SEFA requirements and the de-termination of federal expenditures for reporting and audit threshold purposes. • Establish cutoff procedures to capture year-end accruals/deferred items and ensure completeness of ex-penditures for the SEFA. Views of Responsible Officials: Port of Brookings Harbor acknowledges this finding. Management recognizes that it did not fully understand SEFA reporting requirements. Management is committed to enhancing its under-standing of federal reporting requirements and strengthening internal controls to ensure future SEFA’s are prepared accurately, completely, and in a timely manner. Corrective Action Plan: While the Port disagrees with the characterization that the SEFA preparation was untimely, the Port acknowledges that inaccuracies were present in the report. The inaccuracies occurred because the Port believed it was following the direction and guidance contemplated in the Municipal Auditing Services Proposal provided by Umpqua Valley Financial, LLC, which indicated time would be dedicated to assisting the Port with grant administration regulations and related compliance requirements. Nevertheless, the Port accepts responsibility for strengthening its internal processes and will immediately develop and implement formal procedures for timely and accurate SEFA preparation. In addition, the Port will provide Uniform Guidance and SEFA training to appropriate perso,mel to improve compliance and federal financial reporting practices. The Port has attached a copy of the Municipal Auditing Services Proposal from Umpqua Valley Financial, LLC to demonstrate that the Port proactively sought guidance well in advance of the completion of the fiscal year and prior to the commencement and finalization of the audit process. Port Management remains committed to improving its understanding of Uniform Guidance requirements and strengthening its federal financial reporting and grant compliance practices moving forward. Sincerely, Travis Webster Port Manager

The Village will establish formal UG policies and procedures.

The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.

Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorporate the auditors' feedback during the FY24 audited period. However, the Organization took immediate, proactive steps to deploy enhanced internal controls for FY25 to ensure continuous alignment with federal standards. To ensure strict adherence to 2 CFR § 200.302(a), we are actively implementing a more regular reconciliation process between government grant revenue claimed and actual revenue earned. As a key part of this initiative, the Organization has developed and deployed new internal financial tools designed to incorporate automation into our daily workflows. By utilizing these automated tools-such as standardized templates for recording cash receipts and systematically clearing Accounts Receivable-we have significantly enhanced the accuracy of our data entries and reduced the risk of manual misstatements. Our ongoing objective is to leverage these tools to establish clear, standardized documentation procedures, ensuring that all financial reports and claims are consistently generated from a reconciled general ledger. Management remains fully committed to dedicating the necessary time and resources to mature these financial controls and ensure robust compliance with federal regulations.

The Parish has written a Standard Operating Procedure for "Grant Maangement - Financial Reporting & Reconciliation" which outlines the role of the Finance Department in monitoring grant activities including measures to ensure correct general ledger coding for budget planning, complete and accurate recording of grant expenditures and revenues, and administrative review to confirm reconciliation of grant activities against the general ledger on a monthly basis.

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.